1
|
Affiliation(s)
- Rachel Burman
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
| | - Ruth Cairns
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
| | | | - Robert Elias
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
| | - Victoria Metaxa
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
| | - Gareth Owen
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
| | - Hazel Polat
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
| | - Alex Ruck Keene
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
| | - Emer Sutherland
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
| |
Collapse
|
2
|
Neal JB, Pearlman RA, White DB, Tolchin B, Sheth KN, Bernat JL, Hwang DY. Policies for Mandatory Ethics Consultations at U.S. Academic Teaching Hospitals: A Multisite Survey Study. Crit Care Med 2020; 48:847-853. [PMID: 32317595 PMCID: PMC10765238 DOI: 10.1097/ccm.0000000000004343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine the number of top-ranked U.S. academic institutions that require ethics consultation for specific adult clinical circumstances (e.g., family requests for potentially inappropriate treatment) and to detail those circumstances and the specific clinical scenarios for which consultations are mandated. DESIGN Cross-sectional survey study, conducted online or over the phone between July 2016 and October 2017. SETTING We identified the top 50 research medical schools through the 2016 U.S. News and World Report rankings. The primary teaching hospital for each medical school was included. SUBJECTS The chair/director of each hospital's adult clinical ethics committee, or a suitable alternate representative familiar with ethics consultation services, was identified for study recruitment. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A representative from the adult ethics consultation service at each of the 50 target hospitals was identified. Thirty-six of 50 sites (72%) consented to participate in the study, and 18 (50%) reported having at least one current mandatory consultation policy. Of the 17 sites that completed the survey and listed their triggers for mandatory ethics consultations, 20 trigger scenarios were provided, with three sites listing two distinct clinical situations. The majority of these triggers addressed family requests for potentially inappropriate treatment (9/20, 45%) or medical decision-making for unrepresented patients lacking decision-making capacity (7/20, 35%). Other triggers included organ donation after circulatory death, initiation of extracorporeal membrane oxygenation, denial of valve replacement in patients with subacute bacterial endocarditis, and posthumous donation of sperm. Twelve (67%) of the 18 sites with mandatory policies reported that their protocol(s) was formally documented in writing. CONCLUSIONS Among top-ranked academic medical centers, the existence and content of official policies regarding situations that mandate ethics consultations are variable. This finding suggests that, despite recent critical care consensus guidelines recommending institutional review as standard practice in particular scenarios, formal adoption of such policies has yet to become widespread and uniform.
Collapse
Affiliation(s)
- Jonathan B Neal
- University of Connecticut School of Medicine, Farmington, CT
| | - Robert A Pearlman
- National Center for Ethics in Health Care, Veterans Health Administration, Seattle, WA
- University of Washington School of Medicine, Seattle, WA
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Benjamin Tolchin
- Department of Neurology, Yale School of Medicine, New Haven, CT
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT
| | - Kevin N Sheth
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | | | - David Y Hwang
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| |
Collapse
|
3
|
Guy-Coichard C, Perraud G, Chailleu A, Gaillac V, Scheffer P, Mintzes B. Inadequate conflict of interest policies at most French teaching hospitals: A survey and website analysis. PLoS One 2019; 14:e0224193. [PMID: 31675383 PMCID: PMC6824557 DOI: 10.1371/journal.pone.0224193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 10/08/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There are 32 teaching hospitals in France, including 30 University hospitals and two Regional teaching hospitals. Teaching hospitals have three roles: health care provision, training of healthcare professionals, and medical research. These roles lead to frequent interactions with pharmaceutical and medical device companies, inevitably raising risks of conflicts of interests. Therefore, policies to manage conflict of interests (COI) are crucial. This study aims to examine COI policies in French teaching hospitals. METHODS All French teaching hospitals (n = 32) were included in this study. All hospitals websites were screened for institutional COI policies and curriculum on COI, using standardized keyword searches. More data were collected through a questionnaire addressed to each chief executive officer (CEO) of the teaching hospital. We used predefined criteria (n = 20) inspired by similar surveys on COI policies in French, US and Canadian medical schools, with some additions to reflect the local hospital context. A global score for each hospital, ranging from 0 to 60 (higher scores denoting stronger policies) was calculated by summing points obtained for each criterion. RESULTS All 32 hospitals had websites; 21 hospitals listed policies or regulations on their websites or provided them on request. In December 2017, 17 (53.1%) had rules and regulations for some items only, four of which (12.5%) have considered implementing a policy, and only two (6.3%) have begun implementation. 15 (46.9%) had no evidence of COI policies and a null score. The maximum score was 24 out of 60. CONCLUSION This is the first systematic assessment of COI policies in teaching hospitals in France. Such policies are needed to protect patients, clinicians and students from undue commercial influence. Despite public and political pressure for better management of COI, few teaching hospitals have implemented comprehensive and protective policies, and some hospitals lacked policies altogether. These results highlight the need for greater attention to management of COI within teaching hospitals. One potential solution would be to integrate COI policies into hospital accreditation procedures, in order to ensure a baseline of management at all teaching hospitals.
