In an unusual instance of lay participation in biomedical research, U.S. AIDS treatment activists have constituted themselves as credible participants in the process of knowledge construction, thereby bringing about changes in the epistemic practices of biomedical research. This article examines the mechanisms or tactics by which these lay activists have constructed their credibility in the eyes of AIDS researchers and government officials. It considers the inwlications of such interventions for the conduct of medical research; examines some of the ironies, tensions, (...) and limitations in the process; and argues for the importance of studying social movements that engage with expert knowledge. (shrink)

Much social theory takes for granted the core conceit of modern culture, that modern actors-individuals, organizations, nation states-are autochthonous and natural entities, no longer really embedded in culture. Accordingly, while there is much abstract metatheory about "actors" and their "agency," there is arguably little theory about the topic. This article offers direct arguments about how the modern (European, now global) cultural system constructs the modern actor as an authorized agent for various interests via an ongoing relocation into society of agency (...) originally located in transcendental authority or in natural forces environing the social system. We see this authorized agentic capability as an essential feature of what modern theory and culture call an "actor," and one that, when analyzed, helps greatly in explaining a number of otherwise anomalous or little analyzed features of modern individuals, organizations, and states. These features include their isomorphism and standardization, their internal decoupling, their extraordinarily complex structuration, and their capacity for prolific collective action. (shrink)

Research ethics education in the biosciences has not historically been a priority for research universities despite the fact that funding agencies, government regulators, and the parties involved in the research enterprise agree that it ought to be. The confluence of a number of factors, including scrutiny and regulation due to increased public awareness of the impact of basic research on society, increased public and private funding, increased diversity and collaboration among researchers, the impressive success and speed of research advances, and (...) high-profile cases of misconduct, have made it necessary to reexamine how the bioscience research community at all levels provides ethics education to its own. We discuss the need to and reasons for making ethics integral to the education of bioscientists, approaches to achieving this goal, challenges this goal presents, and responses to those challenges. (shrink)

The 1948 constitution of the World Health Organization (WHO) defines health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. It was a bold and revolutionary health idea to gain international consensus in a period characterized by fervent anti-communism. This article explores the genealogy of the health definition and demonstrates how it was possible to expand the scope of health, redefine it as ‘well-being’, and overcome ideological resistance to progressive and (...) international health approaches. The first part of the article demonstrates how the health definition was composed through a trajectory of draft ideas from scholars in the history of medicine, as well as political actors working to promote national health insurance. The definition was authored by League of Nations veteran Raymond Gautier, but secretly drew heavily on medical historian Henry E. Sigerist’s controversial book Socialized Medicine in the Soviet Union (1937). The second part analyses how it was possible to resist the ideological pushback against the WHO and secure US ratification. The WHO’s progressive constitution was not simply a deviation from dominant health ideas, but a direct outcome of the entrenched health conflict. The genealogy is based on original archival material from international organizations and US government archives. The article contributes to understandings of the political controversies surrounding the WHO and to scholarship on understandings of health. It also illustrates how influential health ideas cross the boundaries between politics and health sciences, as well as the boundaries between domestic health policy and global health. (shrink)

In June 2001, the American Medical Association (AMA) issued a revised and expanded version of the Principles of Medical Ethics (last published in 1980). In light of the new and more comprehensive document, the present essay is geared to consideration of a longstanding tension between physician's autonomy rights and societal obligations in the AMA Code. In particular, it will be argued that a duty to treat overrides AMA autonomy rights in social emergencies, even in cases that involve personal risk to (...) physicians (e.g., bioterrorist attack, HIV infection, SARS). The argument will be made by way of the logic and language of the AMA Code through its history, commentaries, and precedents. It also will be shown that there are substantial reasons to believe that the logic of the Code is sound in morally relevant ways. The essay will conclude with some philosophical proposals suggesting a framework for the duty to render aid and the extension of those duties to physicians facing personal risks. (shrink)

