Lynette Reid

Medical Professionalism and the Social Contract

Conceptions of professionalism in medicine draw on social contract theory; its strengths and weaknesses play out in how we reason about professionalism. The social contract metaphor may be a heuristic device prompting reflection on social responsibility, and as such is appealing: it encourages reasoning about privilege and responsibility, the broader context and consequences of action, and diverse perspectives on medical practice. However, when this metaphor is elevated to the status of a theory, it has well-known limits: the assumed subject position of contractors engenders blind spots about privilege, not critical reflection; its tendency to dress up the status quo in the trappings of a theoretical agreement may limit social negotiation; its attempted reconciliation of social obligation and self-interest fosters the view that ethics and self-interest should coincide; it sets up false expectations by identifying appearance and reality in morality; and its construal of prima facie duties as conditional misdirects ethical attention in particular situations from current needs to supposed past agreements or reciprocities. Using philosophical ideas as heuristic devices in medical ethics is inevitable, but we should be conscious of their limitations. When they limit the ethical scope of debate, we should seek new metaphors.

Medical Need: Evaluating a Conceptual Critique of Universal Health Coverage

Some argue that the concept of medical need is inadequate to inform the design of a universal health care system—particularly an institutional (universal, comprehensive) rather than a residual (minimalist, safety net) system. They argue that the concept (a) contradicts the idea of comprehensiveness; (b) leads to unsustainable expenditures; (c) is too indeterminate for policy; and (d) supports only a prioritarian distribution (and therefore a residual system). I argue (a) that ‘comprehensive’ understood as ‘including the full continuum of care’ and ‘medically necessary’ understood as ‘prioritized by medical criteria’ are not contradictory, and (b) that UHC is a solution to the problem of sustainability, not its cause. Those who criticize ‘medical need’ for indeterminacy (c) are not transparent about the source (ethical, semantic, political, or other) of their commitment to their standards of determinacy: they promote standards that are higher than is necessary for legitimate policy, ignoring opportunity costs. Furthermore, the indeterminacy of concepts affects all risk-sharing systems and all systems that rely on medical standard of care. I then argue that (d) the concept of need in itself does not imply a minimal sufficientist standard or a prioritarian distribution; neither does the idea of legitimate public policy dictate that public services be minimalist. The policy choice for a system of health care that is comprehensive and offers as good care as can be achieved when delivered on equal terms and conditions for all is a coherent option.

Truth or Spin? Disease Definition in Cancer Screening

Are the small and indolent cancers found in abundance in cancer screening normal variations, risk factors, or disease? Naturalists in philosophy of medicine turn to pathophysiological findings to decide such questions objectively. To understand the role of pathophysiological findings in disease definition, we must understand how they mislead in diagnostic reasoning. Participants on all sides of the definition of disease debate attempt to secure objectivity via reductionism. These reductivist routes to objectivity are inconsistent with the Bayesian nature of clinical reasoning; when they appeal to the sciences, they are inconsistent with what philosophy of biology tells us about its natural kinds. Proposals that we narrow the scope of our claims in the disease definition debates (proposing adoption of a specific disease paradigm for a specific context) are useful, but paradigms can still distort our reasoning in particular cases, even when we are self-conscious about their status.

Deliberative curriculum inquiry for integration in an MD curriculum: Dalhousie University's curriculum renewal process.

Background: Dalhousie Universitys MD Programme faced a one-year timeline for renewal of its undergraduate curriculum. Aim: Key goals were renewed faculty engagement for ongoing quality improvement and increased collaboration across disciplines for an integrated curriculum, with the goal of preparing physicians for practice in the twenty-first century. Methods: We engaged approximately 600 faculty members, students, staff and stakeholders external to the faculty of medicine in a process described by Harris (1993) as ‘deliberative curriculum inquiry’. Temporally overlapping and networked intraprofessional and interprofessional teams developed programme outcomes, completed environment scans of emerging content and best practices, and designed curricular units. Results: The resulting curriculum is the product of new collaborations among faculty and exemplifies distinct forms of integration. Innovations include content and cases shared by concurrent units, foundations courses at the beginning of each year and integrative experiences at the end, and an interprofessional community health mentors programme. Conclusion: The use of deliberative inquiry for pre-med curriculum renewal on a one-year time frame is feasible, in part through the use of technology. Ongoing structures for integration remain challenging. Although faculty collaboration fosters integration, a learner-centred lens must guide its design.

Ethics in Radiology: Wait Lists Queue Jumping

Education in ethics is a requirement for all Royal College residency training programs as laid out in the General Standards of Accreditation for residency programs in Canada. The ethical challenges that face radiologists in clinical practice are often different from those that face other physicians, because the nature of the physician-patient interaction is unlike that of many other specialties. Ethics education for radiologists and radiology residents will benefit from the development of teaching materials and resources that focus on the issues that are specific to the specialty. This article is intended to serve as an educational resource for radiology training programs to facilitate teaching ethics to residents and also as a continuing medical education resource for practicing radiologists. In an environment of limited health care resources, radiologists are frequently asked to expedite imaging studies for patients and, in some respects, act as gatekeepers for specialty care. The issues of wait lists, queue jumping, and balancing the needs of individuals and society are explored from the perspective of a radiologist.

Compensation for Gamete Donation: The Analogy with Jury Duty

In Canada, laws and policies consistently reject the commodification of human organs and tissues, and Canadian practice is consistent with international standards in this regard. Until the Assisted Human Reproduction (AHR) Act of 2004, gamete donation in Canada was an exception: Canadians could pay and be paid open market rates for gametes (sperm and egg) for use in in vitro fertilization (IVF). As sections of the AHR Act forbidding payment for gametes (Section 6) and permitting only reimbursement of receipted expenses (Section 12) gradually came into effect in 2005, Canada did away with this anomaly. Medical practice and legal prohibitions in assisted human reproduction are now consistent with other areas of medicine where tissues and organs are taken from one person to benefit others: Altruistic donation, rather than selling and buying, will be the norm. The authors thank Francoise Baylis, Jocelyn Downie, and members of the Novel Tech Ethics Research Team at Dalhousie University for their assistance with and feedback on earlier drafts of this paper. We also thank Tim Krahn for assistance in formatting this paper.

Introduction to the Special Issue: Precarious Solidarity—Preferential Access in Canadian Health Care

Systems of universal health coverage may aspire to provide care based on need and not ability to pay; the complexities of this aspiration (conceptual, practical, and ethical) call for normative analysis. This special issue arises in the wake of a judicial inquiry into preferential access in the Canadian province of Alberta, the Vertes Commission. I describe this inquiry and set out a taxonomy of forms of differential and preferential access. Papers in this special issue focus on the conceptual specification of health system boundaries (the concept of medical need) and on the normative questions raised by complex models of funding and delivery of care, where patients, providers, and services cross system boundaries.

Scientism in Medical Education and the Improvement of Medical Care: Opioids, Competencies, and Social Accountability

Scientism in medical education distracts educators from focusing on the content of learning; it focuses attention instead on individual achievement and validity in its measurement. I analyze the specific form that scientism takes in medicine and in medical education. The competencies movement attempts to challenge old “scientistic” views of the role of physicians, but in the end it has invited medical educators to focus on validity in the measurement of individual performance for attitudes and skills that medicine resists conceptualizing as objective. Academic medicine should focus its efforts instead on quality and relevance of care. The social accountability movement proposes to shift the focus of academic medicine to the goal of high quality and relevant care in the context of community service and partnership with the institutions that together with medicine create and cope with health and with health deficits. I make the case for this agenda through a discussion of the linked histories of the opioid prescribing crisis and the professionalism movement.