Collapse
Affiliation(s)
| | | | | | | | - Paul Scheffer
- Sciences of Education Department, Paris 8 University, Saint-Denis, France
| | - Barbara Mintzes
- Faculty of Pharmacy, Charles Perkins Centre, The University of Sydney, Sydney, Australia
| |
Collapse
|
4
|
McCarthy MW, de Asua DR, Gabbay E, Christos PJ, Fins JJ. Frequency of Ethical Issues on a Hospitalist Teaching Service at an Urban, Tertiary Care Center. J Hosp Med 2019; 14:290-293. [PMID: 30897052 PMCID: PMC7343177 DOI: 10.12788/jhm.3179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/29/2019] [Indexed: 11/20/2022]
Abstract
Little is known about the daily ethical conflicts encountered by hospitalists that do not prompt a formal clinical ethics consultation. We describe the frequencies of ethical issues identified during daily rounds on hospitalist teaching services at a metropolitan, tertiary-care, teaching hospital. Data were collected from September 2017 through May 2018 by two attending hospitalists from the ethics committee who were embedded on rounds. A total of 270 patients were evaluated and 113 ethical issues were identified in 77 of those patients. These issues most frequently involved discussions about goals of care, treatment refusals, decision-making capacity, discharge planning, cardiopulmonary resuscitation status, and pain management. Only five formal consults were brought to the Hospital Ethics Committee for these 270 patients. Our data are the first prospective description of ethical issues arising on academic hospitalist teaching services and are an important step in the development of a targeted ethics curriculum for hospitalists.
Collapse
Affiliation(s)
- Matthew W McCarthy
- Division of Hospital Medicine, Department of Medicine, New York–Presbyterian–Weill Cornell Medical Center, New York, New York
- Corresponding Author: Matthew W McCarthy, MD, FACP; E-mail: ; Telephone: 212-746-4071
| | - Diego Real de Asua
- Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Ezra Gabbay
- Division of Hospital Medicine, Department of Medicine, New York–Presbyterian–Weill Cornell Medical Center, New York, New York
| | - Paul J Christos
- Department of Healthcare Policy & Research, NewYork–Presbyterian Hospital–Weill Cornell Medicine, New York, New York
| | - Joseph J Fins
- Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York
- Department of Healthcare Policy & Research, NewYork–Presbyterian Hospital–Weill Cornell Medicine, New York, New York
- CASBI, Consortium for the Advanced Study of Brain Injury, Weill Cornell and Rockefeller University, New York, New York
- Solomon Center for Health Law & Policy, Yale Law School, New Haven, Connecticut
| |
Collapse
|
5
|
|
6
|
Affiliation(s)
- Chryssa McAlister
- From the Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto
| |
Collapse
|
7
|
Haramati N. The physician payments sunshine act: what the average radiologist and manager need to know. J Am Coll Radiol 2014; 10:449-51. [PMID: 23735270 DOI: 10.1016/j.jacr.2012.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Accepted: 12/14/2012] [Indexed: 11/19/2022]
Abstract
The Physician Payments Sunshine Act (PPSA) was enacted in 2010 and requires applicable manufacturers of medical devices, drugs, biological material, or medical supplies to report payments or transfers of value that are provided to physicians or teaching hospitals. PPSA has value in creating greater transparency in the financial relationships between industry, physicians, and teaching hospitals, and in potentially reducing problematic conflicts of interest. PPSA requires that this data be published, in searchable form, on a public website. CMS has delayed the reporting under PPSA until after January 1, 2013, and has yet to issue its final rules for PPSA; however, Physician Payments data already exist in a publically searchable database. It is important to realize that names of individuals may appear in the PPSA public database, even if those individuals did not actually receive a transfer of value. As with all broad-stroke legislation, consequences not anticipated or not considered sufficiently important for our government leaders may well present a problem for individuals. It behooves all physicians and healthcare managers to carefully follow the CMS PPSA regulations. In advance of meeting or interacting with any PPSA-applicable manufacturer, obtain a clear and mutual understanding regarding what reportable value, if any, will be prepared for and provided by the applicable manufacturer. In this, as in all situations in which government regulations are at play, "knowledge is strength."
