Tuesday, October 16, 2012

Research Paper on Medicine and Ethics

Research Paper on Medicine and Ethics

Analyzing the Environment of the Marriage between Medicine and Ethics
The following article raises awareness regarding ethics in the field of medicine. The article highlights issues and institutions that may contribute to the changes of ethical behavior among physicians, patients, health care professionals, and other stakeholders of different forms of health care. The main issue discussed includes the evolving nature of a patient-doctor relationship, starting with paternalism. Applications of theory include of the involvement of the pharmaceutical industry, the role of technology, and special circumstances such as sports medicine.

Ethics is a subject that has been aged like fine wine, discussed and disagreed upon by many. Therefore it is unavoidable that the coupling of ethics with a field as important as medicine is bound to create friction among many. The topics surrounding ethics in medicine face a lot of contradicting theories that have been debated and will continue to be debated for a long time. A clinical ethics study released in 2001, but conducted ten years prior, correctly predicted many factors to change in the proceeding ten year period, including ethical challenges posed by advanced in biotechnology. The concern was manifested by the recent controversies concerning issues such as stem cells and the Human Genome Project. 

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The result is an increasing involvement and greater activity of journals such as the American Journal of Bioethics, BMC Medical Ethics, and the Cambridge Quarterly of Healthcare ethics. This has caused maturation and a raised awareness of the importance of ethics in the medical field. It is due to a collaborative effort of those exploring challenges through narrative ethics, feminist theory, and clinical ethics, which we will speak about in detail throughout this research paper.

There are many distinctions in these theories associated with these schools of thought. The root of the problem according to clinical ethics, whether the topic being argued is about fitness, abortion, euthanasia, or pharmaceutical products, lies within the patient- doctor relationship. This relationship, due to major changes in societal values as well as many internal and external influential factors, should be examined as precept to determining what classifies as ethical practice and communication of medicine.

Dr Richard Friedenberg reiterates Dr Mark Stiegel’s 1998 article entitled “The future of the doctor patient relationship”, reminding readers that throughout the years, the patient-doctor relationship has passed through three primary phases; the age of paternalism, the age of autonomy, and the age of bureaucracy (the age of the payor).1 The move from one age to the other changed the way people viewed and interacted with the healthcare industry. When it came to making health related decisions, the decision-making process used to rely heavily on the expertise of the physician. More recently, it became heavily dependant on the choices of the patient and the patient’s family, and it is becoming more and more centered on health care corporations such as insurance companies and pharmaceuticals.  As health care not so slowly but surely turns to managed care, the focus shifts from patient-orientation to cost-efficiency orientation. Health care and its associated products are being treated as a scarce resource. Phrases such as managed care, marginal benefits, the futility standard, and end of life decisions spring to mind when considering the issues that should be examined to any health professional trying to determine how to provide the best quality care for each patient.

Paternalism, Autonomy, and Bureaucracy
As mentioned before, medical practice has seen a dramatic change in the communication of its publics, benefactors, and stakeholders. It has become a standardized process that focuses on norms and general acceptance. However, the decision is now split up into many deciding factors that blur the ethics of the situation. Nevertheless, one of the longest argued and prevalent forms of patient doctor relationships we find today is that of one which is paternalistic.

This is the type of relationship gives authority and power to a physician, while setting the patient down into a more dependent role. Many believe this to be the safest and most beneficial power structure for the medical field as the professional is often much more advanced in the knowledge of the subject at hand. This can be especially true for the severely injured, minors, and the mentally ill.

From an ethical standpoint, it makes sense to allow the medical professional to decide health related decisions. However, moral dilemmas are not necessarily the expertise of a physician, and this may cause some friction. For instance, a secular physician may not value the same things as a religious patient, and vice versa.

This is why in the past 50 years; we have seen autonomy takeover paternalism quite aggressively. The idea of self-determination has been used to reject paternalism in western bioethics, giving patients stronger rights such as informed consent. 6 Often times, it is hard  to determine whether the patient is acting out of relational identity with his or her family, or whether it is undue pressure that is causing them to decide differently. Although there are negative connotations with a patient’s autonomy in regards to the medical paternalistic approach, Dr. Ho, the Associate PhD argues family intervention should usually be considered a positive contribution to a patient’s health decisions, barring neglect and abuse.

Dr Mark Stiegler 1 explains that the present age of bureaucracy has demonstrated an unwillingness to include individualism in managed care. It is defined by the cost of care, rather than quality of care, a wish of both patient and doctor, which loses priority as the involvement of external stakeholders, administrators, and bureaucrats. He defines five factors that can obstruct the autonomy of both patient and physician.

