In our society, some aspects of life are off-limits to commerce. We prohibit the selling of children and the buying of wives, juries, and kidneys. Tainted blood is an inevitable consequence of paying blood donors; even sophisticated laboratory tests cannot supplant the gift-giving relationship as a safeguard of the purity of blood. Like blood, health care is too precious, intimate, and corruptible to entrust to the market.The hospice movement in the United States is approximately 40 years old. During these past (...) four decades, the concept of holistic, multidisciplinary care for patients who are suffering from a terminal illness has evolved from a modest, grassroots constellation of primarily volunteer-run and community-governed endeavors to a multimillion dollar industry where the surviving nonprofits compete with for-profit providers, often publicly traded, managed by M.B.A.-trained executives, and governed by corporate boards. The relatively recent emergence of for-profit hospice reflects an increasing commercialization of health care in the United States, the potentially adverse impact of which has been well documented. (shrink)

This article critically questions the commercialization of hospice care and the ethical concerns associated with the industry's movement toward “market-driven medicine” at the end of life. For example, the article examines issues raised by an influx of for-profit hospice providers whose business model appears at its core to have an ethical conflict of interest between shareholders doing well and terminal patients dying well. Yet, empirical data analyzing the experience of patients across the hospice industry are limited, and general claims that (...) end-of-life patient care is inferior among for-profit providers or even that their business practices are somehow unseemly when compared to nonprofit providers cannot be substantiated. In fact, non-profit providers are not immune to potentially conflicting concerns regarding financial viability (i.e., “no margin, no mission”). Given the limitations of existing empirical data and contrasting ideological commitments of for-profit versus non-profit providers, the questions raised by this article highlight important areas for reflection and further study. Policymakers and regulators are cautioned to keep ethical concerns in the fore as an increasingly commercialized hospice industry continues to emerge as a dominant component of the U.S. health care system. Both practitioners and researchers are encouraged to expand their efforts to better understand how business practices and commercial interests may compromise the death process of the patient and patient's family — a process premised upon a philosophy and ethical tradition that earlier generations of hospice providers and proponents established as a trusted, end-of-life alternative. (shrink)

Financial ties between physicians and pharmaceutical companies are pervasive and controversial. However, little is known about how patients perceive such ties. This paper describes an experiment examining how a national sample of U.S. adults perceived a variety of financial relationships between physicians and drug companies. Each respondent read a single scenario about a hypothetical physician and his financial ties to the pharmaceutical industry; scenarios varied in terms of payment type of and amount. Respondents then evaluated the physician on several dimensions (...) . Findings revealed that perceptions of the physician were more strongly influenced by payment type than by payment amount. Specifically, respondents were quite critical of doctors who owned drug company stock or received industry payments for meals and lodging, but were more forgiving of physicians who received free drug samples or consulting fees . Interestingly, physicians who received no payments, while seen as honest, were also viewed by some respondents as inexperienced or uninformed about new treatments. Implications for public policy and future research are discussed. (shrink)

Financial relationships and business transactions between physicians and the health care industry are common. These relationships take a variety of forms, including payments to physicians in exchange for consulting services, reimbursement of physician travel expenses when attending medical device and pharmaceutical educational conferences, physician ownership in life science company stocks, and the provision of free drug samples. Such practices are not intrinsic to medical practice, but as the Institute of Medicine described in its 2009 report, these relationships have the potential (...) to produce positive collaborations that improve patient care and public health, and most physicians view it as “ethically proper to accept items ranging from drug samples to a lucrative consultantship.”However, financial relationships between physicians and pharmaceutical, medical device and biotechnology companies can also create negative influences on physician judgment that compromise patient care and jeopardize the public’s trust. (shrink)

