Conscientious objections,the nature of medicine,and the need for reformability

The debate over whether the medical profession should accommodate its members' conscientious objections (COs) has raged on in the bioethics literature and on legislative floors for decades. Unfortunately, participants on all sides of the debate fail to distinguish among different types of CO, a failure that obstructs the view of which cases warrant accommodation and why. In this paper, we identify one type of CO that warrants consideration for accommodation, called Nature of Medicine COs (NoMCOs). NoMCOs involve the refusal of physicians to perform actions they reasonably judge to be contrary to the nature of medicine and their professional obligations. We argue that accommodating NoMCOs can be justified based on the profession's need to preserve reformability. Importantly, this previously underdeveloped position evades some of the concerns commonly raised by opponents of CO accommodations.     

Nuremberg lamentation: for the forgotten victims of medical science.

Fifty years after the Nuremberg medical trial there remain many unanswered questions about the role of the German medical profession during the Third Reich. Other than the question of human experimentation, important ethical challenges arising from medicine in Nazi Germany which have continuing relevance were not addressed at Nuremberg. The underlying moral question is that of the exercise of professional power and its impact on vulnerable people seeking medical care. Sensitisation to the obligations of professional power may be achieved by an annual commemoration and lament to the memory of the victims of medical abuse which would serve as a recurring reminder of the physician''s vulnerability and fallibility.     

THE ROLE OF GOVERNMENT IN MEDICINE

On the fundamental question of how far a government should be involved in health services, the author believes these things can appropriately be said: The government should continue to assume complete control over public health measures, and public health officials could well be permitted to invade medical services insofar as is necessary to achieve public health ends.To assist in the production of medical personnel, it is also fitting for the government to provide for increased teaching facilities, higher salaries for teachers in the medical field and scholarships for worthy students.In the area of insurance and prepayment plans, a really intelligent supervision of such devices, with the exercise of no more arbitrary governmental power than is now used by the various other regulatory commissions, is a suitable governmental function. The government''s buying policies for its wards, rather than providing direct medical services for them, should be encouraged. This would give the private practice of medicine a boost and would improve the quality of medical care. Government should encourage the regionalization of medical services with as much of the actual controls exercised at the local level as can be achieved. Private means should be utilized for the provision of these services and public means should be used for their payment when this is an obligation of the government.The problem of mass education in health matters should be tackled by government. It would be a fine thing if the medical profession and governmental agencies could agree upon delineation of their respective roles in the health field.Because further experimentation is needed before the ideal solution is found, both government and organized medicine should encourage the exploration of new approaches.     

Primary care--opportunities and threats. The changing meaning of the GP contract.

The meaning of the GP contract has changed since the last major upheaval in the mid-1960s. The government has always dealt with general practitioners as independent contractors, but the way in which it treated them in 1990 was entirely different from the way in which they were treated in 1966. In 1966, the profession''s independent contractor status effectively served to protect professional autonomy. In 1990, with the change in the form of government towards a "contract state," general practitioners were treated as independent contractors more in the sense of business entrepreneurs. The article finishes by raising the issue of how general practitioners can gain control over the medicopolitical agenda in the future.     

Medicine in Society—Part I: Change and Challenge

The Committee to Study the Role of Medicine of the California Medical Education and Research Foundation (CMERF) is grateful to Dr. Watts for the following paper which served as the philosophical basis for the Committee''s study and discussions. The Committee is also grateful to CMERF and to its president, James C. Doyle, for the encouragement and cooperation it has received in the course of its intensive study of a problem which is of great interest and concern to the medical profession of California.Dr. Watts'' background paper has served as a potent stimulus in directing the Committee''s attention to the continuing dialogue between medicine and society, and in focussing on problems and issues which will be the subject of the Committee''s Second Progress Report, excerpts from which are scheduled for publication in the next issue of California Medicine.     

Demonstrating social accountability in medical education

The author considers the University of Toronto''s Health, illness and the Community course for undergraduate medical students, described in this issue by Wasylenki and associates (see pages 379 to 383). Social accountability in medical education demands a community orientation and hence an emphasis on outreach. Medical schools should expand their clinical service to the community, provide community-based residency placements and offer continuing medical education in rural and regional centres. Accountability also requires community involvement in planning and implementing research projects. Placing students in a community setting as part of the curriculum is praiseworthy, but it is not sufficient to ensure social accountability. What is needed now is a more comprehensive acceptance by faculties of medicine of the mandate of community-centred learning, together with well-targeted funding for education and research initiatives.     