Collapse
Affiliation(s)
- Nogah Haramati
- Department of Radiology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA.
| |
Collapse
|
8
|
Wilson M. The Sunshine Act: commercial conflicts of interest and the limits of transparency. Open Med 2014; 8:e10-3. [PMID: 25009680 PMCID: PMC4085090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Mark Wilson
- Mark Wilson is a bioethicist living in Guelph, Ontario, Canada
| |
Collapse
|
9
|
Kelle Silva L, Dos Santos Marins PR, Nascimento Nobre TC, da Silva Frazão I, de Oliveira Santa Rosa D. Ethical implications and decision making in care education process. Invest Educ Enferm 2014; 32:236-243. [PMID: 25230034 DOI: 10.17533/udea.iee.v32n2a06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Accepted: 02/10/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To determine ethical implications for nursing practice at the point of decision making by nursing professors in practice area. METHODOLOGY A qualitative method was adopted, with use of semistructured interviews with sixteen nursing professors who delivered care at a teaching hospital in Salvador, Bahia, from May to June 2011. The methodological reference used was the discourse of the collective subject (DCS) by Lefévre and Lefévre. RESULTS . In response to DCSs, the following subjects appeared: "Ethics is fundamental and of vital importance in the decision making process," "searching for knowledge and research to identify problems and solutions, including alternatives and support for decisions," and "to act in the best way." CONCLUSION Professors who provide education about patient care also delivered care. They have the responsibility to consider the ethical implications of decision making because they stimulate fundamental reflection and could positively influence future nursing professionals.
Collapse
|
10
|
Abstract
Introduction National Health Service hospitals and government agencies are increasingly using mortality rates to monitor the quality of inpatient care. Mortality and Morbidity (M&M) meetings, established to review deaths as part of professional learning, have the potential to provide hospital boards with the assurance that patients are not dying as a consequence of unsafe clinical practices. This paper examines whether and how these meetings can contribute to the governance of patient safety. Methods To understand the arrangement and role of M&M meetings in an English hospital, non-participant observations of meetings (n=9) and semistructured interviews with meeting chairs (n=19) were carried out. Following this, a structured mortality review process was codesigned and introduced into three clinical specialties over 12 months. A qualitative approach of observations (n=30) and interviews (n=40) was used to examine the impact on meetings and on frontline clinicians, managers and board members. Findings The initial study of M&M meetings showed a considerable variation in the way deaths were reviewed and a lack of integration of these meetings into the hospital's governance framework. The introduction of the standardised mortality review process strengthened these processes. Clinicians supported its inclusion into M&M meetings and managers and board members saw that a standardised trust-wide process offered greater levels of assurance. Conclusion M&M meetings already exist in many healthcare organisations and provide a governance resource that is underutilised. They can improve accountability of mortality data and support quality improvement without compromising professional learning, especially when facilitated by a standardised mortality review process.
Collapse
Affiliation(s)
- Juliet Higginson
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, UK
| | | | | |
Collapse
|
11
|
Affiliation(s)
- Robert Steinbrook
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, I-456 SHM, PO Box 208008, New Haven, CT 06520, USA.
