Physicians are instrumental to our national defense against epidemics, whether natural or bioterror-related. Broadly speaking, they are obligated to help rapidly identify…
Physicians are instrumental to our national defense against epidemics, whether natural or bioterror-related. Broadly speaking, they are obligated to help rapidly identify threats, prevent the spread of disease, and care for infected patients. Each task presents ethical challenges, including the need to address access to care, balance the medical needs of individuals and communities, and ensure that health professionals continue to treat infectious patients in spite of the risk they present. If physicians can acknowledge these duties and meet these challenges, they have an opportunity to strengthen medicine's public trust and professional identity.
Surveys about ethically important topics, when successfully conducted and analyzed, can offer important contributions to bioethics and, more broadly, to health policy and clinical care. But there is a dynamic interplay between the quantitative nature of surveys and the normative theories that survey data challenge and inform. Careful attention to the development of an appropriate research question and survey design can be the difference between an important study that makes fundamental contributions and one that is perceived as irrelevant to ethical analysis, health policy, or clinical practice. This chapter presents ways to enhance the rigor and relevance of surveys in bioethics through careful planning and attentiveness in survey development, fielding, and analysis and presentation of data.
Matthew Wynia and his co-authors and Charmers Clark, in their two chapters, take on thorny issues concerning the moral responsibilities of physicians – and, by…
Matthew Wynia and his co-authors and Charmers Clark, in their two chapters, take on thorny issues concerning the moral responsibilities of physicians – and, by implication, all health care professionals – regarding preparation for and response to epidemics (Clark, 2006; Wynia, Kurlander, & Green, 2006). Their chapters are especially timely, inasmuch as they address ethical challenges associated with bioterrorism, which, should it occur, could create an epidemic of catastrophic proportions, at least for the locality or localities in which the bioterrorism occurs. In this commentary, I provide a critical assessment of their chapters. I begin with a review of the foundational concept of the Wynia et al. chapter, social-trustee professionalism, and of the Clark chapter, a covenant of public trust. I then take up four issues: the moral demands of social-trustee professionalism and how the social-contract theory of medical ethics advocated by the framers of the 1847 American Medical Association Code of Ethics (American Medical Association, 1847) should be understood; social-role related obligations as ethically-justified limits on fiduciary responsibility in bioterrorism events and how such obligations should be addressed in a preventive ethics fashion by health care organizations; legitimate self-interests as ethically-justified limits on fiduciary responsibility and how such interests should be distinguished from mere self-interests and be addressed in a preventive ethics fashion by health care organizations; and the nature and limits of the standard of care in the large-scale emergencies that bioterrorism events could create.
Karl Marx could only pen the memorable line, “the history of all hitherto existing society is the history of class struggles” because he was heir to the sanitary and…
Karl Marx could only pen the memorable line, “the history of all hitherto existing society is the history of class struggles” because he was heir to the sanitary and public health reforms of the nineteenth century (Marx  1972, p. 335). The Black Death, which had wiped out much of fourteenth-century Florence and which had regularly decimated sixteenth- and seventeenth-century London, was now but a faint memory. Yet had a historian of some earlier period of European history thought to pen a line as presumptuous as Marx's, it might have read: “the history of all hitherto existing society is the history of struggle with plague or pestilence.” Epidemics and pandemics have haunted human societies from their beginnings. The congregation of large masses of humans in urban settings, in fact, made the evolution of human infectious disease microorganisms biologically possible (McNeill, 1976; Porter, 1997, pp. 22–25). Epidemics have been as determinative of the course of economic, social, military and political history as any other single factor – emptying cities, decimating armies, wiping out generations and destroying civilizations.
Objectives: To discuss whether, during an influenza pandemic, public health authorities could be ethically justified in implementing a mandatory vaccination program…
Objectives: To discuss whether, during an influenza pandemic, public health authorities could be ethically justified in implementing a mandatory vaccination program directed at health care professionals.
Methods: Ethical analysis is carried out by examining arguments that can be made in favor or against such a mandatory measure and by seeking a reasonably balanced position between them. Arguments under consideration are based on the duties of health professionals and public health authorities, the consequences of their actions and on other ethical principles. The importance of relevant empirical data is stressed without any attempt to review or analyze them systematically.
