Do physicians have an ethical obligation to care for patients with AIDS?

This paper responds to the question: Do physicians have an ethical obligation to care for patients with acquired immunodeficiency syndrome (AIDS)? First, the social and political milieu in which this question arises is sampled. Here physicians as well as other members of the community are found declaring an unwillingness to be exposed to people with AIDS. Next, laws, regulations, ethical codes and principles, and the history of the practice of medicine are examined, and the literature as it pertains to these areas is reviewed. The obligation to care for patients with AIDS, however, cannot be located in an orientation to morality defined in rules and codes and an appeal to legalistic fairness. By turning to the orientation to morality that emerges naturally from connection and is defined in caring, the physicians'' ethical obligation to care for patients with AIDS is found. Through an exploration of the writings of modern medical ethicists, it is clear that the purpose of the practice of medicine is healing, which can only be accomplished in relationship to the patient. It is in relationship to patients that the physician has the opportunity for self-realization. In fact, the physician is physician in relationship to patients and only to the extent that he or she acts virtuously by being morally responsible for and to those patients. Not to do so diminishes the physician''s ethical ideal, a vision of the physician as good physician, which has consequences for the physician''s capacity to care and for the practice of medicine.     

Determining medical fitness to drive: physicians' responsibilities in Canada.

Current legislation indicates that physicians in Canada have a legal responsibility to know which medical conditions may impede driving ability, to detect these conditions in their patients and to discuss with their patients the implications of these conditions. The requirements to report unfit drivers vary among the provinces, and the interpretations of the law vary among the courts; therefore, physicians'' risks of liability are unclear. Physicians may be sued by their patients if they fail to counsel the patients on the dangers of driving associated with certain medications or medical conditions. Physicians may also face legal action by victims of motor vehicle accidents caused by their patients if the court decides that the physicians could have foreseen the danger of their patients'' continuing to drive. Physicians'' legal responsibilities to report patients with certain medical conditions override their ethical responsibilities to keep patients'' medical histories confidential.     

Taking care of patients--does it matter whether the physician is a woman?

Researchers have recently begun to compare male and female physicians'' attitudes toward patients, medical knowledge, and practice styles. Although women start medical school with more "humanistic views," the conservative effect of medical socialization on both male and female students attenuates these differences. While some studies suggested that men are more scientifically knowledgeable, recent studies showed no significant differences in physicians'' medical knowledge. Male and female physicians also had comparable diagnostic and therapeutic behavior. In the intimate world of physicians and patients, however, there were notable differences. Women physicians seemed better able to communicate sensitivity and caring to patients, which may account for the common perception that women are more caring and empathic physicians. Medical educators may wish to study more closely female physicians'' communication styles to identify these behaviors and inculcate them into all physicians.     

Understanding physicians' response to AIDS.

Attempts to comprehend physicians'' extreme reaction to AIDS (acquired immune deficiency syndrome) have met with great difficulty since the disease brings into question traditional norms and assumptions. As the medical profession struggles to develop guidelines and policies to help it deal with this disease, it can draw on very little systematic research on the effect of AIDS on physicians'' attitudes and practices. We suggest a framework developed from the literature on physicians'' and society''s response to other disorders that would provide a basis for organizing the ever-increasing amount of information on physicians and AIDS and would guide systematic research aimed at understanding and predicting physicians'' participation in the prevention and management of AIDS. Within this framework we consider how characteristics of the disease, elements of the health care system and physicians'' attitudes interact to influence clinical and personal practices. AIDS had led to new delineations of physicians'' responsibility, modification of prevailing beliefs about physician autonomy and thus a redefinition of the role of the physician in North America.     

Alberta euthanasia survey: 2. Physicians' opinions about the acceptance of active euthanasia as a medical act and the reporting of such practice.

OBJECTIVE: To ascertain the opinions of Alberta physicians about the acceptance of active euthanasia as a medical act (the "medicalization" of active euthanasia) and the reporting of colleagues practising active euthanasia, as well as the sociodemographic correlates. DESIGN: Cross-sectional survey of a random sample of Alberta physicians, grouped by site and type of practice. SETTING: Alberta. PARTICIPANTS: A total of 2002 (46%) of the licensed physicians in Alberta were mailed a 38-item questionnaire in May through July 1991; usable responses were returned by 1391 (69%). RESULTS: Although only 44% of the respondents considered active euthanasia morally "right" at least 70% opted to medicalize the practice if it were legal by restricting it to be performed by physicians and to be taught at medical sites. Even though active euthanasia is criminal homicide in Canada, 33% of the physicians stated that they would not report a colleague participating in the act of anyone, and 40% and 60% stated that they would not report a colleague to medical or legal authorities respectively. Acceptance or rejection of active euthanasia as a medical act was strongly related to religious affiliation and activity (p < 0.01). CONCLUSIONS: This survey about active euthanasia revealed profound incongruities in the opinions of the sample of Alberta physicians concerning their ethical and social duties in the practice of medicine. These data highlight the need for relevant modifications of health education policies concerning biomedical ethics and physicians'' obligations to society.     

