Abstract:In this paper we highlight the emergence of organizational ethics issues in health care as an important outcome of the changing structure of health care delivery. We emphasize three core themes related to business ethics and health care ethics: integrity, responsibility, and choice. These themes are brought together in a discussion of the process of Mission Discernment as it has been developed and implemented within an integrated health care system. Through this discussion we highlight how processes of institutional reflection, such (...) as Mission Discernment, can help health care organizations, as well as corporations, make critical choices in turbulent environments that further the core mission and values and fulfill institutional responsibilities to a broad range of stakeholders. (shrink)

Modern American medicine has wedded scientific advance to a small business model of the individual practitioner, defining professionalism as technical understanding. If the profession is to survive, it must draw on older ideals of the learned professions as acting on behalf of the community, and reinvigorate a civic understanding of professional life.

February is Black History Month and so healthcare practitioners will soon rummage history books for information about famous African Americans, like Onesimus, the African slave who...

Language used to describe measles in the press has altered significantly over the last sixty years, a shift that reflects changing perceptions of the disease within the medical community as well as broader changes in public health discourse. California, one of the most populous U.S. states and seat of the 2015 measles outbreak originating at Disneyland, presents an opportunity for observing these changes. This article offers a longitudinal case study of five decades of measles news coverage by the Los Angeles (...) Times and the San Francisco Chronicle, which represented two of the largest news markets in California when the measles vaccine was released, in 1963, and during the 2015 outbreak. Measles reporting during this period displays patterns pointing to an active role for journalists in shaping public understanding of health and medical matters, especially as they recede from public memory, through the employment of available and circulating political and cultural frames. Moreover, journalistic frames in this period of reporting incorporated presentist descriptions of the disease, which imposed present values on the medical past, and which were constructed of decontextualized historical references that supported prevailing contemporary notions of the disease. Framing and the tendency toward presentism, in the context of shifting public health discourse, had the effect of communicating an increasingly severe sounding disease over time, and of shifting blame for that disease’s spread from nature to government to individuals. Journalistic framing and causal stories have much power to shape public understanding of medical matters as they recede from public memory. (shrink)

Abstract:This paper utilizes a qualitative case study of the health care industry and a recent legal case to demonstrate that stakeholder theory’s focus on ethics, without recognition of the effects of incentives, severely limits the theory’s ability to provide managerial direction and explain managerial behavior. While ethics provide a basis for stakeholder prioritization, incentives influence whether managerial action is consistent with that prioritization. Our health care examples highlight this and other limitations of stakeholder theory and demonstrate the explanatory and directive (...) power added by the inclusion of the interactive effects of ethics and incentives in stakeholder ordering. (shrink)

This paper examines the crisis in the nursing profession in Western industrial societies in the light of Max Weber's theory of rationalisation. The domination of instrumental rational action in modern industrial societies in evident in the field of modern medicine. The burgeoning mechanistic approach to the human body and health makes modern health care services increasingly devoid of human values. Although the nursing profession has been influenced by various changes that took place in health care during the last few decades (...) (for example greater reliance on technology), the underlying values of the nursing profession still emphasise a broad definition of the well-being of patients. Hence, in recent years the irrational consequences of growing technological medicine in North America has resulted in a serious crisis in the nursing profession. To resolve this crisis the authors propose a reorganisation of modern health care services on the basis of a new paradigm which is compatible with both the health care needs of the people and the main emphasis in education and training of the nursing profession. (shrink)

This is a volatile time for health insurance policy. Medicare and Medicaid are in turmoil, as is the private health insurance market. Public and private health insurance costs constitute eighty percent of healthcare spending in the United States. Public health professionals depend on the insurance system to behave in ways that are responsive to public health in prevention and crisis management.Seventy-five percent of the American population, excluding the elderly, has coverage through the private health insurance system. Ninety percent of this (...) group receives their insurance through employer-sponsored programs, and the remaining ten percent buy their own coverage. Approximately ten percent of the non-elderly population has insurance through a government program, and fifteen percent of the non-elderly population, almost forty-one million Americans, is uninsured. (shrink)

The role of government in assuring population access to affordable and appropriate health care represents a central question for any nation. Of particular concern is access to prescription drug coverage, not only because of the vital role played by drugs in modern medicine, but also because of their high costs. This article examines the sharply contrasting prescription drug coverage and payment policies found in Australia and the U.S. – strong political allies and international trading partners – and describes how key (...) U.S. interests have sought, through an aggressive trade agenda, to expand markets for U.S. goods and services, even when market expansions clash with other nations’ contrasting emphasis on social equity and fairness. Indeed, the nation’s bilateral free trade negotiations have brought the contours of this policy schism into sharp relief. (shrink)