Regulation and governance of medical research is frequently criticised by researchers. In this paper, we draw on Everett Hughes’ concepts of professional licence and professional mandate, and on contemporary sociological theory on risk regulation, to explain the emergence of research governance and the kinds of criticism it receives. We offer explanations for researcher criticism of the rules and practices of research governance, suggesting that these are perceived as interference in their mandate. We argue that, in spite of their complaints, researchers (...) benefit from the institutions of governance and regulation, in particular by the ways in which regulation secures the social licence for research. While it is difficult to answer questions such as: “Is medical research over-regulated?” and “Does the regulation of medical research successfully protect patients or promote ethical conduct?”, a close analysis of the social functions of research governance and its relationship to risk, trust, and confidence permits us to pose these questions in a more illuminating way. (shrink)

Nursing professionalization is both ongoing and global, being significant not only for the nursing workforce but also for patients and healthcare systems. For this reason, it is important to have an in‐depth understanding of this process and the factors that could affect it. This literature review utilizes a welfare state approach to examine macrolevel structural determinants of nursing professionalization, addressing a previously identified gap in this literature, and synthesizes research on the relevance of studying nursing professionalization. The use of a (...) welfare state framework facilitates the understanding that the wider social, economic, and political system exercises significant power over the distribution of resources in a society, providing a glimpse into the complex politics of health and health care. The findings shed light on structural factors outside of nursing, such as country‐level education, health, labor market, and gender policies that could impact the process of professionalization and thus could be utilized to strengthen nursing through facilitating increased professionalization levels. Addressing gender inequalities and other structural determinants of nursing professionalization could contribute to achieving health equity and could benefit health systems through enhanced availability, skill‐level, and sustainability of nursing human resources, improved and efficient access to care, improved patient outcomes, and cost savings. (shrink)

As our knowledge of the functional and pharmacological architecture of the nervous system increases, we are getting better at treating cognitive and affective disorders. Along with the ability to modify cognitive and affective systems in disease, we are also learning how to modify these systems in health. “Cosmetic neurology,” the practice of intervening to improve cognition and affect in healthy individuals, raises several ethical concerns. However, its advent seems inevitable. In this paper I examine this claim of inevitability by reviewing (...) the evolution of another medical practice, cosmetic surgery. Cosmetic surgery also enhances healthy people and, despite many critics, it is practiced widely. Can we expect the same of cosmetic neurology? The claim of inevitability poses a challenge for both physicians and bioethicists. How will physicians reconsider their professional role? Will bioethicists influence the shape of cosmetic neurology? But first, how did cosmetic surgery become common? (shrink)

Physicians and nurses need to sustain their unique strengths and work in true collaboration, recognizing their interdependence and the complementarity of their knowledge, skills and perspectives, as well as their common moral commitments. In this article, challenges often faced by both nurses and physicians in working collaboratively are explored with a focus on the ways in which each profession's preparation for practice has differed over time, including shifts in knowledge development and codes of ethics guiding their practice. A call for (...) envisioning their practice as shared moral work as well as practical strategies to begin that work are offered as a basis for reflection towards enhanced nurse-physician relationships. (shrink)

Empathy is commonly regarded as an essential attribute for doctors and there is a conviction that empathy must be taught to medical students. Yet it is not clear exactly what empathy is, from a philosophical or sociological point of view, or whether it can be taught. The meaning, role and relevance of empathy in medical education have tended to be unquestioningly assumed; there is a need to examine and contextualise these assumptions. This paper opens up that debate, arguing that ‘empathy’, (...) as it is commonly understood, is neither necessary nor sufficient to guarantee good medical or ethical practice. (shrink)

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)