A rural emergency department.

The appropriate use of emergency departments is of growing concern. By knowing which patients are more likely to make inappropriate visits to these departments, efforts can be directed to encourage more suitable care. Our study was done in a rural county hospital in eastern New Mexico. Data were collected from all emergency department visits over a 4-week period. Patient and physician questionnaires were administered to assess aspects of emergency department use, including appropriateness based on published criteria, physicians'' opinion of appropriateness, groups who made inappropriate visits, and the perception of the need for and the urgency of a visit. We found that 32% of visits were inappropriate based on published criteria and 24% were considered inappropriate by physician opinion. Two groups with a high rate of inappropriate visits were Hispanics and Medicaid recipients. Patients and physicians have differing opinions of the urgency of a visit and of how soon medical treatment is required. To decrease the frequency of inappropriate use of emergency departments, educational efforts should be focused on the subgroups with high rates of such use.     

The Ethical and Legal Framework for the Decision Not to Resuscitate

Practicing physicians are frequently faced with the question of whether or not to institute cardiopulmonary resuscitation in case of cardiac or respiratory arrest in a patient in hospital. Medical training has usually not included any systematic analysis of this issue from either an ethical or a legal standpoint. Many physicians may be unaware that ethical and legal principles, as well as professional guidelines, exist to guide such decision making. In practice, physicians make this decision without the benefit of training in ethical analysis. The problem is especially acute in teaching hospitals when young physicians unacquainted with formal ethics or the law must often make decisions emergently. Studies show some discrepancy between ethical and legal principles and the actual decision making by physicians. For this reason, we recommend an approach that will enable physicians to make and implement decisions not to resuscitate that are consistent with current ethical and legal standards.     

Physician time-saving by employment of expanded-role nurses in family practice

Registered nurses working in five family practices in Kingston, Ontario, were given a period of in-service training and supplementary formal instruction at Queen''s University to expand their skills and enable them to undertake prescribed procedures in the physicians'' offices. Operational data collected from the five practices before and after training was analysed to assess the saving of physician time effected by the expansion of the nurses'' activities in providing primary medical care. Physician time was saved in all cases but the amount varied. The results are presented and discussed in relation to staff, physical premises and patterns of practice of the participating physicians. Under the most advantageous practice circumstances in this study, a 33.7% saving in original physician time was obtained. The mean time-saving for the five practices was 18.2%.     

Impact of patient care appraisal on physician behaviour in the office setting

The effect of patient care appraisal on physicians'' management of patients'' problems was assessed. Sixteen family physicians were involved. The eight in the experimental group helped in the selection of two of the five disease conditions to be audited and in the generation of optimal criteria of care for two of the conditions. Participation in the generation of optimal criteria was followed by a significant improvement in the physicians'' behaviour, but involvement in the selection of the conditions to be audited caused no change. The patient care appraisal did not lead to significant improvement of physicians'' management of the conditions. In a second analysis, in which only essential criteria of care were considered, the physicians who participated in the patient care appraisal significantly improved their management of patients'' problems. However, participation in the selection of the conditions and in the generation of the criteria of care had no effect on their performance. Patient care appraisal is an effective tool in continuing medical education and leads to improvement in the quality of care, provided the process focuses on essential criteria of care.     

The ethically trained physician: myth or reality?

Through a questionnaire distributed to 300 physicians in the Toronto area, three aspects of their ethical awareness were examined: the formal codes, the need for consultation in making decisions and the need for training in medical ethics. Most of the physicians (81%) felt that they were facing ethical problems in their daily practice. A majority of these would try to solve the problems either themselves (30%) or through discussion with a colleague (43%). When they turned outside the profession it was sometimes to a lawyer (12%), which suggests concern with the legalities of some situations. Only a small proportion of the respondents were found to be familiar with two of the established codes of ethics, yet 13% would still turn to the code of the Canadian Medical Association for guidance. Finally, there was widespread recognition of the need for proper training in medical ethics and for the establishment of a specialty in this field.     