| | | |
Collapse
|
12
|
Abstract
OBJECTIVES To describe the population served and issues encountered by Hospital Ethics Committee consultation, to describe the incidence of consultation per hospital admission, and to describe the resource utilization per consult. PATIENTS AND METHODS This is a retrospective review of all ethics consults at a large urban teaching hospital and level one trauma center in a metropolitan area from January 1, 2004, through December 31, 2006. The data points analyzed were patient demographics, time spent by consultants (resource utilization), and the choice to pursue a full consult, which differs from a brief consult by the number of ethics consultants involved and the formality of the deliberative process. RESULTS A total of 285 consults were conducted or 0.16% (95% confidence interval, 0.14%-0.18%) of all hospital admissions. The highest incidence was 0.88% (95% confidence interval, 0.59%-1.3%) for the trauma intensive care unit. The average age of patients consulted on was 51 years, and 54% were in the intensive care unit. Of the consults, 90% were brief, and 52% were requested by house staff. Consultants logged 60,368 minutes, 38% of which were devoted to full consults (10% of total). Consults in obstetrics, general medicine, and surgery were the most time-consuming. Pregnancy and human immunodeficiency virus were more prevalent in full consults. The "classic" ethics cases of confidentiality (5%), patients requesting futile treatment (5%), brain death (4%), error disclosure (1%), and organ-donor rights (0.3%) were marginal in our series. CONCLUSION Little data exist on the practice of ethics consultation services. To our knowledge, this series represents the largest to date. Specific issues, patient characteristics, and hospital services were more prevalent in the most time-consuming consults. These data can be used to target the education of residents and inform hospital quality initiatives.
Collapse
Affiliation(s)
| | - Christian J. Vercler
- Individual reprints of this article are not available. Address correspondence to Christian J. Vercler, MD, at his current address: Division of Plastic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 ()
| | | | | |
Collapse
|
13
|
Dubovsky SL, Kaye DL, Pristach CA, DelRegno P, Pessar L, Stiles K. Can academic departments maintain industry relationships while promoting physician professionalism? Acad Med 2010; 85:68-73. [PMID: 20042827 DOI: 10.1097/acm.0b013e3181c42deb] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The authors describe the development of a comprehensive policy for relationships of full-time and volunteer faculty and residents with industry. The underlying philosophy was that an academic approach to relations with industry that emphasizes objective outcomes and internal change will be more effective than rote restrictions on behavior that assume that physicians cannot learn new behaviors and that are impossible to enforce. The policy, developed through much discussion and debate with stakeholders, involves elimination of industry-supplied meals, gifts, and favors; integration of industry-sponsored and academic research; education of faculty and residents about the ways in which industry marketing influences clinical decision making; and comprehensive disclosure by faculty, including to patients, of financial interests in industry. At occasional points in the psychopharmacology curriculum and at a departmental "pharma symposium," industry representatives or industry-sponsored guest speakers are allowed to present peer-reviewed articles followed by comments by a faculty member with relevant expertise about aspects of the presentation that are accurate or misleading and by a general discussion of research and clinical implications of the research and the manner in which it is presented. Adherence to new protocols has been high because faculty and residents participated in developing them and are involved in their implementation. Acceptance by industry representatives has been variable. Experience with this approach suggests that it is possible to develop a collaborative relationship with industry that maintains appropriate boundaries between industry and academia.
Collapse
Affiliation(s)
- Steven L Dubovsky
- Department of Psychiatry, University at Buffalo, Buffalo, New York, USA.
| | | | | | | | | | | |
Collapse
|
14
|
Abstract
PURPOSE To obtain prospective evidence of whether industry support of continuing medical education (CME) affects perceptions of commercial bias in CME activities. METHOD The authors analyzed information from the CME activity database (346 CME activities of numerous types; 95,429 participants in 2007) of a large, multispecialty academic medical center to determine whether a relationship existed among the degree of perceived bias, the type of CME activity, and the presence or absence of commercial support. RESULTS Participants per activity ranged from 1 to 3,080 (median: 276). When asked the yes/no question, "Overall, was this activity satisfactorily free from commercial bias?" 97.3% to 99.2% (mean: 98.4%) of participants answered "yes." In responding on a four-point scale to the request, "Please rate the degree to which this activity met the Accreditation Council for Continuing Medical Education requirement that CME activities must be free of commercial bias for or against a specific product," 95.8% to 99.3% (mean: 97.2%) of participants answered "excellent" or "good." When analyzed by type of funding relative to commercial support--none (149), single source (79), or multiple source (118)--activities were deemed to be free of commercial bias by 98% (95% CI: 97.3, 98.8), 98.5% (97.5, 99.5), and 98.3% (97.4, 99.1) of participants, respectively. None of the comparisons showed statistically significant differences. CONCLUSIONS This large, prospective analysis found no evidence that commercial support results in perceived bias in CME activities. Bias level seem quite low for all types of CME activities and is not significantly higher when commercial support is present.
