Physicians' willingness to participate in the process of lethal injection for capital punishment

BACKGROUND

It has been found that physicians condone colleague involvement in capital punishment. Physicians' own willingness to participate has not been explored.

OBJECTIVE

To examine physicians' willingness to be involved in cases of capital punishment.

DESIGN

Survey exploring physicians' willingness to participate in 10 aspects of capital punishment by lethal injection, 8 of which are disallowed by the American Medical Association.

SETTING

United States.

PARTICIPANTS

1000 randomly selected practicing physicians.

MEASUREMENTS

Questions assessing willingness to be involved in and attitudes toward capital punishment.

RESULTS

41% of respondents indicated that they would perform at least one action disallowed by the American Medical Association; 25% would perform five or more disallowed actions. Perceived duty to society (P < 0.001), approval of the death penalty (P < 0.001), and approval of assisted suicide (P = 0.015) correlated with increased willingness to perform disallowed actions. Only 3% of respondents knew of any guidelines on this issue.

CONCLUSIONS

Despite medical society policies, many physicians would be willing to be involved in the execution of adults. The medical profession needs to be better informed about the ethical issues involved in physician participation in capital punishment.

Physicians' experiences with patients who transgress boundaries

BACKGROUND

Boundary violations have been discussed in the literature, but most studies report on physician transgressions of boundaries or sexual transgressions by patients. We studied the incidence of all types of boundary transgressions by patients and physicians' responses to these transgressions.

METHODS

We surveyed 1,000 members of the Society of General Internal Medicine (SGIM) for the number of patient transgressions of boundaries which had occurred in the previous year. Categories were created by the investigators based on the literature. Physicians picked the most important transgression, and then were asked about their response to the transgression and its effect on the patient-physician relationship. Attitudinal questions addressed the likelihood of discharging patients who transgressed boundaries. The impact of demographic variables on the incidence of transgressions was analyzed using analysis of variance.

RESULTS

Three hundred thirty (37.5%) randomly selected SGIM members responded to the survey. Almost three quarters of the respondents had patients who used their first name, while 43% encountered verbal abuse, 39% had patients who asked personal questions, 31% had patients who were overly affectionate, and 27% encountered patients who attempted to socialize. All other transgressions, including physical abuse and attempts at sexual contact, were uncommon. Only gender affected the incidence of transgressions; female physicians encountered more personal questions (P = .001), inappropriate affection (P < .005), and sexually explicit language (P < .05) than male physicians and responded more negatively to boundary transgressions. Respondents dealt with transgressions by discussion with the patient or colleagues or by ignoring the incident, but such transgressions generally had a negative impact on the relationship. Most physicians would discharge patients who engaged in physical abuse or attempts at sexual contact, but were more tolerant of verbal abuse and overly affectionate patients.

CONCLUSIONS

Boundary transgressions by patients is common, but usually involves more minor infractions. Female physicians are more likely to encounter certain types of transgressions. The incidence and outcomes of such transgressions are important in assisting physicians to deal effectively with this issue.

Physicians' attitudes about involvement in lethal injection for capital punishment

BACKGROUND

Physicians could play various roles in carrying out capital punishment via lethal injection. Medical societies like the American Medical Association (AMA) and American College of Physicians have established which roles are acceptable and which are disallowed. No one has explored physicians' attitudes toward their potential roles in this process.

METHODS

We surveyed physicians about how acceptable it was for physicians to engage in 8 actions disallowed by the AMA and 4 allowed actions involving lethal injection. Questions assessing attitudes toward capital punishment and assisted suicide were included. The impact of attitudinal and demographic variables on the number of disallowed actions deemed acceptable was analyzed via analysis of variance and multiple logistic regression analysis.

RESULTS

Four hundred eighty-two physicians (51%) returned questionnaires. Eighty percent indicated that at least 1 of the disallowed actions was acceptable, 53% indicated that 5 or more were acceptable, and 34% approved all 8 disallowed actions. The percentage of respondents approving of disallowed actions varied from 43% for injecting lethal drugs to 74% for determining when death occurred. All 4 allowed actions were deemed acceptable by the majority of respondents. Favoring the death penalty (P<.001) and the acceptance of assisted suicide (P<.001) were associated with an increased number of disallowed actions that were deemed acceptable.

CONCLUSIONS

Despite medical society policies, the majority of physicians surveyed approved of most disallowed actions involving capital punishment, indicating that they believed it is acceptable in some circumstances for physicians to kill individuals against their wishes. It is possible that the lack of stigmatization by colleagues allows physicians to engage in such practices. Arch Intern Med. 2000;160:2912-2916

Confidentiality and health insurance fraud

BACKGROUND

Health insurance fraud committed by patients may be an increasing problem given the number of underinsured and uninsured people in the United States. Physicians recognizing acts of health insurance fraud perpetrated by patients face an ethical dilemma: should they disclose the incident to the insurance company, or protect patient confidentiality?

OBJECTIVE

To explore physicians' attitudes toward the reporting of patient-initiated health insurance fraud.

METHODS

Three hundred seven physician members of the American College of Physicians returned a mailed questionnaire that presented 6 case vignettes (3 variables) of patients who used a relative's insurance to obtain health care in the past. For each vignette, respondents were asked whether the treating physician should report insurance fraud to the health insurance carrier.