构建融合医学人文教育的新型医学遗传学教学模式

医学遗传学是广泛涉及基础与临床学科的综合性课程,对于医学生是至关重要的必修课程。现代医学已由传统的生物-医学模式向生物-心理-社会医学模式转化,医学诊疗模式从最初的以"疾病为中心"到"以病人为中心"的方式转变,医生不仅精通医术,更要理解患者的心理,与其进行良好的沟通,因此现代医学成为了一门具有自然科学、人文社会科学双重属性的综合性科学体系。长期以来,我国医学院校的教学仍然是生物医学知识和技能占据主导地位,人文课程不受重视。因此,必须加强医学人文知识的学习和技能培训,只有这样才能在未来的医疗工作中掌握良好的医患沟通技巧,建立和谐的医患关系,对处理好日渐增多的医疗纠纷、维护医患双方的共同利益具有重要意义。     

Where is the silver lining? Anxious doctors ask.

When Nova Scotia elected a Liberal government in September 1993, a wave of optimism washed over the province''s medical community. One of their own, Dr. John Savage, was now premier, and another, Dr. Ron Stewart, was minister of health. However, anticipation soon turned to anger as Stewart took aim at physician fees and hospital costs to help reduce the province''s health care budget by $62 million. Last November, relations between him and the Medical Society of Nova Scotia (MSNS) hit bottom. In an uncharacteristically political move, the society launched an ad campaign featuring slogans such as "Death by 1000 cuts" and "Uncle Sam want me. Ron Stewart doesn''t." Four months later, the health department and the MSNS called a truce, with an agreement that many physicians consider a positive step. Today the province and its doctors are speaking again, and the medical society is working hard to help define physicians'' roles in a new, regionalized health care system. But has the mood of doctors really improved? Last spring, CMAJ interviewed a cross section of Nova Scotia physicians to find out.     

INDUSTRY CALLING!—Is There a Doctor in the House?

Medical service is needed in industry by both management and labor as never before. Industry is just beginning to awaken to this need. The medical profession is largely unaware of it. Unless physicians are prepared to heed this call, there is danger that management and labor will come to a bipartisan agreement over the bargaining table which will specify the amount, quality, and price of medical service irrespective of the effects of such an agreement on the practice of medicine. Such agreements should invariably be tripartite—between management, labor and medicine—if we are to continue to strive for medicine''s traditional ideals: The best of medical care for all alike.This situation imposes at least two important obligations on organized medicine at the national level and especially at state and local levels where there is industrial concentration:1. Provision of a strong and competent committee or council whose members are especially interested in occupational medicine and who will make their presence known to management and labor alike, offering to advise with them on all medical problems, to mediate their disagreements or medical questions, and to help them attain a common goal.2. Assisting the members of organized medicine who are interested, to learn more about the medical problems peculiar to occupational health.     

Results from CMA's huge 1998 physician survey point to a dispirited profession

Results from the CMA''s 1998 Physician Resource Questionnaire are in, and they point to a serious decline in physician morale. The PRQ, the country''s most important poll of physician attitudes, provides an annual "state-of-the-nation" message for the medical profession.     

Human guinea pigs and the ethics of experimentation: the BMJ's correspondent at the Nuremberg medical trial.

Though the Nuremberg medical trial was a United States military tribunal, British forensic pathologists supplied extensive evidence for the trial. The BMJ had a correspondent at the trial, and he endorsed a utilitarian legitimation of clinical experiments, justifying the medical research carried out under Nazism as of long term scientific benefit despite the human costs. The British supported an international medical commission to evaluate the ethics and scientific quality of German research. Medical opinions differed over whether German medical atrocities should be given publicity or treated in confidence. The BMJ''s correspondent warned against medical researchers being taken over by a totalitarian state, and these arguments were used to oppose the NHS and any state control over medical research.     

THE SCOPE AND RESPONSIBILITY OF MEDICINE—A Forum with a Purpose

To engender discussion of what the scope and responsibility of medicine ought to be in today''s society, California Medicine printed in its June issue six essays by authors known to have keen if various interest in the subject.In presenting the essays the editors expressed hope that they would be the beginning of a forum from which a definition of our profession''s responsibilities may be distilled. Readers were invited to take part in a continuation of the forum in succeeding issues. Following are three contributions selected from those received to date. Others will be published in the months ahead.If you have thoughts on the subject, just address them to the editors of California Medicine, 693 Sutter Street, San Francisco, California 94102. Keep your essays short, please.     

THE SCOPE AND RESPONSIBILITY OF MEDICINE—A Forum with a Purpose

To engender discussion of what the scope and responsibility of medicine ought to be in today''s society, California Medicine printed in its June issue six essays by authors known to have keen if various interest in the subject.In presenting the essays the editors expressed hope that they would be the beginning of a forum from which a definition of our profession''s responsibilities may be distilled. Readers were invited to take part in a continuation of the forum in succeeding issues. Following are two contributions selected from those received to date. Others will be published in the months ahead.If you have thoughts on the subject, just address them to the editors of California Medicine, 693 Sutter Street, San Francisco, California 94102. Keep your essays short, please.     

