Ruth B. Purtilo

The ethical dilemmas of a rural physician.

Physicians in rural settings confront many of the same ethical dilemmas as their urban counterparts: confidentiality, quality-of-life decisions, resource allocation, and their moral responsibility for bettering the life of the community. However, the courses of action they choose as morally justifiable are influenced by distance from other professional facilities, the interrelationship of private and professional roles in a small community, and the non-specialized orientation of their practices.

Is the Use of Placebo Controls Ethically Permissible in Clinical Trials of Agents Intended to Reduce Fractures in Osteoporosis

Substantial progress has been made in developing treatments that reduce the risk of fractures in osteoporosis. However, available treatments are only partially effective, they are not widely used, and there is need to search for more effective means of fracture prevention. Currently known effective means of reducing fractures were found using randomized placebo‐controlled trials. The use of placebo controls in clinical trials has been a subject of significant controversy in recent years. The Declaration of Helsinki revision of October 2000 caused great concern among clinical investigators about the future use of placebo controls if known effective therapeutic agents are available. A working group of ethicists, clinical trial design experts, and clinical investigators examined the current state of knowledge of osteoporosis treatment and trials. They concluded that if placebo controls put subjects at substantial risk of serious outcomes, they are not ethically permissible. Placebo controls in osteoporosis trials with fracture as the measured outcome are permissible only under narrowly defined conditions. Placebo controls may be used if competent, well‐informed patients refuse approved therapies for sound reasons, there is a reasonable basis for substantial disagreement or lack of consensus among professionals about whether approved treatments are better than placebos, or subjects are refractory to known effective agents. Active control trials are permissible and desirable if they can be designed and conducted in ways that overcome the interpretive difficulties often associated with such trials.

Ethical issues in the treatment of chronic ventilator-dependent patients

Two important ethical concerns facing physicians and others involved in the management of ventilator-dependent patients in the medical rehabilitation environment are: the cost of employing the respirator and the accompanying allocation issues entailed in that consideration, and the quality of life the ventilator imposes on or improves for a patient. Present practices are described and analyzed and suggestions are made for how physiatrists can constructively address key problems which arise in the professions attempt to act in accord with high ethical standards of practice.

Ethical issues and the patient-provider relationship.

In enabling disabled persons to gain increased function and independence, rehabilitation practitioners try to emphasize the patients goals by providing the patient with some control over the process. As the patient enters the active rehabilitation phase, the patient actively becomes involved with the design of the treatment plan. If the patient does not fully participate in this plan, his/her motivation may be questioned. Rehabilitation professionals prefer patients who comply with the original treatment plan. Conflicts arise when patients do not comply, and the war between patient autonomy and medical paternalism ensues. When the disabled person becomes an outpatient, we must learn to measure the quality of life, not just the functional outcome. Rehabilitation professionals have become masters of inpatient rehabilitation but are less prepared to facilitate comprehensive rehabilitation care in the outpatient setting. Outpatient rehabilitation also needs to measure community reintegration. In the continuum of chronic disability, the care-giver and the disabled person develop an intermittent interdependence with an alternating relationship between autonomy and paternalism. Mutal respect such as that experienced in friendship provides a useful model for this idealized patient-care enabler team. To understand more of the essence of the disabled persons life is the responsibility of the rehabilitation provider.

Team challenges: regulatory constraints and patient empowerment

This paper addresses two new challenges to the rehabilitation team. The first is to continue to provide high quality services in an era when government and other regulations place constraints on what the rehabilitation team can offer. The second challenge is to honor the ideal of patient empowerment in this era of policy constraint. Ethical issues involved in responding constructively to these challenges are discussed and practical suggestions offered.

Interdisciplinary health care teams and health care reform.