In this paper, I consider the role of conscience in medical practice. If the conscientious practice of individual practitioners cannot be defended or is incoherent or unreasonable on its own merits, then there is little reason to support conscience protection and to argue about its place in the current medical landscape. If this is the case, conscience protection should be abandoned. To the contrary, I argue that conscience protection should not be abandoned. My argument takes the form of an analysis (...) of an essential feature of the conscience dissenter’s argument, the role of disagreement within “the medical profession.” Conscience dissenters make certain assumptions within their arguments about the profession, disagreements within the professions, and how such disagreement should be adjudicated. If it is the case that these assumptions are accurate reflections of the current medical landscape, then the advocate of conscience protection has one less leg to stand on. I aim to show that this is not the case and that the assumptions of the conscience dissenter are not only mistaken but are mistakes of significant magnitude, so significant as to raise serious questions about the merit of their position. If the argument in this paper is sound, then, at the very least, the conversation over conscience protection in medicine, in particular, and health care, in general, must continue. (shrink)

Is being responsible good enough? Stone (1975) argued that we need corporate moral responsibility because neither law nor market is adequate to forestall harmful effects of business activities. However, it is not possible for businesses to become responsible for all forms of foreseeable, preventable harm that they produce. This is illustrated here by cases from insurance, television programming, automobiles and weapons production. Reflection on these examples leads to the formulation of a new conception of unintended harms as moral externalities of (...) business activities. Although one might argue that these (negative) moral external effects are outweighed by the desirable end products of business activities, three reasons not to accept the results of such a moral subtraction(or double effect) argument are presented. Instead, the article concludes by offering four techniques for a qualitative, ethical analysis of produced artefacts and their consequences; intended not to displace but to supplement the study of moral responsibility in business. (shrink)

Technology- and product-oriented movements are mobilizations of civil society organizations that generally include alliances with private-sector firms, for which the target of social change is support for an alternative technology and/or product, as well as the policies with which they are associated. TPMs generally involve “private-sector symbiosis,” that is, a mixture of advocacy organizations/networks and private-sector firms. Case studies of nutritional therapeutics, wind energy, and open-source software are used to explore the tendency for large corporations in established industries to incorporate (...) the products and technologies advocated by the TPM. As the incorporation process proceeds, the alternative technologies undergo design transformations that make them more compatible with existing products and technological systems. As the technological/product field undergoes diversification, “object conflicts” erupt over a range of design possibilities, from those advocated by the more social movement–oriented organizations to those advocated by the established industries. (shrink)

The Hippocratic Oath, the Hippocratic tradition, and Hippocratic ethics are widely invoked in the popular medical culture as conveying a direction to medical practice and the medical profession. This study critically addresses these invocations of Hippocratic guideposts, noting that reliance on the Hippocratic ethos and the Oath requires establishingwhat the Oath meant to its author, its original community of reception, and generally for ancient medicine what relationships contemporary invocations of the Oath and the tradition have to the original meaning of (...) the Oath and its original reception what continuity exists and under what circumstances over the last two-and-a-half millenniums of medical-moral reflections what continuity there is in the meaning of professionalism from the time of Hippocrates to the 21st century, and what social factors in particular have transformed the medical profession in particular countries. This article argues that the resources for a better understanding of medical professionalism lie not in the Hippocratic Oath, tradition, or ethos in and of themselves. Rather, it must be found in a philosophy of medicine that explores the values internal to medicine, thus providing a medical-moral philosophy so as to be able to resist the deformation of medical professionalism by bioethics, biopolitics, and governmental regulation. The Oath, as well as Stephen H. Miles' recent monograph, The Hippocratic Oath and the Ethics of Medicine, are employed as heuristics, so as to throw into better light the extent to which the Hippocratic Oath, tradition, and ethics can provide guidance and direction, as well as to show the necessity of taking seriously the need for a substantive philosophy of medicine. (shrink)