Collapse
Affiliation(s)
- Steven Kawczak
- Center for Continuing Education, Cleveland Clinic, Cleveland, Ohio 44195, USA.
| | | | | | | |
Collapse
|
15
|
Abstract
There are differences in conflicts of interest (COIs) in professional organizations compared with academic medical centers. The authors discuss nine major questions pertaining to industry relationships of professional organizations: (1) What makes COI management different in professional membership organizations? (2) What COI challenges are specific to professional organizations? (3) What are potential impacts of perceived or real COIs involving professional organizations and the management of COIs? (4) Is regulation necessary, or should professional organizations proactively resolve COI issues independently? (5) Are guidelines portable from academic medical centers to professional organizations? (6) What approaches may be considered for managing COIs of the organization's leaders? (7) What approaches are reasonable for managing COI issues at professional meetings? (8) What approaches are important for integrity of educational programs, publications, and products? and (9) What approaches are reasonable for managing and enforcing COI guidelines on an ongoing basis? Responses to these questions focus on four principles: First, a code of ethics governing general behavior of members and safeguarding the interest of patients must be in place; second, the monitoring and management of COI for leadership, including, in some cases, recusal from certain activities; third, the pooling and consistent, transparent management of unrestricted grants from corporate sponsors; and, fourth, the management of industry marketing efforts at membership meetings to ensure their appropriateness. The perspectives offered are intended to encourage individuals and learned bodies to further study and provide commentary and recommendations on managing COIs of a professional organization.
Collapse
|
16
|
Cheatham M. Isn't it time for us to "give something back?". Surg Neurol 2009; 72:434-435. [PMID: 19604549 DOI: 10.1016/j.surneu.2009.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Accepted: 02/09/2009] [Indexed: 05/28/2023]
MESH Headings
- Asia, Southeastern
- Craniocerebral Trauma/surgery
- Education, Medical, Continuing/ethics
- Education, Medical, Continuing/history
- Education, Medical, Continuing/trends
- History, 20th Century
- Hospitals, Teaching/ethics
- Hospitals, Teaching/supply & distribution
- Hospitals, Teaching/trends
- Humans
- International Educational Exchange/trends
- Medically Underserved Area
- Neurosurgery/education
- Neurosurgery/ethics
- Neurosurgery/history
- Volunteers/history
Collapse
|
17
|
MESH Headings
- Drug Industry/ethics
- Drug Industry/standards
- Education, Medical/economics
- Education, Medical/ethics
- Education, Medical/standards
- Education, Medical, Continuing/economics
- Education, Medical, Continuing/ethics
- Education, Medical, Continuing/standards
- Ethics, Institutional
- Ethics, Professional
- Gift Giving
- Hospitals, Teaching/economics
- Hospitals, Teaching/ethics
- Hospitals, Teaching/standards
- Interinstitutional Relations
- Interprofessional Relations
- Organizational Policy
- Policy Making
- Schools, Medical/economics
- Schools, Medical/ethics
- Schools, Medical/standards
- Training Support/ethics
- Training Support/organization & administration
- Training Support/standards
- United States
Collapse
Affiliation(s)
- Arnold S Relman
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| |
Collapse
|
18
|
Abstract
CONTEXT Institutional academic-industry relationships have the potential of creating institutional conflicts of interest. To date there are no empirical data to support the establishment and evaluation of institutional policies and practices related to managing these relationships. OBJECTIVE To conduct a national survey of department chairs about the nature, extent, and consequences of institutional-academic industry relationships for medical schools and teaching hospitals. DESIGN, SETTING, AND PARTICIPANTS National survey of department chairs in the 125 accredited allopathic medical schools and the 15 largest independent teaching hospitals in the United States, administered between February 2006 and October 2006. MAIN OUTCOME MEASURE Types of relationships with industry. RESULTS A total of 459 of 688 eligible department chairs completed the survey, yielding an overall response rate of 67%. Almost two-thirds (60%) of department chairs had some form of personal relationship with industry, including serving as a consultant (27%), a member of a scientific advisory board (27%), a paid speaker (14%), an officer (7%), a founder (9%), or a member of the board of directors (11%). Two-thirds (67%) of departments as administrative units had relationships with industry. Clinical departments were more likely than nonclinical departments to receive research equipment (17% vs 10%, P = .04), unrestricted funds (19% vs 3%, P < .001), residency or fellowship training support (37% vs 2%, P < .001), and continuing medial education support (65% vs 3%, P < .001). However, nonclinical departments were more likely to receive funding from intellectual property licensing (27% vs 16%, P = .01). More than two-thirds of chairs perceived that having a relationship with industry had no effect on their professional activities, 72% viewed a chair's engaging in more than 1 industry-related activity (substantial role in a start-up company, consulting, or serving on a company's board) as having a negative impact on a department's ability to conduct independent unbiased research. CONCLUSION Overall, institutional academic-industry relationships are highly prevalent and underscore the need for their active disclosure and management.