Alasdair MacIntyre described the late modern West as driven by two moral values: efficiency and effectiveness. Regardless of whether you accept MacIntyre's overarching story, it seems clear that efficiency and effectiveness have achieved a zenith in institutional health care structures, such that these two aspects of care become the final arbiters of what counts as “good” care. At the very least, they are dominant in many clinical contexts and act as the interpretative lens for the judgments of successful health care (...) managers. The drive of efficiency can also be seen in “lean” management methods (originally imported from the automotive manufacturing industry) increasingly deployed in the intensive care unit. This drive gives us pause. The high stress of the ICU is exacerbated by the enormous complexity of technological interventions designed to maintain physiological functioning as the body heals, as well as the ever‐present concerns related to cost, effectiveness, and efficiency. The ICU, therefore, provides an illustrative view of the challenges facing clinicians, as well as resource managers, in terms of delivering care. In short, the goal of technocratic efficiency often ends up at odds with humane purposes. To better understand these contemporary health care dynamics, we conducted a limited series of focus group discussions and interviews with residents experienced in the challenges of delivering care in the ICU environment. In what follows, we highlight some narrative observations drawn from these focus groups. We found a recurrent and disconcerting refrain among our informants that has not been adequately described or addressed in the literature: technocratic management techniques have crept into and bifurcated clinical care strategies in the ICU. Specifically, we highlight the influence of concerns around efficiency and effectiveness and the ways in which these foci have contributed to a bifurcation in care in the ICU along two trajectories: either compassionate care or curative care. (shrink)

"Thinking like a lawyer" is a phrase familiar to every law student, and the development of these analytical skills are, of course, essential. In this essay, however, I reflect on the value of a more expansive approach to professional formation. I argue that legal education best serves students, the bar, and the society when it takes seriously the importance of moral imagination, interpersonal relationships, and personal wellness.

The empirical literature exploring lawyers and their moral decision making is limited despite the “crisis” of unethical and unprofessional behavior in the bar that has been well documented for over a decade. In particular we are unaware of any empirical studies that investigate the moral landscape of the health lawyer’s practice. In an effort to address this gap in the literature, an interdisciplinary team of researchers at Vanderbilt University designed an empirical study to gather preliminary evidence regarding the moral reasoning (...) of health care attorneys. The primary research question was how health lawyers respond when they encounter ethical or moral dilemmas in their practice for which the law fails to offer a bright-line solution. In exploring this question, we sought to understand better what motivations or influences guide action when health lawyers confront ethical quandaries, and whether there are specific differences, e.g., gender, experience, or religiosity, that are associated with specific responses to situations testing ethical or moral boundaries. (shrink)

Writing in 1999, legal ethics scholar Brad Wendel noted that “[v]ery little empirical work has been done on the moral decision making of lawyers.” Indeed, since the mid-1990s, few empirical studies have attempted to explore how attorneys deliberate about ethical dilemmas they encounter in their practice. Moreover, while past research has explored some of the ethical issues confronting lawyers practicing in certain specific areas of practice, no published data exists probing the moral mind of health care lawyers. As signaled by (...) the creation of a regular column “devoted to ethical issues arising in the practice of health law” in the Journal of Law, Medicine & Ethics, the time to address the empirical gap in the professional ethics literature is now. Accordingly, this article presents data collected from 120 health care lawyers. Presenting this population with a number of hypothetical scenarios relating to how they would respond when confronting an ethical dilemma without an obvious solution or when facing a situation in which their personal values were in tension with their professional obligations, this article represents a first step toward better understanding how lawyers who practice in health care settings understand and resolve the moral discomfort they encounter in their professional lives. (shrink)

Sex determination in most organisms involves a simple binary fate choice between male or female development; the outcome of this decision has profound effects on organismal biology, biochemistry and behaviour. In the nematode C. elegans, there is also a binary choice, either male or hermaphrodite. In C. elegans, distinct genetic pathways control somatic and germline sexual cell fate. Both pathways share a common set of globally acting regulatory genes; however, germline-specific regulatory genes also participate in the decision to make male (...) or female gametes. The determination of sexual fate in the germline of the facultative hermaphrodite poses a special problem, because first sperm then oocytes are produced. It has emerged that additional layers of post-transcriptional regulation have been imposed to modulate the activities of the global sex-determining genes, tra-2 and fem-3; the balance between these activities is crucial in controlling sexual cell fate in the hermaphrodite germline. BioEssays 23:596–604, 2001. © 2001 John Wiley & Sons, Inc. (shrink)

The authors reject arguments by Professor Joseph Fletcher (author of Situation Ethics) that in some circumstances parents may be held responsible for producing genetically defective offspring, but offer arguments of their own for the same conclusion. Their arguments could, they suggest, justify `wrongful life' claims by the genetically defective infant against the mother. While researching this paper both authors were postdoctoral fellows in medical ethics in the Program on Human Values and Ethics at the University of Tennessee Center for the (...) Health Sciences. (shrink)

The diffusion of technology in the US has taken place in an environment of both regulation and free enterprise. Each has been subject to manipulation by doctors and medical administrators that has fostered unprecedented ethical dilemmas and legal challenges. Understanding these developments and historical precedents may allow a more rational diffusion policy for medical technology in the future.

