Advocacy and community: the social roles of physicians in the last 1000 years. Part I.
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Over the last 1000 years, the practice of medicine in the Western world has been shaped by extraordinary transformations -- in the organizational structures of healthcare delivery, the changing concepts of disease and illness, and the ethical and social issues posed to a growing and diversified profession. Some critical aspects that characterize contemporary Western medicine -- as professionally defined, highly organized and regulated, and scientifically and technologically based -- have emerged only within the last 200 years. For most of its history, medicine was practiced without these distinctions -- but precursors to many current tensions can be traced back to Hippocratic times. In the last millennium, medicine developed in tandem with emerging political ideologies and social structures, and the roles of physicians evolved to respond to the needs of individual patients, the profession, and society at large. As medicine became increasingly effective, it was harnessed into the political objectives of promoting social cohesion and productivity. Professional regulation and social mechanisms for the equitable distribution of healthcare became significant considerations for the profession and society. In this brief 3-part history, we will trace the major organizational, conceptual, and political changes that, together, by the year 2000, created a profession with responsibilities of advocacy for individual patients in concert with attention to the needs and demands of all the individuals in the larger community. (+info)
Complaints concerning the hospital care of elderly patients: a 12-month study of one hospital's experience.
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OBJECTIVE: to determine the number, instigators, nature and outcome of complaints concerning elderly patients treated at a single hospital over 1 year. DESIGN: descriptive analysis of computerized data gathered prospectively; follow-up of complaints until resolution. SETTING: large, urban, university teaching hospital in Australia. SUBJECTS: all patients aged 65 years and above whose hospital care was the subject of complaint. METHODS: analysis of computerized database of all complaints made in a single year. RESULTS: 1.44 complaints were made per 1000 occasions of service to elderly people (95% confidence intervals, 1.19 - 1.69). This was similar to the overall complaint rate of 1.32 per 1000 occasions of service for patients of all age groups (95% confidence intervals, 1.19- 1.45). However, 73% of complaints were made by advocates rather than by elderly patients themselves and 96% related to communication or treatment issues. Many complaints resulted in an explanation and/or an apology and, to date, none has resulted in litigation. CONCLUSIONS: complaints concerning older hospitalized people are as common as those concerning younger patients. Analysis of complaints provides pointers for improvements in quality of care. (+info)
Debate: what constitutes 'terminality' and how does it relate to a living will?
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A moribund and debilitated patient arrives in an emergency department and is placed on life support systems. Subsequently it is determined that she has a 'living will' proscribing aggressive measures should her condition be judged 'terminal' by her physicians. But, as our round table of authorities reveal, the concept of 'terminal' means different things to different people. The patient's surrogates are unable to agree on whether she would desire continuation of mechanical ventilation if there was a real chance of improvement or if she would want to have her living will enforced as soon it's terms were revealed. The problem of the potential ambiguity of a living will is explored. (+info)
An argument for intolerance.
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"Multiculturalism", "pluralism" and "tolerance" have become buzz words in applied ethics. While serious and well thought out work is going on in these areas, a misunderstanding of the importance of tolerance, and the difficulties raised by multicultural moral conflict seems common. In this paper I argue that intolerance of some cultural traditions is morally required, and suggest that the forging of a moral mono-culture is preferable to pluralism. (+info)
A little toleration, please.
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Value pluralism does not imply relativism or subjectivism about values. What it does is allow respect for an at least limited toleration of values with which one may profoundly disagree. Thus a doctor can respect the autonomy of a patient whose values he does not share. (+info)
Bioethics for clinicians: 20. Chinese bioethics.
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Chinese Canadians form one of the largest groups in the Canadian cultural mosaic. Many of the assumptions implicit in a Western autonomy-based approach to bioethical deliberation may not be shared by Chinese Canadians. In traditional Chinese culture, greater social and moral meaning rests in the interdependence of family and community, which overrides self-determination. Consequently, many Chinese may vest in family members the right to receive and disclose information, to make decisions and to organize patient care. Furthermore, interactions between Chinese patients and health care workers may be affected by important differences in values and goals and in the perception of the nature and meaning of illness. Acknowledging and negotiating these differences can lead to considerable improvement in communication and in the quality of care. (+info)
When is surgery research? Towards an operational definition of human research.
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The distinction between clinical practice and surgical research may seem trivial, but this distinction can become a complex issue when innovative surgeries are substituted for standard care without patient knowledge. Neither the novelty nor the risk of a new surgical procedure adequately defines surgical research. Some institutions tacitly allow the use of new surgical procedures in series of patients without informing individuals that they are participating in a scientific study, as long as no written protocol or hypothesis exists. Institutions can justify this practice by viewing human research in narrow terms as an activity outlined in a formal protocol. Application of limited definitions, however, erodes patients' rights and risks losing public confidence in how biomedical research is conducted. I propose an operational definition of human research also be recognised. Enforcing more rigid and less ambiguous guidelines of human research may curtail enrolment into some studies, but it will also protect patients from being used as subjects without their knowledge. (+info)
Disability prevention principles in the primary care office.
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The simple request for a sick note can disguise important medical, psychologic or social issues. Disability may be influenced by social and cultural factors as well as by patient expectations. Assessment of impairment and subsequent disability is best made on the basis of objective data by use of a biopsychosocial model to ensure that the expression of disability does not mask other unaddressed psychologic or social issues. Enabling prolonged disability in such a situation can be a dysfunctional physician response to a maladaptive process. The physician's role is to treat the condition, to fulfill the appropriate role of patient advocate, to facilitate health (including resumption of activity), to offer proactive advice on the basis of prognosis, to be familiar with the patient's social obligations and resources and to provide education about the therapeutic benefits of returning to optimal function. This factual, medical-based approach offers an effective preventive strategy that will save many patients from unnecessary disability and morbidity. (+info)