The promises of precision medicine are often heralded in the medical and lay literature, but routine integration of genomics in clinical practice is still limited. While the “last mile” infrastructure to bring genomics to the bedside has been demonstrated in some healthcare settings, a number of challenges remain — both in the receptivity of today's health system and in its technical and educational readiness to respond to this evolution in care. To improve the impact of genomics on health and disease (...) management, we will need to integrate both new knowledge and new care processes into existing workflows. This change will be onerous and time-consuming, but hopefully valuable to the provision of high quality, economically feasible care worldwide. (shrink)

The ArgumentAmerican eugenics developed out of a cultural tradition independent of medicine. However, the eugenicist Harry Hamilton Laughlin and some legal experts involved in eugenic practice in the United States used medical language in discussing and evaluating enforced eugenic sterilizations. They built on medicine as a model for healing, while at the same time playing down medicine's concern with its traditional client: the individual patient. Laughlin's attitude toward medicine was ambivalent because he wanted expert eugenicists, rather than medical experts, to (...) control eugenic practice. In contrast, legal experts saw eugenics as an integral part of medicine, though one expert challenged basing the judicial system on eugenically minded medicine. All in all, the medicalization of American eugenics involved expanding the scope of medicine to include the mutilation of individuals for the benefit of society. The judicial system was medicalized in that an expanded medicine became the basis of legislation in the thirty states that permitted eugenic sterilizations. (shrink)

I argue for compatibility between feminism and medicine by developing a model of the physician-other relationship which is essentially egalitarian. This entails rejection of (a) a paternalistic model which reinforces sex-role stereotypes, (b) a maternalistic model which exclusively emphasizes patient autonomy, and (c) a model which focuses on the physician's conscience. The model I propose (parentalism) captures the complexity and dynamism of the physician-other relationship, by stressing mutuality in respect for autonomy and regard for each other's interests.

One understanding of health conceives of it as a state of freedom from pathology, achieved by an individual, through the mediation of a doctor. On this view, improvements in health flow from the application of science to specific ills of the body, and access to medical care is the chief determinant of health. This “medicalized” view of health underlies the current debate over medical care payment reform. This is the dominant way of talking about health.An alternative is the view of (...) health commonly associated with the practice of public health. On this view, health is an attribute of communities in social and physical environments. Health takes its shape in large numbers—in morbidity and mortality statistics—and, ideally, includes not just a high level of well-being for some, but also its even distribution throughout a society. Improvements in health are seen to arise from healthful changes in the environment. (shrink)

The American health care system long has been distinctive in its embrace of market forces. For-profit private insurers play a major role in providing coverage, though they operate alongside public insurance programs that cover over one-third of the population. Historically, federal and state governments’ regulation of insurance markets was limited, leaving insurers to set premiums and coverage rules largely as they saw fit.Government’s role in controlling health care spending has been even more circumscribed. Purchasing power is fragmented, with each insurer (...) negotiating its own rates with physicians and hospitals. A formidable medical-industrial complex of for-profit providers, from hospitals to home-health care agencies, dialysis facilities, pharmaceutical companies and much more, has arisen to sell services. (shrink)

ABSTRACTDuring the past 2 decades, sports organizations have turned their websites into news portals, a transition that has included hiring reporters to produce stories that often look like the dai...

Over one hundred years after Max Weber delivered his lecture “Science as a Vocation,” his description of the work of the physician in a disenchanted world still resonates. As a chronically ill patient who interacts with physicians frequently, I struggle with reconciling my understanding of my ill body with how my physician makes sense of my illness. My diagnosis created an existential crisis that caused me to search for meaning in my embodied experience, but I soon learned there is little (...) room for such a search within modern biomedicine. Instead, I turned to fine art to help me make sense of my ill body and its purpose in my life. With the aid of my printmaker sister, Darian Goldin Stahl, I have transformed the magnetic resonance images of my body into works of art, which help to re-enchant my body and give purpose to my illness. (shrink)

“Medicalization” has been a contentious notion since its introduction centuries ago. While some scholars lamented a medical overreach into social domains, others hailed its promise for social justice advocacy. Against the backdrop of a growing commitment to health equity across the nation, this article reviews historical interpretations of medicalization, offers an application of the term to non-biologic risk factors for disease, and presents the case of housing the demonstrate the great potential of medicalizing poverty.