Mainstream addiction science is today widely marked by an antinomy between a neurologically determinist understanding of the human brain ‘hijacked’ by the biochemical allure of intoxicants and a liberal voluntarist conception of drug use as a free exercise of choice. Prominent defenders of both discourses strive, ultimately without complete success, to provide accounts that are both universal and value-neutral. This has resulted in a variety of conceptual problems and has undermined the utility of such research for those who seek to (...) therapeutically care for people presumed to suffer from addictions. This article contrasts these two contemporary discourses to two others that played vital historical roles in initiating both scientific and popular concern for addiction. These are the Puritan and civic republican discourses that dominated scholarly discussions of addiction in the early modern era. In each case, the place of values in these discussions is highlighted. By comparing them to their early modern historical antecedents, this article seeks to reflexively explore and develop more intellectually sound and therapeutically relevant alternatives to the troubled attempts at universality and value-neutrality now fettering debates in mainstream addiction science. (shrink)

This article examines the cultural practices through which a group of professionals infuse their work and community with charisma. Although previous research has theorized the “charisma of office” (Weber 1978), we know little about how the occupants of such offices sustain it. I focus on a group of psychoanalytically-inclined psychotherapists, whose field, despite its early charismatic beginnings, has been especially embattled in recent decades. Drawing on ethnographic and interview data, I reveal how they share stories emphasizing their “idealization” by others, (...) draw boundaries between their professional and private lives to manage their work identities, and perform interpersonal affective work that shores up their claims to extraordinary abilities. Together, these cultural practices constitute charisma within the professional group. This article thus makes a case that, as expertise becomes increasingly contested, we must look beyond social organization and the evidentiary bases of knowledge to understand professional authority. (shrink)

This article examines how distrust drives exchange. We propose a theoretical framework integrating the literature of trust into cultural sociology and use a case of patients giving hongbao (red envelopes containing money) to doctors in China to examine how distrust drives different forms of unofficial exchange. Based on more than two years’ ethnography, we found that hongbao exchanges between Chinese patients and doctors were, ironically, bred by the public’s generalized distrust in doctors’ moral ethics. In the absence of institutional assurance, (...) Chinese patients drew on the cultural logic of particularism and its associated cultural repertoire to induce fidelity from their physicians. They mobilized interpersonal networks to function as assurance and presented hongbao as a return of favor to the doctors. This form of exchange is gifting-oriented. Alternatively, if there were no interpersonal networks to rely on, they proactively offered hongbao to doctors at arm’s length in an attempt to personalize the relationship to seek assurance and abate their anxieties. This form of exchange is bribery-oriented. Both forms of exchange co-existed when there was one-way generalized distrust manifested from patients to doctors. When doctors also developed generalized distrust in patients, arm’s length exchanges declined, leaving embedded exchanges as the dominant form. Our study asserts the central role of culture in constituting exchange behaviors and the importance of institutions in shaping the form of exchange. It contributes to the midrange theory of trust, generating a number of hypotheses for future research on the relationships among culture, institutions, distrust, assurance, and illicit exchange. (shrink)

When something serves a function, it is easy to overlook its origins. The tendency is to proceed directly to function and retroactively construct a story about origin based on the function it fills. In this article, I address this problem of origins as it appears in the sociology of knowledge, using a case study of the publication of the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. The manual revolutionized American psychiatry and the treatment (...) of mental illness, because it served the function of classification that had become critical to the field of mental health by this time. But this function must be bracketed in order to reveal the “extra-functional” origins of the DSM-III. Using field theory, I argue that the manual was necessary for reasons other than the function it filled as a classification. Specifically, its origin lies in a series of conflicts among psychiatrists, psychoanalysts, and clinical psychologists within the field of mental health, which followed in the wake of the collapse of psychoanalysis as the dominant treatment type for mental illness. I reveal the generative formula behind the production of the DSM-III, capturing a variety of social processes that influenced the format of the manual and made it a useful classification, but which are not reducible to function. In this way, I reproduce its raison d’etre in a manner similar to how the DSM-III appeared for the people who produced it. This focus on generative formulas offers the sociology of knowledge a way to capture the epistemic importance of a range of different social processes. Most importantly, it avoids the functional fallacy of reducing origin to function, and ignoring the idea that innovations might appear necessary even without clear recognition of their functional consequences. (shrink)