RESULTS

Sixty-three respondents (20.7%) indicated that physicians should report all the patients presented in the vignettes, while 45 (14.8%) indicated none should be reported; the rest indicated that the decisions to-report should be based on the characteristics presented, with acute vs terminal illness (P < .001), history of fraud (P < .001), and wealth of the patient (P < .001) all causing physicians to be more likely to report the patient to the health insurance carrier. Multivariate analysis demonstrated that type of practice (P = .04) and respondents' experiences with insurance fraud (P = .03) had significant effects on the willingness to report patients.

CONCLUSIONS

Physicians are divided about whether to report patients who have committed insurance fraud. Their decisions to report insurance fraud are influenced by their attitudes and demographic features, as well as by patient factors.

Telling patients about the diagnosis of HIV infection

This study used a questionnaire to examine how patients in the HIV/AIDS Clinic at a Department of Veterans Affairs hospital were told of their diagnosis, by whom, and to what degree they were given emotional and educational support. Nearly 17% of patients were informed by someone not in the health professions (often military personnel), and 27% of patients were notified in a nonprivate setting. Forty-seven percent indicated they received little or no educational support at the time of diagnosis, while 39% received little or no emotional support. Educational and emotional support for patients at the time of HIV diagnosis may be lacking.

Intern candidates who withdraw from contracts: incidence and internal medicine program directors' attitudes

OBJECTIVE

To study the prevalence of intern candidates accepted through the National Resident Matching Program (NRMP) or after the match who subsequently withdraw and the attitudes of program directors regarding this issue.

DESIGN

Mailed survey.

SETTING

Four hundred fifty-four internal medicine program directors.

MEASUREMENTS

Questionnaires assessing program directors' attitudes toward interns who contract for positions after having verbal or written agreements elsewhere (and the program directors who accept them), the importance of this problem, and the incidence of this problem.

MAIN RESULTS

Fifty-five programs (of the 221 responding) experienced intern withdrawals. Programs with larger numbers of open positions after the match had more intern withdrawals (p = 0.03). Eleven of the program directors knew of the prior commitment of the intern, and in all cases the other program director was called for permission to accept the intern. Program directors had negative feelings about both the interns who withdrew and the program directors who accepted them. Community, municipal, and Veterans Affairs hospital program directors were significantly less negative than those in university and university-affiliated hospitals toward interns who withdrew from written commitments (p = 0.001) and the program directors who accepted them (p < 0.05).

CONCLUSION

Problems with intern candidate withdrawals from offered/matched programs affect a significant proportion of programs, especially those with larger numbers of unmatched positions. Program directors are generally disapproving.

Residents' decisions to breach confidentiality

This study assessed variables involved in physician decisions to breach confidentiality in cases of patients' self-reported past crimes. Seventy internal medicine residents completed a questionnaire containing case vignettes of patients' self-reports of crimes; likelihood of informing the police was ascertained. Results were analyzed according to the type and cost of the crime, previous criminal record, patient characteristics, and intent of the patient to commit future crimes. Results also were analyzed by postgraduate year of the resident. Patient characteristics of race and socioeconomic status had no effect on the decision (p less than 0.122 and p 0.182), although age did (p less than 0.001). Reports of past violence (p less than 0.001), previous criminal record (p less than 0.001) and high-cost crime (p less than 0.007) increased the likelihood of breaching confidentiality. Future intent affected the decision (p less than 0.005), but less than reports of past violence. No differences were seen among postgraduate years of respondents (p less than 0.873). Residents base decisions to breach confidentiality on factors other than the future intent of specific violence. This finding has legal and ethical implications.

Values and CPR decisions: a comparison of physicians and administrators in training

A report of a study to analyze the effect of sociocultural patient characteristics (age, terminal diseases, drug abuse, alcoholism, mental retardation, dementia, suicide attempts, institutionalization, noncompliance with medical regimens, violent crimes, lack of support system, or relationship to a staff physician) on decisions to initiate or withhold cardiopulmonary resuscitation in an emergency situation. Pairs of vignettes were presented to residents in internal medicine and graduate students in an MBA program for comparisons of physicians' decisions with administrators' decisions. On some patient characteristics there were significant differences between the two groups. For most factors (drug abuse, multiple suicide attempts, age, violent crime, lack of known support systems, and relationship to staff), doctors are more likely to initiate CPR than are business students representing health care administrators. In chronic, long-term situations (carcinoma or heart disease, dementia, mental retardation, and institutionalization), the doctors are less likely to initiate CPR than the business students. If objectivity is a goal in deciding whether or not to initiate CPR, physicians should be aware of differences between their opinions and others'.

Cardiopulmonary resuscitation. Values and decisions--a comparison of health care professionals

The authors studied the effect of various patient factors (biomedical, mental status, and psychosocial) on the decision to perform cardiopulmonary resuscitation by internal medicine house staff and registered nurses. Clinical vignettes were utilized to assess the likelihood of initiation of cardiopulmonary resuscitation (CPR) by the respondents. In most cases, these factors had similar significant effects on decisions to initiate CPR by both physicians and nurses. However, some differences in the likelihood of performing CPR were found between the physician and nurse populations, particularly in the areas of mental status and institutionalization. Dementia, mental retardation, and nursing home status all caused residents to be significantly less likely to initiate CPR than nurses (P less than 0.001). This study demonstrates that biomedical, mental status, and psychosocial patient factors have a significant impact on the decision to initiate CPR by both internal medicine residents and nurses. These decisions apparently are rooted in similar criteria, although the basis for the differences between the two groups warrants further study.