This article considers John Harris’ work on autonomy, specifically reproductive autonomy, outlined in The Value of Life and developed throughout his career. Harris often used the concept of reproductive autonomy to make the case for liberal approaches to developments in reproductive and genetic technologies. Harris argued that reproductive autonomy should be highly valued, and therefore we need compelling arguments to justify limiting it in anyway. When discussing reproductive autonomy, Harris focused mainly on restrictions on the potential users of reproductive technologies (...) autonomy, that is, prospective parents. This article extends the discussion of autonomy and the appropriate limits to individuals exercising their autonomy to medical professionals working in this area. Given reproductive technologies have become part of routine medical practice, this article considers whether the current restrictions on both patients and clinicians, as imposed by regulators and professional guidelines, remain ethically justified. (shrink)

This article examines the gamification of health applications designed to help patients manage chronic pain. Through description of one such program and in-depth interviewing, I describe why gamified pain applications are appealing to patients living with chronic pain. Individuals living with chronic pain are especially disposed to try novel pain management technologies due to the in-control and out-of-control paradox of pain (Leder, 2016). These applications are seductive not only due to this embodied phenomenon, but also because gamification taps into the (...) logic of proactive self-management that is tantamount to an era of biomedicalization, wherein subjects are incentivized to take control of their own health in the face of austerity budgets. However, pain also limits the user’s ability to adopt an immersive, lusory attitude. Thus, the speculative promises of gamified health technologies are just that – speculative, and their immersive potential should not be overstated. (shrink)

Entry into the practice of medicine is heavily regulated through scope of practice and licensing laws that make it illegal for nonlicensed individuals to perform many medical services. As institutions are structured at the beginning of the twenty-first century, most regulation takes place at the state level, through state departments of health that establish criteria for performing different types of medical activities, and that restrict allowable activities for various types of health care professionals. The regulations over the activities of physicians (...) are more uniform across states than for other health care professionals because, although the regulation is done by individual state governments, the standards for physicians are set by the National Board of Medical Examiners, a group controlled by physicians themselves. The justification for this regulation is that it produces higher quality health care. Some would make an even stronger argument that regulation is necessary because patients do not have sufficient knowledge to distinguish effective practitioners from ineffective ones. (shrink)

There have always been medical standards of care in the American health-care sector. However, never before have they been so deeply incorporated in the delivery of health care as they are today. With the increased delivery of care through integrated delivery systems, as well as the development of the computerized patient record, medical standards of care are now used in innovative ways by providers and health plans in delivering health care to individual patients. There is great potential for even more (...) innovative uses of medical standards of care in the future.This article first presents a taxonomy of the medical standards of care that are involved in health-care delivery today Next, the article traces the historical evolution of medical standards of care since the early 1980s. Included in this discussion are the origins of the standard-setting movement as well as the developments that led to the way standards of care are currently used by large institutional providers and managed care plans to improve the quality of their health-care services. The article concludes with a brief analysis of the key legal issues that affect how standards of care can be used to improve the health care of patients. (shrink)

The recent high-profile financial difficulties of Harvard Pilgrim Health Care, the largest HMO in Massachusetts and consistently rated as one of the top ten HMOs in the nation, shed light on many problems common to health insurers throughout the country. This article explores those difficulties in the context of the short but complicated history of Harvard Pilgrim, and its regulatory and competitive environments. The state legislation which made a receivership proceeding possible for Harvard Pilgrim offered some protection for subscribers, but (...) failed to provide the means for achieving a long term solution. The statute merely presented a method for staving off immediate collapse by temporarily protecting the plan from dissolution, and forcing the plan's contracting providers to continue delivering care even if owed money by the plan. The article concludes by drawing lessons for understanding and ideally avoiding similar managed care nearfatalities in the future. (shrink)

Hospitals long ago shed their role as alms houses for the poor. What vestiges remain of the early American hospital are the tax-exempt, nonprofit hospital form and a general perception that hospitals, as charitable institutions, owe a duty to their communities. The appropriateness of the nonprofit hospital tax exemption has long been debated, and many theories have been advanced to justify the tax exemption of nonprofit hospitals. In a growing number of jurisdictions, however, state and local authorities have gone beyond (...) the theoretical debate and are challenging the tax exemption of their nonprofit hospitals. For various reasons, efforts are afoot to capture greater community benefit from nonprofit hospitals.At the heart of such challenges is the debate over the nature and extent of the duty charitable institutions owe to their communities. A demand is growing for nonprofit hospitals to earn their tax exemptions by benefiting their communities in concrete ways. Some have been stripped of their tax-exempt status by local authorities or pressured to make payments in lieu of taxes. A number of states have recently implemented initiatives in an attempt to make hospitals more accountable for their community benefits. Many hospitals are responding to this heightened scrutiny in a proactive way, by voluntarily documenting community benefits. A number of nonprofit hospitals and hospital associations are cooperating with—or even sponsoring—state legislation in this area. (shrink)