There are (5) five ways in which patient and physician’s autonomy are limited and can directly be linked to and referenced as resulting factors of managed care. In the past, patient’s and their physicians tried to maximize even a 1% chance of success. (1) Futility standards can affect (2) end of life decisions, via insurer imposing standards such as greater than 15% chance of success; otherwise the case is deemed futile. As an ethical maxim, the health care system is taking a universal/ collectivistic approach while traditional beliefs state that health care require an individualistic approach. A perfect example of this is the discrepancies in the view of  (3) quality of life standards. If a patient is currently living in a situation that the insurer deems as a low quality of life situation, the insurer may not cover treatment. The concept of (4) social utility causes third party intervention in regards to dying patients and valuable resources, which limits the patients and the doctor’s decision-making rights. (5) Practice Guidelines and clinical paths further standardize health practice and limit the rights of individual patients and physicians.

Medical Students and Doctors Via Pharmaceutical Industry
When patients weigh in the influences that accompany health related decision, they may take into account their own knowledge, the advice of their family and close friends, and of course the recommendations of their physician. However, it can be assumed that not every patient is aware of how many outside forces may be influencing the decision making of the physician. A standard practice for pharmaceutical companies is to shower doctors with gifts, lucrative job opportunities, and most effectively, free drug samples which are then passed on to the patient, 89.1% of the time merely because they are available. Under 63% of the respondents claimed to distribute due to a “knowledge of the efficacy of the product”.

However, this statistic comes rather surprising seeing as the pharmaceutical industry is responsible for over 60% of America’s medical education. Pharmaceutical companies have given out scholarships and grants, meanwhile the term healthcare PR is becoming synonymous with medical education in general. 5 In the past decades, it has become a common practice for pharmaceutical groups, and even tobacco companies to pay academic writers and journals, such as “Journal of the American Medical Association upwards of $300,000 to write favourable literature in order to promote their products. As the goal of every for profit corporation is to provide stakeholders with positive returns, whereas the goal of a physician and a clinic is to provide the best quality care for a patient, a conflict of interest may arise. This is where the ethical dilemma gains even more importance.

The Role of Technology
Advances in technology have transformed the way doctors practice and patients communicate. Biotechnological advances have recently created opportunities that were never thought to be possible before. However, the high price tag on much of the new technology makes it virtually impossible to the average patient. Electronic medical records are replacing physical records and are allowing patients greater flexibility. Whereas in times prior, physical records meant that it was hard for patients to acquire a valid second opinion, giving more power and responsibility to the regular family physician that is familiar with the patient. Due to the recent advances in information and communication technologies such as practice management systems, autonomy gains more power.
On the other hand, patients are still vulnerable to the organized usage and manipulation of private information that is now wired to many sources at once. In order to qualify, patients often have no choice but to surrender the rights to their private information to those in and out of the Health industry. There is hope that there is a possibility of establishing electronic medical records without a problem, should the health industry follow the model of the military and the banks. 8 The ethical proportions here are tremendous and they can be qualified as simultaneously positive and negative contributions to the argument in favour of a more paternalistic patient-doctor relationship. Should patients begin to doubt the system, a shift back towards paternalism should manifest. Should the public gain trust in the system, they would feel free to choose their providers more selectively and they would not require nor appreciate the same support. As of now, the general consensus is that electonic medical records may present a more secure alternative to traditional paper records.

Ethics in Sports Medicine
Although it is a general consensus that the health of the patient is the primary responsibility of a physician, there are some situations that are not so clear, in which paternalism can be detrimental in this regard. Let us assume a team physician for a professional sports team. The rules are a little different and physician must make that clear to the patient, as the patient must trust him. Some would say trust should not be in the hands of organizations who’s primary concern and responsibility in an organization is to meet fiduciary duty to their stockholders.

The physician’s primary goal is to improve performance and prevent patient injury. These are goals through which a completely different set of norms apply, such as those associated with confidentiality, patient autonomy, third parties, advertising, and innovative technology. 7 In this case, innovative technology refers to experimental high-end treatments that a team physician may be inclined to over-credit. Here we can clearly foresee how there is a possibility of undue pressure for the athlete coming from multiple sources. These issues, along with others such as drugs and confidentiality are all ethically and legally outstanding but not unusual circumstances, which would not be served well by a paternalistic approach alone.

Although paternalism is a model of health care that served a long time effectively, the idea that this is currently the only realistic and effective model of the doctor patient relationship is challengeable proclamation. There is a clear intervention of both the autonomous and bureaucratic trends, and their effect is strong. As the medical process becomes more streamlined, and influenced by biotechnology, communications technology and privately owned corporations in the professional and educational field, it may create the need for more autonomy among both physicians and patients. All forms of communication have their weaknesses and strengths. Ethical considerations must always be made on so many levels, whether it’s the patients’ privacy or their ability to live or die according to their own values. Although there are certainly situations where paternalism can prove to be utmost effective, such as life or death situations, it is not always necessarily the right decision for every patient. Outside factors such as careers, family and finances are inevitable and unavoidable. The best form of communication for patients is to surround them selves with trustworthy people who will assist them to make an informed decision every step of the way, whether it is a physician, friend, family member or even themselves.
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