Collapse
|
19
|
Rentmeester CA, O'Brien RL. Moral priorities in a teaching hospital. Hastings Cent Rep 2007; 36:13; discussion 13-4. [PMID: 17278866 DOI: 10.1353/hcr.2006.0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
20
|
Kapiriri L, Martin DK. Priority setting in developing countries health care institutions: the case of a Ugandan hospital. BMC Health Serv Res 2006; 6:127. [PMID: 17026761 PMCID: PMC1609114 DOI: 10.1186/1472-6963-6-127] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2006] [Accepted: 10/06/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Because the demand for health services outstrips the available resources, priority setting is one of the most difficult issues faced by health policy makers, particularly those in developing countries. However, there is lack of literature that describes and evaluates priority setting in these contexts. The objective of this paper is to describe priority setting in a teaching hospital in Uganda and evaluate the description against an ethical framework for fair priority setting processes--Accountability for Reasonableness. METHODS A case study in a 1,500 bed national referral hospital receiving 1,320 out patients per day and an average budget of 13.5 million US dollars per year. We reviewed documents and carried out 70 in-depth interviews (14 health planners, 40 doctors, and 16 nurses working at the hospital). Interviews were recorded and transcribed. Data analysis employed the modified thematic approach to describe priority setting, and the description was evaluated using the four conditions of Accountability for Reasonableness: relevance, publicity, revisions and enforcement. RESULTS Senior managers, guided by the hospital strategic plan make the hospital budget allocation decisions. Frontline practitioners expressed lack of knowledge of the process. RELEVANCE Priority is given according to a cluster of factors including need, emergencies and patient volume. However, surgical departments and departments whose leaders "make a lot of noise" are also prioritized. Publicity: Decisions, but not reasons, are publicized through general meetings and circulars, but this information does not always reach the frontline practitioners. Publicity to the general public was through ad hoc radio programs and to patients who directly ask. Revisions: There were no formal mechanisms for challenging the reasoning. Enforcement: There were no mechanisms to ensure adherence to the four conditions of a fair process. CONCLUSION Priority setting decisions at this hospital do not satisfy the conditions of fairness. To improve, the hospital should: (i) engage frontline practitioners, (ii) publicize the reasons for decisions both within the hospital and to the general public, and (iii) develop formal mechanisms for challenging the reasoning. In addition, capacity strengthening is required for senior managers who must accept responsibility for ensuring that the above three conditions are met.
Collapse
Affiliation(s)
- Lydia Kapiriri
- Joint Centre for Bioethics, University of Toronto. 88 College Street, Toronto, Ontario, M5G 1L4, Canada
| | - Douglas K Martin
- Joint Centre for Bioethics, University of Toronto. 88 College Street, Toronto, Ontario, M5G 1L4, Canada
- Department of Health Policy, Management and Evaluation. University of Toronto Health Sciences Building, 155 College Street, Suite 425 Toronto, ONM5T 3M6, Canada
| |
Collapse
|
21
|
Walrond ER, Jonnalagadda R, Hariharan S, Moseley HSL. Knowledge, attitudes and practice of medical students at the Cave Hill Campus in relation to ethics and law in healthcare. W INDIAN MED J 2006; 55:42-7. [PMID: 16755819 DOI: 10.1590/s0043-31442006000100010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The purpose of this study is to assess the knowledge, attitudes and practices among medical students in relation to medical ethics and law. The results of the study will be a useful guide to tutors of medical students and curricula designers. METHODS A thirty-item self-administered questionnaire about knowledge of law and ethics, and the role of an ethics committee in the healthcare system was devised, tested and distributed to all levels of students and staff at the Queen Elizabeth Hospital in Barbados (a tertiary care teaching hospital) in 2003. The data from the completed questionnaires were entered into an SPSS database and analyzed using frequency and multiple cross-tabulation tables. RESULTS Completed responses were obtained from 55 (96%) of the medical students. Medical students generally attested to the importance of ethical knowledge but felt that they knew little of the law. Students varied widely as regards the frequency with which they saw ethical or legal problems, with a quarter seeing them infrequently, but another quarter seeing them every day. They received their knowledge from multiple sources and particularly from lectures/seminars, and found case conferences the most helpful. Only a few students felt that text books had been helpful. Students were generally knowledgeable about most ethical issues, but many had uncertainties on how to deal with religious differences in treating patients, on the information to be given to relatives, and how violent patients should be treated. CONCLUSIONS The results of the study highlight that medical students felt an inadequacy of knowledge of law as it pertains to their chosen career Since most of their knowledge of law was obtained from lectures, these should be reviewed and other avenues of tuition explored. The study also highlights the need to identify the minority of students who have problems with their ethical knowledge and to devise means whereby any deficiencies can be discussed and modified.