Millions of Americans are dependent on what is often called the “safety net.” These loosely-organized networks of health and social service providers serve the many Americans who are uninsured, dependent on public coverage, or for a variety of reasons unable to access other private systems of care. The Institute of Medicine report, America’s Health Care Safety Net: Intact but Endangered, called attention to both the fragility and the resilience of this health care safety net. The IOM report underscored the critical (...) importance of the safety net to the health and well-being of millions of individuals and called for efforts to strengthen it and improve the nation’s ability to monitor its viability. Given this central role, any health care reform efforts need to be fully informed by an understanding of what the safety net includes, how it is financed, and how it is responding to a series of challenges it now faces. (shrink)

In a White House ceremony on May 16, 1997, President Clinton issued an apology on behalf of the nation for the Tuskegee Syphilis Study, a forty-year research project in which African-American men were deceived and denied treatment in order to document the natural course of syphilis. Reflection on this occasion can give us pause to take pride in the progress made toward more ethical research with humans. The President's apology is perhaps the most public of a number of recent events (...) representing a renewed attention to ethics in research with human participants. Alongside it stand the efforts of treatment activists for people with acquired immune deficiency syndrome and the revelations of the human radiation experiments. In 1995, President Clinton called for the creation of the National Bioethics Advisory Commission, which was charged with a host of projects aimed at investigating the organization and function of the federal system for overseeing human subjects research in the United States, and giving guidance on specific forms of research. (shrink)

BackgroundWhat can the analysis of the evolution of a code of ethics tell us about the dental profession and the association that develops it? The establishment of codes of ethics are foundational events in the social history of a profession. Within these documents it is possible to find statements of values and culture that serve a variety of purposes. Codes of ethics in dentistry have not frequently presented as the subjects of analyses despite containing rich information about the priorities and (...) anxieties within the profession’s membership at the time that the code was written.Main textThis essay uses critical discourse analysis to explore the 2012 and 2018 versions of the Code of Ethics produced by the New South Wales Branch of the Australian Dental Association. This method of discourse analysis examines contradictions between the discourses within the codes and how these relate to broader social realties that surround the dental profession in New South Wales. By analysing the 2012 and 2018 codes together, it is possible to understand how the dental profession views its commitments to society as established through the social contract. Through this assessment, it will be demonstrated that both codes suffer due to their failure to consider the public as a key stakeholder in the creation and curation of the Code of Ethics and how this this relates intimately with the social contract between the profession and the public.ConclusionWithout the public being the central consideration, both codes amount to declarations of professional privilege and dominance. Although the more recent 2018 Code of Ethics demonstrates insight into the changes in public trust placed in the professions, this analysis shows that that the current code of ethics is still reluctant to recognise and engage with the public as an equal stakeholder in the planning and provision of oral health care and the development of the profession’s values and cultural trajectory. (shrink)

As the millennium approaches, the United States is on the verge of major health care reform. While swallowing scarce national resources, our health care system produces unenviable results and major inconsistencies. In 1992, $838.5 billion were spent on health care, biting more than 14 percent out of our gross national product. From 35 to 37 million Americans, or approximately 14 percent of the populationn, are uninsured. Our health care system is inherently inconsistent: We have the highest birthweight-specific survival rate of (...) any country in the world, yet we rank 19th worldwide in infant mortality rate, i.e., state-of-the-art medical technology allows us to save a 500-gram infant, yet the mother of that infant may not have had access to basic, minimal prenatal care. (shrink)

The ArgumentEmergency medicine, a new medical specialty in the United States, is an ethical practice that has developed through its interaction with the spaces in which it is situated. We discuss this claim in two steps followed by a demonstration. First we examine the historical evolution of the hospital, to provide the background for a lengthier account of the historical transformation of the emergency room. We then introduce Foucault's approach to ethics, to explain the sense in which emergency medicine is (...) an ethical practice constituted, in part, by its space(s) of operation. The preliminaries of the application of our historico-ethical framework to emergency medicine, are presented, focusing on cardiopulmonary resuscitation. Our intention is to provide a framework for the newest clinical specialty as an ethical practice in order to understand how to individuate its emerging ethical problems. The emphasis on space throughout enables us to integrate the historical development of emergency medicine with its present concrete setting, and to establish a basis for analyzing emergency medicine that does not rely uncritically on either a preferred ethical perspective or the perspective of its practitioners. (shrink)