After describing the disorder of psychopathy, I examine the theories and the evidence concerning the psychopaths’ deficient moral capacities. I first examine whether or not psychopaths can pass tests of moral knowledge. Most of the evidence suggests that they can. If there is a lack of moral understanding, then it has to be due to an incapacity that affects not their declarative knowledge of moral norms, but their deeper understanding of them. I then examine two suggestions: it is their deficient (...) practical reason or their stunted emotions that are at fault. The evidence supports both explanations. I conclude with an overview of the debate concerning whether they are morally or legally responsible for their actions. (shrink)

Medical educators invoke professionalism as a core competency in curricula. This paper criticizes classic definitions. It also identifies some negative traits of medicine as a profession. The call to professionalism is naive nostalgia. Straightforward didactics in professionalism cannot do the desired work in medical education. The most we can say is that students should adopt the good aspects of professionalism and the profession should stop being some of what it has been. This is a platitude. If the notion is to (...) be more than shallow, each student and practitioner will have to engage in much dialogue, reflection and refinement over many years. (shrink)

This essay attempts to describe contemporary Catholic sponsored health care in the United States and to describe the purpose and structure of these particular Christian charitable organizations within the broader society. As health care has become more complex, critics claim that there is not a need for Catholic sponsored health care any longer. The author attempts to evaluate critically whether Catholic health care has a place in contemporary society. He reviews some salient biblical, ecclesial, and justice teachings of the Church (...) to demonstrate why religious institutional presence is still needed. The author reviews contemporary health care structures to show how this is accomplished. He also uncovers additional issues which need to be addressed in order for these charitable institutions to carry on the ministry of the Church, to shape social structures, and to proclaim the reign of God. (shrink)

Medicine increasingly envisions health promotion in terms of reducing risk as determined by quantitative risk factors, such as blood pressure, blood lipids, or genetic variants. This essay argues that this vision of health care as risk reduction is dangerous for Christian bioethics, since risk can be infinitely reduced leading to a self-defeating spiral of iatrogenic effects. Moreover, it endangers character because this vision of health is connected to a reductionist vision of the body and an understanding of individual risk that (...) undermines the more communal virtue of solidarity. The essay concludes by discussing how recent Thomistic analyses in favor of physical enhancements illustrate some of the problems that envisioning health care in terms of risk reduction holds for Christian bioethics. (shrink)

The use of Big Data—however the term is defined—involves a wide array of issues and stakeholders, thereby increasing numbers of complex decisions around issues including data acquisition, use, and sharing. Big Data is becoming a significant component of practice in an ever-increasing range of disciplines; however, since it is not a coherent “discipline” itself, specific codes of conduct for Big Data users and researchers do not exist. While many institutions have created, or will create, training opportunities to prepare people to (...) work in and around Big Data, insufficient time, space, and thought have been dedicated to training these people to engage with the ethical, legal, and social issues in this new domain. Since Big Data practitioners come from, and work in, diverse contexts, neither a relevant professional code of conduct nor specific formal ethics training are likely to be readily available. This normative paper describes an approach to conceptualizing ethical reasoning and integrating it into training for Big Data use and research. Our approach is based on a published framework that emphasizes ethical reasoning rather than topical knowledge. We describe the formation of professional community norms from two key disciplines that contribute to the emergent field of Big Data: computer science and statistics. Historical analogies from these professions suggest strategies for introducing trainees and orienting practitioners both to ethical reasoning and to a code of professional conduct itself. We include two semester course syllabi to strengthen our thesis that codes of conduct can be harnessed to support the development of ethical reasoning in, and a sense of professional identity among, Big Data practitioners. (shrink)