Collapse
Affiliation(s)
- E R Walrond
- School of Clinical Medicine and Research, Queen Elizabeth Hospital, Barbados, West Indies.
| | | | | | | |
Collapse
|
22
|
Affiliation(s)
- James W Jones
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX 77030, USA.
| | | | | |
Collapse
|
23
|
Abstract
Industry and medicine share a complicated relationship that engenders a considerable degree of controversy. Although they share a relationship, industry and medicine have different perspectives toward their involvement with each other. Industry conceives of medicine as one aspect of the "drug pipeline", a larger set of relationships that is necessary for producing and marketing products. In contrast, select physicians refer to medicine's relationship with industry as "dancing with the porcupine", an inherently difficult and dangerous activity. This paper compares the "pipeline" and "porcupine" metaphors, and draws upon ethnographic data from fieldwork conducted among clinical neuroscientists at a Canadian medical school to further elucidate the perspectives of physicians toward industry and the nature of the physician-industry relationship. The paper argues that the physician-industry relationship is akin to a type of gift-exchange known as a total prestation, and that this form of total prestation is part of a strategy of capital reconversion.
Collapse
Affiliation(s)
- Charles Mather
- Department of Anthropology, University of Calgary, 2500 University Drive N.W., Calgary, Alberta, Canada T2N IN4.
| |
Collapse
|
24
|
Schniederjan S, Donovan GK. Ethics versus education: pelvic exams on anesthetized women. J Okla State Med Assoc 2005; 98:386-8. [PMID: 16206868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
In a survey of junior and senior medical students at the University of Oklahoma, a large majority of respondents reported having performed pelvic exams on anesthetized gynecologic surgery patients. Nearly three-quarters also reported believing that these patients had not specifically consented to undergo exams by students during their surgical procedures. While some students and medical educators maintain that pelvic exams under anesthesia are necessary for the development of students' examination skills, this assertion has not gone unquestioned. Serious ethical concerns have been raised by members of the medical community and women's advocacy groups, and the practice was recently outlawed in one state. Despite this widespread opposition, non-consented pelvic examinations evidently remain a common practice in US teaching hospitals. Our consideration of this controversial issue leads us to conclude that explicit, informed consent must be obtained in order for pelvic examinations to be performed on surgical patients, or risk compromising the doctor-patient relationship.
Collapse
|
25
|
Abstract
The relationship between medical schools and their teaching hospitals involves a complex and variable mixture of monopoly and monopsony power, which has not been previously been ethically analyzed. As a consequence, there is currently no ethical framework to guide leaders of both institutions in the responsible management of this complex power relationship. The authors define these two forms of power and, using economic concepts, analyze the nature of such power in the medical school-teaching hospital relationship, emphasizing the potential for exploitation. Using concepts from both business ethics and medical ethics, the authors analyze the nature of transparency and co-fiduciary responsibility in this relationship. On the basis of both rational self-interest, drawn from business ethics, and co-fiduciary responsibility, drawn from medical ethics, they argue for the centrality of transparency in the medical school-teaching hospital relationship. Understanding the ethics of monopoly and monopsony power is essential for the responsible management of the complex relationship between medical schools and their teaching hospitals and can assist the leadership of academic health centers in carrying out one of their major responsibilities: to prevent the exploitation of monopoly power and monopsony power in this relationship.