Results: Mandatory vaccination of some health care professionals during a serious pandemic of influenza can be justified, but only under certain limited conditions.
Conclusions: In the throes of an influenza pandemic, health care professionals (and to a variable degree, other health care workers) have an ethical obligation to accept influenza vaccination if it is reasonably safe and effective. The ethical responsibility of public health authorities is to limit the impact of a pandemic on the population by all reasonable means, which clearly includes the appropriate use of vaccine. Consequently, the vaccination of health care staff can be made mandatory under certain conditions. However, a critical objection to this conclusion, which upholds that a voluntary vaccination program (an ethically much less problematic intervention) is just as effective, needs to be addressed.
Purpose – To develop a framework for studying financial incentive program implementation mechanisms, the means by which physician practices and physicians translate…
Purpose – To develop a framework for studying financial incentive program implementation mechanisms, the means by which physician practices and physicians translate incentive program goals into their specific office setting. Understanding how new financial incentives fit with the structure of physician practices and individual providers’ work may shed some insight on the variable effects of physician incentives documented in numerous reviews and meta-analyses.
Design/Methodology/Approach – Reviewing select articles on pay-for-performance evaluations to identify and characterize the presence of implementation mechanisms for designing, communicating, implementing, and maintaining financial incentive programs as well as recognizing participants’ success and effects on patient care.
Findings – Although uncommonly included in evaluations, evidence from 26 articles reveals financial incentive program sponsors and participants utilized a variety of strategies to facilitate communication about program goals and intentions, to provide feedback about participants’ progress, and to assist practices in providing recommended services. Despite diversity in programs’ geographic locations, clinical targets, scope, and market context, sponsors and participants deployed common strategies. While these methods largely pertained to communication between program sponsors and participants and the provision of information about performance through reports and registries, they also included other activities such as efforts to engage patients and ways to change staff roles.
Limitations – This review covers a limited body of research to develop a conceptual framework for future research; it did not exhaustively search for new articles and cannot definitively link particular implementation mechanisms to outcomes.
Practical Implications – Our results underscore the effects implementation mechanisms may have on how practices incorporate new programs into existing systems of care which implicates both the potential rewards from small changes as well as the resources which may be required to obtain buy-in and support.
Originality/Value – We identify gaps in previous research regarding actual changes occurring in physician practices in response to physician incentive programs. We offer suggestions for future evaluation by proposing a framework for understanding implementation. Our model will assist future scholars in translating site-specific experiences with incentive programs into more broadly relevant guidance for practices by facilitating comparisons across seemingly disparate programs.
Off-label drug prescribing by healthcare providers is a growing practice. Yet, the US Food and Drug Administration bans the marketing of drugs for off-label uses. In…
Off-label drug prescribing by healthcare providers is a growing practice. Yet, the US Food and Drug Administration bans the marketing of drugs for off-label uses. In recent years, legal challenges by the pharmaceutical industry have chipped away government restrictions on off-label drug promotion. Although the changing legal landscape has been discussed, this paper aims to examine how key stakeholders and policy-makers might interact to provide a more transparent marketing environment for off-label drug discussions in the patient–provider relationship.
Drawing on a variety of sources, the authors assess the current marketing landscape of off-label drugs and some of the issues that challenge the healthcare provider–patient relationship. The authors then examine opportunities to improve the off-label promotion environment and the relevant decision-making theories that key stakeholders need to consider when formulating marketing efforts and policies.
The authors suggest that fewer restrictions on truthful, non-misleading off-label drug promotion provide an opportunity to improve drug knowledge and, importantly, healthcare provider and consumer decision-making. Key stakeholders should consider, among other solutions, criteria for defining truthful information on off-label drugs, alternative methods of approval of off-label uses and ubiquitous icons to identify off-label prescribing to all stakeholders.
Rather than rehash the legal landscape of off-label drug promotion, this paper focuses on how the healthcare provider–patient relationship is impacted and how stakeholders can improve information flow in this changing environment.