While studies on the characteristics of flow states and their relation to peak performance exist, little is known about the dynamics by which flow states emerge and develop over time. The current paper qualitatively explores the necessary pre-conditions to enter flow, and the development of flow over time until its termination. Using an elicitation interview, participants were asked to recall their flow experiences in sports or music performances. The analysis resulted in the identification of the following three phases that athletes (...) and musicians experience during flow: Preparation to enter flow; Entry into the flow state and; Exit from the flow state. These three phases are characterized by several sub-themes contributing to the experience of flow. The function of emotions is crucial, as they play a core role across all three phases and regulate flow over time. The findings provide insights into the phenomenological characteristics of the transition and maintenance of the three proposed phases and the temporal dynamics of flow. (shrink)

The Alternative Model of Personality Disorders integrates several theoretical models of personality functioning, including interpersonal theory. The interpersonal circumplex dimensions of warmth and dominance can be conceptualized as traits similar to those in AMPD Criterion B, but interpersonal theory also offers dynamic hypotheses about how these variables that change from moment to moment, which help to operationalize some of the processes alluded to in AMPD Criterion A. In the psychotherapy literature, dynamic interpersonal behaviors are thought to be critical for identifying (...) therapeutic alliance ruptures, yet few studies have examined moment-to-moment interpersonal behaviors that are associated with alliance ruptures at an idiographic level. The current study examined the concurrent and cross-lagged relationships between interpersonal behaviors and alliance ruptures within each session in the famous Gloria films. Interpersonal behaviors as well as alliance ruptures were calculated at half minute intervals for each dyad. We identified distinct interpersonal patterns associated with alliance ruptures for each session: Gloria ’s warmth was positively related with withdrawal ruptures concurrently in the session with Carl Rogers; Gloria’s dominance and coldness were related with increased confrontation ruptures in the session with Fritz Perls concurrently, while her coldness was also predicted by confrontation ruptures at previous moments; lastly, both Gloria’s dominance and Albert Ellis’s submissiveness were positively related with withdrawal ruptures. These interpersonal patterns demonstrated the promise of using AMPD dimensions to conceptualize momentary interpersonal processes related to therapy ruptures, as well as the clinical importance of attuning to repetitive, dyad-specific interpersonal cues of ruptures within each session. (shrink)

This paper examines the historical rise of both cardiopulmonary resuscitation and the do-not-resuscitate order and the wisdom of their continuing status in U.S. hospital practice and policy. The practice of universal presumed consent to CPR and the resulting DNR policy are the products of a particular time and were responses to particular problems. In order to keep the excesses of technology in check, the DNR policies emerged as a response to the in-hospital universal presumed consent to CPR. We live with (...) this historical concretion, which seems to perpetuate a false culture that the patient's wishes must be followed. The authors are critical of the current U.S. climate, where CPR and DNR are viewed as two among a panoply of patient choices, and point to UK practice as an alternative. They conclude that physicians in the United States should radically rethink approaches to CPR and DNR. (shrink)

Five experiments provide evidence for a class of ‘dual character concepts.’ Dual character concepts characterize their members in terms of both (a) a set of concrete features and (b) the abstract values that these features serve to realize. As such, these concepts provide two bases for evaluating category members and two different criteria for category membership. Experiment 1 provides support for the notion that dual character concepts have two bases for evaluation. Experiments 2-4 explore the claim that dual character concepts (...) have two different criteria for category membership. The results show that when an object possesses the appropriate concrete features, but does not fulfill the appropriate abstract value, it is judged to be a category member in one sense but not in another. Finally, Experiment 5 uses the theory developed here to construct artificial dual character concepts and examines whether participants react to these artificial concepts in the same way as naturally occurring dual character concepts. The present studies serve to define the nature of dual character concepts and distinguish them from other types of concepts (e.g., natural kind concepts), which share some, but not all of the properties of dual character concepts. More broadly, these phenomena suggest a normative dimension in everyday conceptual representation. (shrink)

Awe and wonder are theorised to be distinct from other positive emotions, such as happiness. Yet little empirical or theoretical work has focused on these emotions. This investigation explored differences in language used to describe experiences of awe and wonder. Such analyses can provide insight into how people conceptualise these emotional experiences, and whether they conceptualise these emotions to be distinct from other positive emotions, and each other. Participants wrote narratives about experiences of awe, wonder and happiness. There were differences (...) in the language used to describe these positive emotional states, consistent with the theorised functions of each emotion. Awe was related to observing the world, reflected in greater use of perception words. Wonder was related to trying to understand the world, reflected in greater use of cognitive complexity and tentative words. Language use for both emotions reflected an environmental focus, whereas language use for happiness reflected a social/relationship focus. (shrink)