Collapse
Affiliation(s)
- Frank A Chervenak
- The New York-Presbyterian Hospital, Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, 525 East 68 Street, Box 122, New York, NY 10021, USA.
| | | |
Collapse
|
26
|
Wilson RF. Autonomy suspended: using female patients to teach intimate exams without their knowledge or consent. J Health Care Law Policy 2005; 8:240-63. [PMID: 16471023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
|
27
|
Abstract
A 42-year-old woman presenting to an academic medical center with low back pain radiating down her left leg was deemed to be a good candidate for a lumbar epidural steroid injection after undergoing a thorough evaluation. The procedure along with all the possible attendant side effects were thoroughly explained to the patient who readily signed the consent form. The patient was prepped and positioned, but, upon seeing that a resident rather than her attending doctor would be doing the procedure, she objected, insisting that the attending do the procedure. The attending explained that she was in a teaching hospital, where residents commonly do procedures under close supervision of attending physicians. Nevertheless, the patient still insisted on whom she wanted to do the procedure and became visibly agitated. How do you accommodate the training needs of medical students, residents, and fellows while maintaining adequate care for patients? Does the "see one, do one, teach one" principle commonly practiced in academic settings compromise the bioethical principles of nonmaleficence and beneficence? What should the attending do in this case with the patient on the table? What are the patient's rights here versus the needs of the training setting?
Collapse
|
28
|
Ferris LE, Singer PA, Naylor CD. Better governance in academic health sciences centres: moving beyond the Olivieri/Apotex Affair in Toronto. J Med Ethics 2004; 30:25-29. [PMID: 14872067 PMCID: PMC1757127 DOI: 10.1136/jme.2003.005181] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The Toronto experience suggests that there may be several general lessons for academic health sciences complexes to learn from the Olivieri/Apotex affair (OAA) regarding the ethics, independence, and integrity of clinical research sponsored by for profit enterprises. From a local perspective, the OAA occurred when there already was a focus on the complex and changing relationships among the University of Toronto, its medical school, the fully affiliated teaching hospitals, and off campus faculty because of intertwined interests and responsibilities. The OAA became a catalyst that accelerated various systemic reforms, particularly concerning academic/industry relations. In this article, the evolving governance framework for the Toronto academic health sciences complex is reviewed and these policy and process reforms discussed. These reforms have created collaborative activity among research ethics boards and contract research offices of the partner institutions, and allowed the joint university/hospital ethics centre to play a role in governance and policy, while respecting the missions and mandates of the involved institutions. Although few of the policies are dramatically innovative, what is arguably novel is the elaboration of an overarching governance framework that aims to move ethics to a central focus in the academic complex. Time alone will tell how sustainable and effective these changes are.
Collapse
Affiliation(s)
- L E Ferris
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | | | | |
Collapse
|
29
|
Abstract
Medical schools and teaching hospitals have been hit particularly hard by the financial crisis affecting health care in the United States. To compete financially, many academic medical centers have recruited wealthy foreign patients and established luxury primary care clinics. At these clinics, patients are offered tests supported by little evidence of their clinical and/or cost effectiveness, which erodes the scientific underpinnings of medical practice. Given widespread disparities in health, wealth, and access to care, as well as growing cynicism and dissatisfaction with medicine among trainees, the promotion by these institutions of an overt, two-tiered system of care, which exacerbates inequities and injustice, erodes professional ethics. Academic medical centers should divert their intellectual and financial resources away from luxury primary care and toward more equitable and just programs designed to promote individual, community, and global health. The public and its legislators should, in turn, provide adequate funds to enable this. Ways for academic medicine to facilitate this largesse are discussed.
Collapse
Affiliation(s)
- Martin Donohoe
- Department of Community Health, Portland State University, Lake Oswego, OR 97034, USA.
| |
Collapse
|
30
|
Sethuraman KR. Ethics of patient care by trainee-doctors in teaching hospitals. J Postgrad Med 2003; 49:159-62. [PMID: 12867695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Affiliation(s)
- K R Sethuraman
- Departments of Medicine & Medical Education, JIPMER, Pondicherry - 6, India.
| |
Collapse
|
31
|
Mitchell C, Truog R. Case reports from the Harvard Ethics Consortium. J Clin Ethics 2003; 13:49-53. [PMID: 12235682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
|