The physician-researcher conflict of interest, a long-standing and widely recognized ethical challenge of clinical research, has thus far eluded satisfactory solution. The conflict is fairly straightforward. Medical research and medical therapy are distinct pursuits; the former is aimed at producing generalizable knowledge for the benefit of future patients, whereas the latter is aimed at addressing the individualized medical needs of a particular patient. When the physician-researcher combines these pursuits, he or she serves two masters and cannot — no matter how (...) well-intentioned — avoid the risk of compromising the duties owed in one of the professional roles assumed. Because of the necessary rigidity of a research protocol, the more demanding of the two masters is frequently the research.The problem of the physician-researcher conflict has been evident since the first attempts to regulate human research in the United States. Otto E. Guttentag, a physician at the University of California School of Medicine in San Francisco, addressed the conflict in a 1953Sciencemagazine article. (shrink)

On January 1, 2006, Medicare Part D prescription drug coverage was initiated. Concern was immediately voiced by the American Association of Retired Persons (AARP) and Families USA that, in response to this program, the pharmaceutical industry may raise prices for drugs most often used by the elderly. This article examines the ethical implications of a revenue-maximizing pricing strategy in an industry in which third party financing mitigates an end product's true cost to the user. The perspectives of three stakeholder groups (...) are examined: the elderly, as consumers of prescription drugs, the pharmaceutical industry, as product manufacturer and beneficiary of derived profits, and the total U. S. population, as the ultimate payer for the program via tax revenues. Key questions explored include the relationships among price strategy and access to drugs at both the micro (Medicare cohort) and macro (total population) levels, and on drug development or enhancement. The role of profit in a capitalism-based health care system is also examined. Hospital industry impact on these same stakeholder groups in response to the original 1965 Medicare law is used to compare and contrast possible outcomes of the new drug program. It is predicted that pharmaceutical firms will mimic the hospital industry, adopting a price maximizing strategy for drugs covered by the program. In the process, a utilitarian effect occurs: the benefits of increased access and diffusion of drugs counterbalance inequities in financing Medicare Part D. (shrink)

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)

Several inquires about healthcare over the past several decades have shown that the evolution of healthcare practices exhibit their own microcosm of local and political influences. Likewise, other studies have shown clearly the ways in which both external and internal institutional factors establish the sectors within which healthcare is delivered. Although restrictions have always been present in some form, it seems obvious that whatever the precise form of healthcare delivery that results from current changes in its organization, there are going (...) to be broader restrictions not only on the choices that providers will be able to make about individual patients' care and needs, but also regarding the character of their clinical judgments. Indeed, there are already reports of instances where physicians' contracts with managed care organizations forbid them to disclose the existence of services not covered by a plan. (shrink)

This article reviews the relationship between managed care and public health. Managed care, with its seemingly infinite structural and organizational variation, dominates the modern American health-care system for the non-elderly U.S. population. Through its emphasis on standarhzed practice norms and performance measurement, coupled with industrial purchasing techniques, prepayment, risk downstreaming, and incentives-based compensation, managed care has the potential to exert considerable influence over the manner in which the health-care system is organized and functions. Given the degree to which the attainment (...) of the basic public health goal of protecting the public against population health threats for which there are known and effective medical interventions depends on the successful interaction between public health policy and the medical care system, the importance of a viable working relationship between public health and managed care is difficult to overstate.The potential for conflict between public health and medical care is nothing new; indeed, delineating the boundaries of public health to shape and influence medical practice has occupied the energies of policymakers and the medical industry for well over a century. (shrink)