In some cases people judge it morally acceptable to sacrifice one person’s life in order to save several other lives, while in other similar cases they make the opposite judgment. Researchers have identified two general factors that may explain this phenomenon at the stimulus level: (1) the agent’s intention (i.e. whether the harmful event is intended as a means or merely foreseen as a side-effect) and (2) whether the agent harms the victim in a manner that is relatively “direct” or (...) “personal”. Here we integrate these two classes of findings. Two experiments examine a novel personalness/directness factor that we call personal force, present when the force that directly impacts the victim is generated by the agent’s muscles (e.g., in pushing). Experiments 1a and b demonstrate the influence of personal force on moral judgment, distinguishing it from physical contact and spatial proximity. Experiments 2a and b demonstrate an interaction between personal force and intention, whereby the effect of personal force depends entirely on intention. These studies also introduce a method for controlling for people’s real-world expectations in decisions involving potentially unrealistic hypothetical dilemmas. (shrink)

Traditional theories of moral development emphasize the role of controlled cognition in mature moral judgment, while a more recent trend emphasizes intuitive and emotional processes. Here we test a dual-process theory synthesizing these perspectives. More specifically, our theory associates utilitarian moral judgment (approving of harmful actions that maximize good consequences) with controlled cognitive processes and associates non-utilitarian moral judgment with automatic emotional responses. Consistent with this theory, we find that a cognitive load manipulation selectively interferes with utilitarian judgment. This interference (...) effect provides direct evidence for the influence of controlled cognitive processes in moral judgment, and utilitarian moral judgment more specifically. (shrink)

This paper examines the historical rise of both cardiopulmonary resuscitation and the do-not-resuscitate order and the wisdom of their continuing status in U.S. hospital practice and policy. The practice of universal presumed consent to CPR and the resulting DNR policy are the products of a particular time and were responses to particular problems. In order to keep the excesses of technology in check, the DNR policies emerged as a response to the in-hospital universal presumed consent to CPR. We live with (...) this historical concretion, which seems to perpetuate a false culture that the patient's wishes must be followed. The authors are critical of the current U.S. climate, where CPR and DNR are viewed as two among a panoply of patient choices, and point to UK practice as an alternative. They conclude that physicians in the United States should radically rethink approaches to CPR and DNR. (shrink)

Over the past several decades, psychological essentialism has been an important topic of study, incorporating research from multiple areas of psychology, philosophy and linguistics. At its most basic level, essentialism is the tendency to represent certain concepts in terms of a deeper, unobservable property that is responsible for category membership. Originally, this concept was used to understand people’s reasoning about natural kind concepts, such as TIGER and WATER, but more recently, researchers have identified the emergence of essentialist-like intuitions in a (...) number of other contexts, including people’s representation of concepts like SCIENTIST or CHRISTIAN. This paper develops an account that aims to capture how essentialism may operate across these varied cases. In short, we argue that while there is diversity in the forms essentialism can take, these varied cases reflect the same underlying cognitive structure. (shrink)

The present study investigates the importance of emotional disclosure and vulnerability in the production of hegemonic masculinities. Of particular interest is the role that silence and invisibility play in how men talk about recent stressful life events. One-on-one interviews with men who experienced a stressful life event in the past year illustrate how men often talk about these events in simultaneously visible and invisible ways. We use the term “cloudy visibility” to describe this engagement, identified both in terms of what (...) men articulate in relation to their past stressful experiences and how they articulate these experiences within the present moment of the interview. The conversational consequences of these linguistic devices are analyzed to illustrate how men obscure their inner emotional lives, thus reproducing hegemonic masculine ideals of staying strong and stoic in the face of adversity, while they also seek to make aspects of their inner lives seen and heard to an interviewer. (shrink)

