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Biomedical subjects

R M Arnold

Publications and source records attributed to R M Arnold.

At least 55 records · Page 3Linked to original sources
PubMed1994

Should competent patients or their families be notified before HECs review the patients' cases? Yes.

In summary, it is, I believe, fairly uncontroversial that a patient always should be notified before a bioethics committee reviews the case. Respect for a patient"s confidentiality and autonomy also require that patients be asked prior to being interviewed or identifying the patient's name in a committee meeting. Permission is not required for an anonymous discussion of the case with a bioethics committee.

Confidentiality↗
PubMed1993

Professional courtesy--current practices and attitudes.

BACKGROUND: Physicians have long provided care free of charge or at a reduced rate as a professional courtesy to other physicians and their families. We conducted a stratified national mail survey to assess the extent to which this practice has changed in recent years. METHODS: Using the American Medical Association's 1991 master list of physicians, we selected a random sample of 4800 practicing physicians from 12 direct-care specialties. These physicians were asked about their current policy and opinions regarding professional courtesy. RESULTS: Of the 2224 respondents, 2127 (96 percent) offered professional courtesy, defined as providing free or discounted health care to physicians and their families. Psychiatrists were less likely to offer professional courtesy than physicians in any of the other specialties (80 percent vs. 91 to 99 percent, P < 0.05). The forms of free or discounted care offered as a professional courtesy included billing only the insurance company (75 percent), providing care at no charge (49 percent), and giving a partial discount (23 percent). Twenty-three percent of the respondents reported that they had changed their policy regarding professional courtesy since starting to practice. Among those who had changed their policy, the most common changes were to increase the practice of billing only the insurance company (67 percent) and to provide care at no charge less often (58 percent). The majority of physicians responding to the survey thought that professional courtesy solidified bonds between physicians (79 percent) and was sound business practice (62 percent); 12 percent believed that it was too expensive to offer free or discounted care as a professional courtesy, and 14 percent thought that the practice had negative effects on the physician-patient interaction. CONCLUSIONS: Our survey of physicians involved in direct patient care indicates that, with the exception of psychiatrists, almost all American physicians offer free or discounted care as a professional courtesy and support the practice.

Adult↗
PubMed1993

Rationing failure. The ethical lessons of the retransplantation of scarce vital organs.

Because of a shortage of transplantable livers and hearts, the transplant community has had to decide--by who gets an organ--who lives or dies. Despite this shortage, whether one has previously received a transplant is not used as a criterion to distribute organs. The existing allocation system distributes 10% to 20% of available hearts and livers to retransplant patients. This article examines three differences between primary transplantation and retransplantation that may affect the priority that retransplant candidates should receive in vying for organs: (1) the special obligations that transplant teams have not to abandon patients on whom they have already performed a transplant, (2) the fairness of allowing individuals to get multiple transplants while some die awaiting their first, and (3) the difference in efficacy between primary transplantation and retransplantation. Only this last difference holds up to critical analysis. Our moral duty to direct scarce, lifesaving resources to those likely to benefit from them, suggests that, all other things equal, primary transplant candidates should receive priority because their mortality after transplantation is lower. Consistency also demands that previous transplant history be taken into account, as we already allocate organs according to ABO blood group matching, a factor that affects transplant outcome approximately the same amount as a previous transplantation. We therefore conclude that the system should be revised so that primary transplant candidates have a better chance of receiving organs than retransplant candidates.

Ethical Theory↗
PubMed1993

Contributions of empirical research to medical ethics.

Empirical research pertaining to cardiopulmonary resuscitation (CPR), clinician behaviors related to do-not-resuscitate (DNR) orders and substituted judgment suggests potential contributions to medical ethics. Research quantifying the likelihood of surviving CPR points to the need for further philosophical analysis of the limitations of the patient autonomy in decision making, the nature and definition of medical futility, and the relationship between futility and professional standards. Research on DNR orders has identified barriers to the goal of patient involvement in these life and death discussions. The initial data on surrogate decision making also points to the need for a reexamination of the moral basis for substituted judgment, the moral authority of proxy decision making and the second-order status of the best interests standard. These examples of empirical research suggest that an interplay between empirical research, ethical analysis and policy development may represent a new form of interdisciplinary scholarship to improve clinical medicine.

Cardiopulmonary Resuscitation↗
PubMed1993

Discussions about limiting treatment in a geriatric clinic.

