Virtue is the most perdurable concept in the history of ethics, which is understandable given the ineradicability of the moral agent in the events of the moral life. Historically, virtue enjoyed normative force as long as the philosophical anthropology and the metaphysics of the good that grounded virtue were viable. That grounding has eroded in both general and medical ethics. If virtue is to be restored to a normative status, its philosophical underpinnings must be reconstructed. Such reconstruction seems unlikely in (...) general ethics, where the possibility of agreement on the good for humans is remote. However, it is a realistic possibility in the professional ethics of the health professions where agreement on the telos of the healing relationship is more likely to arise. Nevertheless, virtue-based ethics must be related conceptually and normatively to other ethical theories in a comprehensive moral philosophy of the health professions. (shrink)

Physicians, scholars, and policymakers continue to be concerned about conflicts of interests among health care providers. At least two main types of objections to conflicts of interest exist. Conflicts of interests may be intrinsically troublesome if they violate providers’ fiduciary duties to their patients or they contribute to loss of trust in health care professionals and the health care system. Conflicts of interest may also be problematic in practice if they bias the decisions made by providers, adversely impacting patient outcomes (...) or wastefully increasing health care costs. This latter objection may be observed in differences in the prescriptions written, procedures performed, or costs billed by health care professionals who have conflicting interests, when compared to those that do not have such financial relationships. (shrink)

This paper explores the empirical evidence regarding the impact financial relationships on the behavior of health care providers, specifically, physicians. We identify and synthesize peer-reviewed data addressing whether financial incentives are causally related to patient outcomes and health care costs. We cover three main areas where financial conflicts of interest arise and may have an observable relationship to health care practices: physicians' roles as self-referrers, insurance reimbursement schemes that create incentives for certain clinical choices over others, and financial relationships between (...) physicians and the drug and device industries. We found a well-developed scientific literature consisting of dozens of empirical studies, some that allow stronger causal inferences than others, but which altogether show that such financial conflicts of interests can, and sometimes do, impact physicians' clinical decisions. Further research is warranted to document the causal relationship of such changes on health outcomes and the cost of care, but the current base of evidence is sufficiently robust to motivate policy reform. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Introduction: Conflicting Interest in Medicine: Stories by Physicians on How Financing Affects Their WorkJames M. DuBois, Symposium EditorPhysicians frequently enter into special relationships that establish personal financial interests that could conflict with their patients’ best interests. Examples include receiving gifts from drug companies, sharing a patent on a medical device, or accepting funding from industry to conduct a drug study. In recent years, such “conflicts of interests” in medicine (...) have received growing attention from medical associations (Association of American Medical Colleges, 2008, 2010), policy bodies (Institute of Medicine, 2009), industry (Pharmaceutical Research and Manufacturers of America, 2008), journalists (Caputo, 2009; Nguyen, Ornstein, & Weber, 2010), and even Congress, which included in the 2010 Patient Protection Affordable Care Act a Physician Payment Sunshine provision requiring industry to report a wide variety of ties to physicians. All of these efforts appear motivated by a similar assumption: Gifts and financially beneficial relationships can unconsciously motivate physicians to prioritize their own or industry’s interests over patients’ interests when providing care, conducting medical research, or educating physicians (American Association of Medical Colleges, 2008; Dana & Loewenstein, 2003).The call for stories produced for this narrative symposium provided the following request:We are interested in hearing about positive and negative experiences associated with a variety of financial relationships. The stories should give readers a sense of what it is like to be a physician in the midst of complex relationships to industry, physician practices, and third–party payers—relationships that go beyond ordinary reimbursement for care or research expenses.Obtaining stories proved more challenging than anticipated for reasons related to our theme. Precisely because access to physicians is considered valuable, it is highly restricted. Listservs and blogs that serve physicians typically prohibit postings from anyone except physician members, and even they are sometimes not allowed to post messages freely. While at least one listserv circulated our call to members (at the request of a member), others rejected our request, and one blog offered to post our call as a 1–month ad for $20,000. This contrasts radically with the relatively easy access we have had to other groups, including mental health consumers and living organ donors, who have broad grass root communication systems, and bioethicists, who have several listservs and blogs that readily share news about relevant scholarly opportunities.The collection of stories obtained resulted from extensive personal networking and a small amount of arm twisting. The collection was not what we expected to obtain, but is in many ways even more interesting. One story (Hodges) explicitly addresses the impact that pharmaceutical representatives can have on prescribing patterns—the classic, voluntary, conflicted relationship, insofar as sales reps are [End Page 65] welcomed in facilities, often bearing free samples, free lunches, and glossy articles on their products, all in the hopes of influencing prescribing patterns. But most stories do not fit the typical mold found in discussions of conflicts of interest. Among those expressing concerns about the impact of financial factors on medical practice, one focuses on the insufficient management of bias within the Food and Drug Administration (Perlmutter); three focus on the bias that is introduced through our current fee–for–service reimbursement system (Mikulec, Nagaldine, and Zientek)—of these, two illustrate ways that third parties seek to manipulate physician practices to maximize profits; one notes how any kind of clinical trial—whether government or industry sponsored—may affect patient care decisions (Cruz); while two argue that worries over industry sponsorship of research are disproportionate (Bierut and Sofair), and two address widespread concerns about industry sponsorship of educational activities, with one illustrating how bias might be reduced (Seitz & Diao), and another illustrating the potential harms of prohibiting educational sponsorship (Peppin).To be clear, all of these narratives are responsive to our call for stories that “describe positive and negative experiences associated with a variety of financial relationships.” Yet they are not classic conflict of interest stories; rather, they represent the conflicting interests that concern physicians today—conflicts that are often intrinsic to our current healthcare and research systems rather than special relationships courted by physicians.While making no pretense of representativeness or comprehensiveness, these stories provide fertile ground for reflection, as seen in our... (shrink)