BackgroundThe U.S. Food and Drug Administration traditionally has kept confidential significant amounts of information relevant to the approval or non-approval of specific drugs, devices, and biologics and about the regulatory status of such medical products in FDA’s pipeline.ObjectiveTo develop practical recommendations for FDA to improve its transparency to the public that FDA could implement by rulemaking or other regulatory processes without further congressional authorization. These recommendations would build on the work of FDA’s Transparency Task Force in 2010.MethodsIn 2016-2017, we convened (...) a team of academic faculty from Harvard Medical School, Brigham and Women’s Hospital, Yale Medical School, Yale Law School, and Johns Hopkins Bloomberg School of Public Health to develop recommendations through an iterative process of reviewing FDA’s practices, considering the legal and policy constraints on FDA in expanding transparency, and obtaining insights from independent observers of FDA.ResultsThe team developed 18 specific recommendations for improving FDA’s transparency to the public. FDA could adopt all these recommendations without further congressional action.FundingThe development of the Blueprint for Transparency at the U.S. Food and Drug Administration was funded by the Laura and John Arnold Foundation. (shrink)

The complexity and inefficiency of the U.S. health care system complicates the distribution of life-saving medical technologies. When the public health is at stake, however, there are alternatives. The proposal for a national PrEP program published in this issue of the Journal applies some of the lessons of the national COVID vaccine campaign to HIV prevention. In doing so, it draws on other examples of public health approaches to the financing of medical technology, from vaccines for children to hepatitis C (...) treatment. (shrink)

The Twin Earth thought experiment invites us to consider a liquid that has all of the superficial properties associated with water (clear, potable, etc.) but has entirely different deeper causal properties (composed of “XYZ” rather than of H2O). Debates about natural kind concepts have sought to accommodate an apparent fact about ordinary people's judgments: Intuitively, the Twin Earth liquid is not water. We present results showing that people do not have this intuition. Instead, people tend to judge that there is (...) a sense in which the liquid is not water but also a sense in which it is water. (shrink)

Past research has identified a number of asymmetries based on moral judgments. Beliefs about what a person values, whether a person is happy, whether a person has shown weakness of will, and whether a person deserves praise or blame seem to depend critically on whether participants themselves find the agent's behavior to be morally good or bad. To date, however, the origins of these asymmetries remain unknown. The present studies examine whether beliefs about an agent's “true self” explain these observed (...) asymmetries based on moral judgment. Using the identical materials from previous studies in this area, a series of five experiments indicate that people show a general tendency to conclude that deep inside every individual there is a “true self” calling him or her to behave in ways that are morally virtuous. In turn, this belief causes people to hold different intuitions about what the agent values, whether the agent is happy, whether he or she has shown weakness of will, and whether he or she deserves praise or blame. These results not only help to answer important questions about how people attribute various mental states to others; they also contribute to important theoretical debates regarding how moral values may shape our beliefs about phenomena that, on the surface, appear to be decidedly non-moral in nature. (shrink)

Background:Clinical investigation is a growing field employing increasing numbers of nurses. This has created a new specialty practice defined by aspects unique to nursing in a clinical research context: the objectives, setting, and nature of the nurse–participant relationship. The clinical research nurse role may give rise to feelings of ethical conflict between aspects of protocol implementation and the duty of patient advocacy, a primary nursing responsibility. Little is known about whether research nurses experience unique ethical challenges distinct from those experienced (...) by nurses in traditional patient-care settings.Research objectives:The purpose of the study was to describe the nature of ethical challenges experienced by clinical research nurses within the context of their practice.Research design:The study utilized a qualitative descriptive design with individual interviews.Participants and research context:Participating nurses self-identified as having experienced ethical challenges during screening. The majority were Caucasian, female, and worked in outpatient settings. Approximately 50% had > 10 years of research experience.Ethical considerations:The human subjects review board approved the study. Written informed consent was obtained.Findings:Predominant themes were revealed: the inability to provide a probable good, or/do no harm, and dual obligations. The following patterns and subthemes emerged: conflicted allegiances between protocol implementation, needs of the participant, desire to advance science, and tension between the nurse–patient therapeutic relationship versus the research relationship.Discussion:Participants described ethical challenges specific to the research role. The issues are central to the nurse–participant relationship, patient advocacy, the nurse’s role in implementing protocols, and/or advancing science.Conclusion:Ethical challenges related to the specialized role of clinical research nurses were identified. More research is warranted to fully understand their nature and frequency and to identify support systems for resolution. (shrink)

While infant fearfulness, and its expression via crying, may have been adaptive in our evolutionary history, for modern parents, crying can be challenging to respond to. We discuss how and why prolonged crying can raise the risk for difficulties with adult care. Given that crying is the most-reported trigger for shaking, its potential to elicit maladaptive responses should not be overlooked.