Male versus female genital alteration: Differences in legal,medical, and socioethical responses

The different legal, social, and medical approaches to ritually based male and female genital circumcision in the United States are highlighted in this article. The religious and historical origins of these practices are briefly examined, as well as the effect of changing policy statements by American medical associations on the number of circumcisions performed. Currently, no state or federal laws single out male circumcision for regulation. The tolerant attitudes toward male circumcision in law, medicine, and societal opinion stand in striking contrast to the attitudes of those disciplines toward even the least invasive form of female genital alteration. US law tacitly condones male circumcision by providing exemptions that are not available for other medical procedures, while criminalizing any similar or even less extensive procedure on females. The increase in immigration, over the past few decades, of people from countries in which female genital alteration is a cultural tradition has brought the issue to the United States. The medical profession's changing approach over time toward male circumcision is primarily responsible for such different legal and societal reactions toward female genital alteration.     

THE SCOPE AND RESPONSIBILITY OF MEDICINE—A Forum with a Purpose

To engender discussion of what the scope and responsibility of medicine ought to be in today''s society, California Medicine printed in its June issue six essays by authors known to have keen if various interest in the subject.In presenting the essays the editors expressed hope that they would be the beginning of a forum from which a definition of our profession''s responsibilities may be distilled. Readers were invited to take part in a continuation of the forum in succeeding issues. Following are three contributions selected from those received to date. Others will be published in the months ahead.If you have thoughts on the subject, just address them to the editors of California Medicine, 693 Sutter Street, San Francisco, California 94102. Keep your essays short, please.     

THE SCOPE AND RESPONSIBILITY OF MEDICINE—A Forum with a Purpose

To engender discussion of what the scope and responsibility of medicine ought to be in today''s society, California Medicine printed in its June issue six essays by authors known to have keen if various interest in the subject.In presenting the essays the editors expressed hope that they would be the beginning of a forum from which a definition of our profession''s responsibilities may be distilled. Readers were invited to take part in a continuation of the forum in succeeding issues. Following are four contributions selected from those received to date. Others will be published in the months ahead.If you have thoughts on the subject, just address them to the editors of California Medicine, 693 Sutter Street, San Francisco, California 94102. Keep your essays short, please.     

THE SCOPE AND RESPONSIBILITY OF MEDICINE—A Forum with a Purpose

To engender discussion of what the scope and responsibility of medicine ought to be in today''s society, California Medicine printed in its June issue six essays by authors known to have keen if various interest in the subject.In presenting the essays the editors expressed hope that they would be the beginning of a forum from which a definition of our profession''s responsibilities may be distilled. Readers were invited to take part in a continuation of the forum in succeeding issues. Following are three contributions selected from those received to date. Others will be published in the months ahead.If you have thoughts on the subject, just address them to the editors of California Medicine, 693 Sutter Street, San Francisco, California 94102. Keep your essays short, please.     

Medical schools seeking new ways to cope with funding cutbacks

Cuts in government funding mean that Canada''s medical schools have to seek new ways to raise funds. Susan Thorne examines some of the ways faculties of medicine are coping with change. In the brave new world of medical education, schools are combining classes for medical students and other health professionals, seeking business alliances, encouraging attendance by full-tuition students from other countries and diversifying revenue bases through new programs, such as McGill''s new 5-year MD-MBA degree.     

Socio-Economics of Medical Care, Report of Bureau of Research and Planning

Interest in the area of medical socio-economics has largely come about due to the proliferation of social welfare programs and advances in the distribution of health services in the private sector of the economy. The increasing role of our government has also been a stimulus. With the advent of new techniques for the financing of care, a large volume of institutional literature has appeared delving into issues which range from the role of the medical profession in the evaluation of quality of medical care to the measurement of demand for and prepayment of numerous types of health care services. Since the area of medical socio-economics is not considered "pure" enough to be categorized as a discipline, the range of periodicals, government and non-government publications and books, in which data are found, is vast. This report will briefly describe some of the more important sources of data in the area of medical socio-economics. Major emphasis is given to the literature which provides current statistical data on the operational aspects of public and private programs providing health care services, and ancillary activities which affect the market for health care activities. Leading publications of governmental and other community agencies are cited to illustrate the range of materials available to the public and to the medical profession.     

Euthanasia—An Overview for Our Time A Report by the CMA Committee for Continuing Study of Evolving Trends in Society Affecting Life

The Committee for the Continuing Study of Evolving Trends in Society Affecting Life was established by the CMA House of Delegates in 1971, following the consideration of a number of resolutions on the topic of abortion. The committee''s charge was broadened, however, to include topics such as euthansia, biomedical engineering, medicine and religion, ecology and education. The committee''s discussions, as its name indicates can cover a wide range of fields of interest to the medical profession. The following article is the first of several which the committee plans to publish, although the products of its deliberations may take the form of resolutions to future meetings of the House of Delegates.