T he purpose of this paper is to encourage reflection about the harm that could result if the positive A aspects of team-organized health care a;e compromised during the health care reform process. While other models of health care delivery could replace teamwork and serve patients as well or better, the interdisciplinary health care team (IHCT) probably will not be abandoned. However, one or more disciplines whose members play important roles on various teams may be sacrificed in the hasty effort to define essential health care. Moreover, a significant proportion of the types of IHCTs in existence could be rashly eliminated from health plans. These changes should not take place randomly or by default. Substantive analyses ofwhat is likely to happen toIHCTs and, in turn, how their fate will affect quality patient care are curiously absent from almost all discussions of health care reform today One reason for the neglect simply may be the numerous functions performed by IHCTs and the broad range of professionals involved, since so much patient care is offered through team approaches. A barrier to discussion at the national level may be that an IHCT is difficult to characterize as an “interest” with which to be reckoned. At any rate, the significance of the IHCT is difficult to capture and present for political assessment in an environment where ideas are packaged in small soundbytes, not unravelled in lengthy descriptions about complex interactions of groups. A working definition of interdisciplinary health care teams, as they will be discussed in this paper, is the following: an interdisciplinary health care team is two or more health professionals of different disciplines who apply their complementary professional skills to direct patient care, the primary goal being to provide competent and coordinated care. This definition is offered to focus comment foursquare on the critical issues of patient care, and not to ignore the importance of other team goals, or other types of health care teams whose goals might include building and maintaining team morale, educating health professionals, community outreach, advocacy, institutional planning, quality assurance, and others. Scores of IHCTs exist, but our discussion will be limited to generic themes that apply to each of them.

Physicians' Duty of Compassion

This is a time of change in American healthcare. Market forces are restructuring local delivery systems around competing managed care networks. Many leading proposals for healthcare reform intend a reshaping of the national healthcare marketplace itself. Periods of change create an opportunity to reassess traditional values and practices. Such reassessments can be used to help insure that current innovations and proposed reforms preserve and strengthen the best in the traditions of medicine. A legitimate focus of concern in the medical and medical ethics community has been the effect of these delivery system changes on the physician-patient relationship. For example, will the future American healthcare system support and encourage compassion by physicians? Suppose it does not. Would something of significant moral value have been lost? More pointedly, would a system that undervalued or frustrated physician compassion be incompatible with the moral obligations of physicians? In order to address these questions, we examine the meaning of compassion and the role it should play in the physician-patient relationship. We argue that compassion is a duty of all physicians. Because this is so, we believe that changes in the healthcare system must be judged, in part, by how well they protect and encourage compassionate conduct by physicians.

Whom to Treat First, and How Much is Enough?: Ethical Dilemmas that Physical Therapists Confront as They Compare Individual Patients' Needs for Treatment

When there is a scarcity of resources (therapists, modalities), the physical therapist must make decisions about whom to treat and why. This paper discusses ethical dilemmas confronting the therapist and addresses solutions based on approaches of procedural justice and distributive justice.

Ethics Teaching in Allied Health Fields

In a physical therapy department of a rehabilitation center a college student injured in an automobile accident has been treated daily for three months. He is a paraplegic and will never regain the use of his legs. However, the physician has written orders not to let the young man know that his disability is permanent. Until now the student has taken for granted that he will walk again. Today he asks the physical therapist directly if he will always be paralyzed. The physical therapist must decide: should I withhold the truth from the patient, or tell the truth, thereby endangering the doctor-patient relationship? Since physicians are regularly faced with awesome ethical decisions, it is appropriate for medical students to be given a basic course in physician ethics. However, the physical therapists dilemma is only one example of the many cases in which other health-care personnel must make ethical decisions by sharing responsibility with the physician or, in the absence of physicians, assuming full responsibility. Nurses, in particular, have begun to acknowledge unique ethical questions in their work. This, in turn, has given rise to the realization that simply extending to nurses the teaching of physician ethics is inappropriate. The result has been a surge of interest in developing a better understanding of ethical theory, ethics issues, and a hard look at how ethics ought to be addressed in a nursing curriculum.*

Complexities in decision making for persons with disabilities nearing end of life.

Abstract Good end-of-life care requires that clinicians, families, and ethicists be aware of biases that influence patient cases, particularly in the acute care setting where the aim is primarily cure and return to optimal functional level. Persons with disabilities may pose unique challenges; their potential for quality of life is viewed through the lens of highly functional clinicians who might have a biased view of the disabled person’s quality of life. The authors aim to present three categories of disability that do not claim to be absolute but rather offer clinicians and ethicists a lens through which to reflect on bias that unconsciously may influence their approach to the patient who is seriously ill and may be nearing the end of life. The categories include (a) a person who has lived with a disability from birth or early life, due to trauma or disease, and is now faced with a serious illness that requires that life-sustaining treatment; (b) the otherwise healthy person who acquires a disability through an acute event of disease or trauma and whose condition requires that life-sustaining treatment decisions be made; and (c) the person who has lived with a progressive chronic illness, such as lung or heart disease or amyotrophic lateral sclerosis, and may have gradually adjusted to disabilities imposed by the condition and now is faced with lifesustaining treatment decisions. The concept of inherent dignity (Pellegrino 2005) is suggested as a filtering lens in case consideration.