OBJECTIVE: Obtain detailed information about the frequency and content of discussions about withholding treatment between doctors and elderly outpatients. DESIGN: Survey. SETTING: Primary care geriatric clinic at an urban university. PARTICIPANTS: Twelve physicians and one nurse practitioner completed questionnaires for 185/198 (93.4%) patient visits. MEASUREMENTS: Questionnaires were completed by physicians after each patient visit during August 1989. Interviews were conducted with physicians who had discussed limiting life-sustaining treatment with patients. RESULTS: Ten percent (n = 19) of patients seen had had discussions with their physicians about life-sustaining treatment. These patients were older and had worse prognoses as estimated by their physicians. Physicians usually raised the issue with the families of demented patients and mentioned dementia, quality of life, prognosis, and the need to make other clinical decisions as motivation for initiating discussions. The majority of patients with poor prognoses, however, had not had discussions about life support. CONCLUSIONS: Despite increasing attention given to end-of-life decisions in the medical and lay press, discussions with elderly outpatients about limiting treatment occur rarely. They are more likely when patients are older or have worse prognoses, but age, prognosis, and poor quality of life do not consistently lead physicians to raise the issue.

Advance Directives↗
PubMed1993

The dead donor rule: should we stretch it, bend it, or abandon it?

The dead donor rule--that persons must be dead before their organs are taken--is a central part of the moral framework underlying organ procurement. Efforts to increase the pool of transplantable organs have been forced either to redefine death (e.g., anencephaly) or take advantage of ambiguities in the current definition of death (e.g., the Pittsburgh protocol). Society's growing acceptance of circumstances in which health care professionals can hasten a patient's death also may weaken the symbolic importance of the dead donor rule. We consider the implications of these efforts to continually revise the line between life and death and ask whether it would be preferable to abandon the dead donor rule and rely entirely on informed consent as a safeguard against abuse.

Brain Death↗
PubMed1992

Absolutely relative: how research results are summarized can affect treatment decisions.

PURPOSE: To determine whether alternative methods of presenting a contrast between the same two quantities in descriptions of research results could lead to different treatment decisions by physicians. SUBJECTS AND METHODS: We conducted a survey of practicing physicians and of faculty and fellows in training programs in clinical epidemiology and social science research methods. Each questionnaire presented results from a published study of either hypertension or hypercholesterolemia in two different ways: once as the relative change in the outcome rate and once as the absolute change in the outcome rate. We asked respondents to read each summary and indicate how the information contained in the summary would influence decisions about treatment. RESULTS: Of the 235 physicians who completed the questionnaire, 108 (46%) gave different responses to the same results presented in different ways. Of these, 97 (89.8%) indicated a stronger inclination to treat patients after reading of the relative change in the outcome rate (p less than 0.0001). CONCLUSION: The manner of presentation of results can influence physicians' judgments about the treatment of patients.

Abstracting and Indexing↗
PubMed1991

Teaching clinical ethics in the residency years: preparing competent professionals.

Formal training in clinical ethics must become a central part of residency curricula to prepare practitioners to manage the ethical dimensions of patient care. Residency educators must ground their teaching in an understanding of the conceptual, biomedical, and psychosocial aspects of the important ethical issues that arise in that field of practice. Four aspects of professional competence in clinical ethics provide a useful framework for curricular planning. The physician should learn to: (1) recognize ethical issues as they arise in clinical care and identify hidden values and unacknowledged conflicts; (2) think clearly and critically about these issues in ways that lead to ethically justifiable courses of action; (3) apply those practical skills needed to implement an ethically justifiably course of action; and (4) judge when the management of a clinical situation requires consultation with individuals or institutional bodies with additional expertise or authority. We argue that these practical goals can be accomplished with a relatively modest emphasis on the theoretical aspects of medical ethics.

Bioethical Issues↗
PubMed1990

Rewarding medicine: good doctors and good behavior.

Many patients think that there are shortcomings in the ethical dimensions of patient care, and research supports their view. In this issue of Annals, Erde suggests that physicians' incomes should depend on patients' assessments of their ethical behavior in much the same way that waiters' incomes depend on patrons' tips. Although Erde's solution is satiric, the problem is a serious one. The experiences and perspectives of patients regarding their own illness are undervalued by physicians. A truly patient-centered care demands that physicians elicit, understand, and respond to patients' perspectives. Tying physicians' pay to measurements of patient satisfaction is unlikely to dramatically improve the ethical quality of patient care as long as attention to the patient's perspective is seen as peripheral to "good medical care." Rather than relying on a single, easy "fix," we must re-examine all of professional development and practice. We need to choose persons for medical careers who will find patient-centered care rewarding; we need to provide such persons with training and socialization that underscores the value of personalized medicine; and we need to build institutions and systems that facilitate and reinforce patient-centered practice. The best ways to achieve these objectives are as yet unclear, but if we, as physicians, are offended by Erde's "modest proposal," then we must respond by proposing and implementing our own ideas about how patient care can become more humane.

Beneficence↗