In evidence-based medicine (EBM), methodology has become the central means of determining the quality of the evidence base. The “gold standard” method, the randomised, controlled trial (RCT), imbues medical research with an ethos of disinterestedness; yet, as this essay argues, the RCT is itself a rhetorically interested construct essential to medical-professional boundary work. Using the example of debates about methodology in EBM-oriented research on complementary and alternative medicine (CAM), practices not easily tested by RCTs, I frame the problem of method (...) as a fundamentally rhetorical problem, situated within a boundary drama, and deeply rooted in the discursive practices of science and medicine. The genre of the RCT report, for example, idealises the research process and can tilt the course of arguments about CAM, while the notion of efficacy can function as a rhetorically mobile boundary object that can redefine the very terms of debate. I suggest herein that arguments about method in CAM debates can productively be read, metonymically, as expressions of more general anxieties in medicine about knowledge and evidence, community values, and professional boundaries; as such, these debates can illuminate some of the rhetorical dimensions of EBM. (shrink)

The rise and persistence of a commercial model of healthcare and the potential shift towards the commodification of dental services, provided to consumers, should provoke thought about the nature and purpose of dentistry and whether this paradigm is cause for concern. Within this article, whether dentistry is a commodity and the legitimacy of dentistry as a business is explored and assessed. Dentistry is perceived to be a commodity, dependent upon the context of how services are to be provided and the (...) interpretation of the patient–professional relationship. Commercially-focused practices threaten the fiduciary nature of the interaction between consumer and provider. The solution to managing commercial elements within dentistry is not through rejection of the new paradigm of the consumer of dental services, but in the rejection of competitive practices, coercive advertising and the erosion of professional values and duty. Consumerism may bring empowerment to those accessing dental services. However, if the patient–practitioner relationship is reduced to a mere transaction in the name of enhanced consumer participation, this empowerment is but a myth. (shrink)

Narrative medicine is one of medicine’s most important internal reforms, and it should be a critical dimension of healthcare debate. Healthcare reform must eventually ask not only how do we pay for healthcare and how do we distribute it, but more fundamentally, what kind of healthcare do we want? It must ask, in short, what are the goals of medicine? Yet, even though narrative medicine is crucial to answering these pivotal and inescapable questions, it is not easy to describe. Many (...) of its core claims go against the grain of common sense thinking about medicine. This article argues that the best way to understand narrative medicine is to tell a story that puts its emergence in historical context. (shrink)

Surgical training has traditionally involved a lengthy apprenticeship to a series of master surgeons, who teach medical students and residents the techniques of surgery while allowing them to work on patients in the operating room. This article examines surgical training as a structured environment that prepares students for the embodied lessons taught by a surgeon. It argues that even the most seemingly mechanical of surgical techniques contains social lessons when taught by a surgeon within the rich environment of the operating (...) room. (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 article develops a cross-cultural and historical theory of antifeminist movements. Such movements are composed of two elements, which often involve very different types of people: vested-interest groups and voluntary associations. Five predictions concerning the social composition of antifeminist vested-interest groups and voluntary organizations and antifeminist movement ideology are derived from the theory. Evidence taken from existing literature pertaining to both first-wave and second-wave antifeminist movements in a variety of nations is reviewed. Substantial support is found for all five predictions. (...) We conclude that antifeminist movement adherents are responding to realistic threats. For men and vested-interest groups, the threat is primarily class based, but also extends to their status as family head; for women, it is primarily status based as wives and mothers, but also class-based inasmuch as their husbands' economic interests are threatened. (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)

Progressing beyond the given has been a key modern tendency. Yet modern societies are currently facing the problem of how to put limits on progress, expansion, and growth, live within them, and preserve (rather than transcend) the present. Drawing on economic sociology scholarship on valuation and morality in economic life, this article develops and applies the term economization to analyze the enactment of limits on progress. The question of end-of-life care—when to stop medical efforts to prolong life, postpone death, and (...) advance the scientific frontier—serves as an illustrative empirical case that sheds light on limit-setting in general. My analysis of this case combines historical, ethnographic, and in-depth interview data on US palliative care clinicians, who specialize in making life-and-death decisions in acute care hospitals. (shrink)