Survey on Ethical Conduct Thresholds in Cardiologal Medical Practice in Argentina

The purpose of this study was to analyze the attitude of a group of cardiologists on the ethical conducts they would accept or adopt when encountered with different hypothetical situations of medical practice. Between August and September of 2011, 700 Argentine cardiologists were surveyed in situations which posed ethical dilemmas in the patient‐physician relationship, among colleagues or involving financial agreements with employers or the pharmaceutical industry. Ethical conflicts were evidenced in a series of inappropriate conducts such as differential fees, trips and meals sponsored by laboratories, splitting fees, overbilling, self‐referral, charging for patient referral, financial compensation for ordering medical procedures, and various situations derived from the relationship with employers. In general, financial compensation from the pharmaceutical industry was more accepted than the conflictive situations which directly involved patients, colleagues or employers. The rejection of these conducts, the physicians' deontological education and the improvement of financial and organizational conditions in medical practice will help to encourage better medical professionalism and avoid unseemly behaviors.     

Protecting Future Children from In‐Utero Harm

The actions of pregnant women can cause harm to their future children. However, even if the possible harm is serious and likely to occur, the law will generally not intervene. A pregnant woman is an autonomous person who is entitled to make her own decisions. A fetus in‐utero has no legal right to protection. In striking contrast, the child, if born alive, may sue for injury in‐utero; and the child is entitled to be protected by being removed from her parents if necessary for her protection. Indeed, there is a legal obligation for health professionals to report suspected harm, and for authorities to protect the child's wellbeing. We ask whether such contradictory responses are justified. Should the law intervene where a pregnant woman's actions risk serious and preventable fetal injury? The argument for legal intervention to protect a fetus is sometimes linked to the concept of ‘fetal personhood’ and the moral status of the fetus. In this article we will suggest that even if the fetus is not regarded as a separate person, and does not have the legal or moral status of a child, indeed, even if the fetus is regarded as having no legal or moral status, there is an ethical and legal case for intervening to prevent serious harm to a future child. We examine the arguments for and against intervention on behalf of the future child, drawing on the example of excessive maternal alcohol intake.     

Poem: the prophet in his own country

Although generalist physicians appear to be more likely than specialists to provide care for poor adult patients, they may still perceive financial and nonfinancial barriers to caring for these patients. We studied generalist physicians'' attitudes toward caring for poor patients using focus groups and used the results to design a survey that tested the generalizability of the focus group findings. The focus groups included a total of 24 physicians in 4 California communities; the survey was administered to a random sample of 177 California general internists, family physicians, and general practitioners. The response rate was 70%. Of respondents, 77% accepted new patients with private insurance; 31% accepted new Medicaid patients, and 43% accepted new uninsured patients. Nonwhite physicians were more likely to care for uninsured and Medicaid patients than were white physicians. In addition to reimbursement, nonfinancial factors played an important role in physicians'' decisions not to care for Medicaid or uninsured patients. The perception of an increased risk of being sued was cited by 57% of physicians as important in the decision not to care for Medicaid patients and by 49% for uninsured patients. Patient characteristics such as psychosocial problems, being ungrateful for care, and noncompliance were also important. Poor reimbursement was cited by 88% of physicians as an important reason not to care for Medicaid patients and by 77% for uninsured patients. Policy changes such as universal health insurance coverage and increasing the supply of generalist physicians may not adequately improve access to care unless accompanied by changes that address generalist physicians'' financial and nonfinancial concerns about providing care for poor patients.     

Use of botulinum toxin

In an extensive survey of postgraduate physicians in two teaching hospitals (N = 141) for their humanistic attitudes, values and behavior, all ratings of physicians'' humanistic performance, including physicians'' own scores on self-report measures, supervising faculty, nurses and patient ratings, were modestly but significantly correlated with each other. Sex, ethnic or racial background, year of training, marital status, number of children, Alpha-Omega-Alpha membership or number of articles published were unrelated to physicians'' humanistic behavior. Several measures of humanism were positively correlated with having taken more courses in the social sciences and humanities, having had more early person-centered work experience and reporting that before medical school others had confided in them or sought their advice more frequently.     

Great Expectations: Teaching Ethics to Medical Students in South Africa

Many academic philosophers and ethicists are appointed to teach ethics to medical students. We explore exactly what this task entails. In South Africa the Health Professions Council's curriculum for training medical practitioners requires not only that students be taught to apply ethical theory to issues and be made aware of the legal and regulatory requirements of their profession, it also expects moral formation and the inculcation of professional virtue in students. We explore whether such expectations are reasonable. We defend the claim that physicians ought to be persons of virtuous character, on the grounds of the social contract between society and the profession. We further argue that since the expectations of virtue of health care professionals are reasonable, it is also sound reasoning to expect ethics teachers to try to inculcate such virtues in their students, so far as this is possible. Furthermore, this requires of such teachers that they be suitable role models of ethical practice and virtue, themselves. We claim that this applies to ethics teachers who are themselves not members of the medical profession, too, even though they are not bound by the same social contract as doctors. We conclude that those who accept employment as teachers of ethics to medical students, where as part of their contractual obligation they are expected to inculcate moral values in their students, ought to be prepared to accept their responsibility to be professionally ethical, themselves.     