In their own words: nurses’ discourses of cleanliness from the Rehoboth Mission For nurses of the nineteenth and early twentieth centuries, cleanliness was often seen as a virtue next to godliness. For missionary nurses, this analogy took on multiple meanings. This study focuses on discourses of cleanliness at one site of missionary nursing in the early twentieth century: the Rehoboth Mission and its hospital, which provided health‐care to the Navajo in the southwestern USA from 1903 to 1965. Data sources included (...) denominational publications, institutional records, correspondence, questionnaires and interviews of the Dutch–American missionary nurses who practiced at the Rehoboth Mission. Discourse analysis was conducted on references to cleanliness, hygiene and sanitation in these texts. Secondary discourses of embodiment in daily practice, initiation and assimilation, caring, ignorance, environmental factors and gendered work were identified and analyzed. The study interrogates the whiteness of the nurses’ dominant culture and sheds light on nurses’ relationships with normative discursive frames that reflect and perpetuate inequalities, discredit non‐dominant practices, and leave little room for competing discourses. It also illustrates a blurring of religion and health‐care, and the need for a reflective and informed stance as a basis for cultural competence. (shrink)

Resource finitude, cost containment, and a purchaser monopsony market have created public concern-about the moral and legal responsibility for quality assurance in health plans. Resource allocation and standards of care represent a clash of moral values in intensive care treatment. This essay advances a procedural model, based on legislation passed in Oregon, that could govern the incorporation of private sector health insurance plans in Oregon to assure democratic input from consumers, providers, and employers into a limited vision of individual entitlement (...) to consume futile or inappropriate care in intensive care units. The model, which I call the Oregonian ICU, presumes that rationing of care is implicit and not publicly disclosed under managed care. It focuses on maximizing the quality of limited benefits available in the basic managed care insurance tier. Limitations to futile and inappropriate care are developed on the basis of morally weighted prognostic scoring systems that inform the creation of negotiated private sector contracts. (shrink)

In recent years, policy debates in the United States have focused heavily on rising healthcare costs and what measures can be taken to ensure greater provision of healthcare to individuals of limited means. Much of the rhetoric on this subject has taken on an explicitly moral character, and one common sentiment is that healthcare is or should be viewed as a basic human right. However, the notion of a right to healthcare has not been well articulated, and critics have failed (...) to distinguish between legal and moral rights. Additionally, there are numerous problems inherent to viewing healthcare as a basic human right-many of which are in direct conflict with distinctly American conceptualizations of rights. The present paper reviews the debate over “rights”-both legal and natural-to healthcare, and argues that problems associated with natural rights arguments render them severely compromised. Instead, market systems commonly accepted in American society may be better suited to reducing healthcare costs and increasing access to services in the United States. (shrink)

Many writers suggest that managed care had a brief life and that we are now in a post-managed care era. Yet managed care has had a long history and continues to thrive. Writers also often assume that managed care is a fixed entity, or focus on its tools, rather than the context in which it operates and the functions it performs. They overlook that managed care has evolved and neglect to examine the role that it plays in the health system.This (...) article argues that private actors and the state have used managed care tools to promote diverse goals. These include the following: increasing access to medical care; restricting physician entrepreneurialism; challenging professional control over the medical economy; curbing medical spending; managing medical practice and markets; furthering the growth of medical markets and private insurance; promoting for-profit medical facilities and insurers; earning bounties for reducing medical expenditures; and reducing governmental responsibility for, and oversight of, medical care. Struggles over these competing goals spurred the metamorphosis of managed care internationally. (shrink)

National attention on issues of public health preparedness necessarily brings into sharp focus the question of how to assure adequate, community-wide health care financing for preventive, acute care, and long-term medical care responses to public health threats. In the U.S., public and private health insurance represents the principal means by which medical care is financed. Beyond the threshold challenge of the many persons without any, or a stable form of, coverage lie challenges related to the structure and characteristics of health (...) insurance itself, particularly the commercial industry and its newly emerging market of consumer-driven health plans. States vary significantly in how they approach the regulation of insurance and in their willingness to support various types of insurance markets. This variation is attributable to the size and robustness of the insurance market, the political environment, and regulatory tradition and custom. Reconciling health insurance markets with public health-related health care financing needs arising from public health threats should be viewed as a major dimension of national health reform. (shrink)

From the turn of the century, jurists have tended to associate lawyers with doctors as professionals and tried to ground this association in an analogy between law and medicine. Paradoxically, such comparisons suggest that American law and medicine are not analogous, while an analogy proposed by Plato illumines more fundamental respects in which law and medicine might be truly analogous.