The proper role of conscience in healthcare continues to be a topic of deep interest for bioethicists, healthcare professionals, and health policy experts. This issue of HEC Forum brings together a collection of articles about features of these ongoing discussions of conscience, advancing the conversations about conscience in healthcare from a variety of perspectives and on a variety of fronts. Some articles in this issue take up particularly challenging cases of conscientious objection in practice, such as Fleming, Frith, and Ramsayer’s (...) contextually rich piece on midwives in Scotland or Harter’s professionally grounded analysis; others engage the changing institutional landscapes which impact considerations of conscience, such as Cummins’ work on the role of employers in institutional policies about conscience and Ben Moshe’s discussion of publicity and institutional committees. Pieces by Howard and Pilkington both raise conceptual considerations about how we think about the role of conscience in medicine, questioning the use of “conscientious objection” in these discussions, and Byrnes pushes back on the most influential work in this area by Mark Wicclair. The issue concludes with a piece by Wicclair, which engages each of these distinct offerings, further extending the discussions of conscience in healthcare and helpfully connecting key themes discussed by authors in this issue to his contributions and to the longer tradition of discussions of conscience in medicine. This issue challenges readers to engage different arguments from different perspectives and asks them—in some cases—to be open to revising how they think about the role of conscience and the existence of and justification for conscientious objection in the dynamic, interdisciplinary fields of healthcare. (shrink)

This paper analyzes S. Weir Mitchell and his son John Kearsley Mitchell’s views on phantom limb pain in late 19th c. America. Drawing on a variety of primary sources including journal articles, letters, and treatises, the paper pioneers analysis of a cache of surveys sent out by the Mitchells that contain amputee Civil War veterans’ own narratives of phantom limb pain. The paper utilizes an approach drawn from the history of ideas, documenting how changing models of medicine and objectivity help (...) explain the Mitchells’s attitudes, practices, and beliefs regarding the enigma of phantom limb pain as experienced by their patients. The paper also assesses concerns over malingering, pain, authenticity, and deception through these intellectual frameworks of somaticism and mechanical objectivity. The paper concludes that much of relevance to the ways in which the Mitchells and other late 19th c. neurologists regarded and treated their patients’ pain is explicable in terms of the larger intellectual frameworks that structured these healers’ ideas about lesionless pain. (shrink)

Throughout its fifty-year history, the role of the medical humanist and even the name “medical humanities” has remained raw, dynamic and contested. What do we mean when we call ourselves “humanists” and our practice “medical humanities?” To address these questions, we turn to the concept of origin narratives. After explaining the value of these stories, we focus on one particularly rich origin narrative of the medical humanities by telling the story of how a group of educators, ethicists, and scholars struggling (...) to define their relatively new field rediscovered the studia humanitatis, a Renaissance curriculum for learning and teaching. Our origin narrative is composed of two intertwined stories—the history of the studia humanitatis itself and the story of the scholars who rediscovered it. We argue that as an origin narrative the studia humanitatis grounds the medical humanities as both an engaged moral practice and pedagogical project. In the latter part of the paper, we use this origin narrative to show how medical humanists working in translational science can use their understanding of their historical roots to do meaningful work in the world. (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)

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)

In recent philosophy of mind a non-holistic view on concept possession, originally developed by Tyler Burge, has emerged as an alternative to holistic analyses of language mastery. The article discusses the implications of this view for analyses of communication in doctor—patient-interaction. The central question Burge's theory gives an answer to is this: to what extent must a doctor and a patient understand a medical term in the same way in order to communicate in the sense that they express the same (...) concept by the term? Many empirical studies have shown that patients do not, typically, understand medical terms in the same way as doctors they encounter. Holistic approaches therefore imply that doctors and patients seldom communicate. Burge's position, on the other hand, implies that it is sufficient that patients have a minimal understanding. In an important range of cases doctors can make sure that patients have a minimal understanding by being explicit about common dictionary definitions of the terms in question. (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)