AIDS in children

The application of medical quality assurance principles to ambulatory patient care using the traditional methods of medical chart audit, process review, and physician education has yielded generally disappointing results in improving patient care and physician performance. Newer methods assist physicians by providing patient and medical reference data at the time of a patient''s visit. Techniques for tracking treatment outcomes and patients'' test results and for providing instructions to patients may improve both care and patients'' and physicians'' satisfaction.This feature appears regularly in THE WESTERN JOURNAL OF MEDICINE. It is intended to cover recent developments in a broad range of issues that will have an impact—either directly or indirectly—on clinical practice. Occasionally the seminars may include informed speculation about likely future developments.     

AIDS awareness among rural Utah physicians.

Studies of physicians'' attitudes and knowledge of the acquired immunodeficiency syndrome (AIDS) and the clinical precautions they take against exposure to the human immunodeficiency virus (HIV) have focused on urban physicians. To determine rural physicians'' knowledge and attitudes about AIDS, a questionnaire was mailed to 321 physicians practicing in rural Utah. Of the 169 physicians who completed questionnaires, 96% thought that their community or area of service had only a minor or no problem with AIDS; 89%, however, thought that their chance of seeing a patient who was HIV-positive was fair to moderate. Of the 169 respondents, 3% were not sure whether they would even treat a patient who had AIDS, 67% said they would, and 30% said they would not. Although all physicians are at risk of seeing a patient who has had exposure to HIV and other blood-borne diseases such as hepatitis B, only 55% of the respondents felt a need to take clinical precautions to prevent their exposure to the virus. Our study shows the need for all rural Utah physicians to reevaluate their risk of exposure to HIV, to increase precautionary measures for their own protection, to consider the ethical responsibility of treating AIDS patients, and to take a more active role in teaching their patients how to protect themselves from exposure to the virus.     

Sex role ideology among physicians.

Physicians have been accused by some feminist writers of having traditional views on sex roles that make them part of society''s oppressive power structure and therefore responsible in part for the high incidence of psychologic problems and drug dependency among women. To assess whether physicians'' attitudes towards women are indeed polarized in a traditional fashion, a sex role ideology questionnaire was given to all practising physicians belonging to the Manitoba Medical Association. Overall the physicians were found to be more feminist than male college students and a group of women with traditional beliefs. Psychiatrists, who had the highest adjusted group mean score on a sex role ideology scale (high indicating feminist beliefs), were found to be significantly more feminist than family practitioners, surgeons, and obstetricians and gynecologists, although not more so than internists, radiologists, pediatricians and anesthesiologists. These findings do not support the assumption that physicians have traditional views that reflect those of society. However, the significant differences between specialties emphasize the need for educating physicians and medical students in the behaviour of women.     

Physician communication skills and malpractice claims. A complex relationship.

We assessed the relationship between patients'' opinions about their physicians'' communication skills and the physician''s history of medical malpractice claims. The sample consisted of 107 physicians and 2,030 of their patients who had had an operation or a delivery. Although patients tended to give their physicians favorable ratings, they were least satisfied with the amount of explanations they received. Patients gave higher ratings to general surgeons and obstetrician-gynecologists and poorer ratings to orthopedists and anesthesiologists. Women and better-educated patients gave higher ratings on explanations and communication to physicians with fewer claims. Men and patients with less education, however, gave higher ratings on these dimensions to physicians with more claims. These findings suggest the need for physicians to tailor their communications to a patient''s individual needs. Improved communication between physicians and patients may result in fewer nonmeritorious malpractice claims while leading to less costly resolution of meritorious claims.     

WHEN CONCRETIZED EMOTION‐BELIEF COMPLEXES DERAIL DECISION‐MAKING CAPACITY

There is an important gap in philosophical, clinical and bioethical conceptions of decision‐making capacity. These fields recognize that when traumatic life circumstances occur, people not only feel afraid and demoralized, but may develop catastrophic thinking and other beliefs that can lead to poor judgment. Yet there has been no articulation of the ways in which such beliefs may actually derail decision‐making capacity. In particular, certain emotionally grounded beliefs are systematically unresponsive to evidence, and this can block the ability to deliberate about alternatives. People who meet medico‐legal criteria for decision‐making capacity can react to health and personal crises with such capacity‐derailing reactions. One aspect of this is that a person who is otherwise cognitively intact may be unable to appreciate her own future quality of life while in this complex state of mind. This raises troubling ethical challenges. We cannot rely on the current standard assessment of cognition to determine decisional rights in medical and other settings. We need to understand better how emotionally grounded beliefs interfere with decision‐making capacity, in order to identify when caregivers have an obligation to intervene.