Decisional autonomy undermines advisees' judgments of experts in medicine and in life.

Over the past several decades, the United States medical system has increasingly prioritized patient autonomy. Physicians routinely encourage patients to come to their own decisions about their medical care rather than providing patients with clearer yet more paternalistic advice. Although political theorists, bioethicists, and philosophers generally see this as a positive trend, the present research examines the important question of how patients and advisees in general react to full decisional autonomy when making difficult decisions under uncertainty. Across six experiments (N = 3,867), we find that advisers who give advisees decisional autonomy rather than offering paternalistic advice are judged to be less competent and less helpful. As a result, advisees are less likely to return to and recommend these advisers and pay them lower wages. Importantly, we also demonstrate that advisers do not anticipate these effects. We document these results both inside and outside the medical domain, suggesting that the preference for paternalism is not unique to medicine but rather is a feature of situations in which there are adviser-advisee asymmetries in expertise. We find that the preference for paternalism holds when advice is solicited or unsolicited, when both paternalism and autonomy are accompanied by expert guidance, and it persists both before and after the outcomes of paternalistic advice are realized. Lastly, we see that the preference for paternalism only occurs when decision makers perceive their decision to be difficult. These results challenge the benefits of recently adopted practices in medical decision making that prioritize full decisional autonomy.

Financial Profit in Medicine: A Position Paper From the American College of Physicians.

The steady growth of corporate interest and influence in the health care sector over the past few decades has created a more business-oriented health care system in the United States, helping to spur for-profit and private equity investment. Proponents say that this trend makes the health care system more efficient, encourages innovation, and provides financial stability to ensure access and improve care. Critics counter that such moves favor profit over care and erode the patient-physician relationship. American College of Physicians (ACP) underscores that physicians are permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high-quality, appropriate care within the guardrails of medical professionalism and ethics. In this position paper, ACP considers the effect of mergers, integration, private equity investment, nonprofit hospital requirements, and conversions from nonprofit to for-profit status on patients, physicians, and the health care system.

Quantifying Risk of Financial Incapacity and Financial Exploitation in Community-dwelling Older Adults: Utility of a Scoring System for the Lichtenberg Financial Decision-making Rating Scale.

Objectives: This work examines the clinical utility of the scoring system for the Lichtenberg Financial Decision-making Rating Scale (LFDRS) and its usefulness for decision making capacity and financial exploitation. Objective 1 was to examine the clinical utility of a person centered, empirically supported, financial decision making scale. Objective 2 was to determine whether the risk-scoring system created for this rating scale is sufficiently accurate for the use of cutoff scores in cases of decisional capacity and cases of suspected financial exploitation. Objective 3 was to examine whether cognitive decline and decisional impairment predicted suspected financial exploitation.Methods: Two hundred independently living, non-demented community-dwelling older adults comprised the sample. Participants completed the rating scale and other cognitive measures.Results: Receiver operating characteristic curves were in the good to excellent range for decisional capacity scoring, and in the fair to good range for financial exploitation.Conclusions: Analyses supported the conceptual link between decision making deficits and risk for exploitation, and supported the use of the risk-scoring system in a community-based population.Clinical Implications: This study adds to the empirical evidence supporting the use of the rating scale as a clinical tool assessing risk for financial decisional impairment and/or financial exploitation.

Different labs.

In this case a young dentist has signed onto a managed care plan that has several attractive features. Eventually, however, he notices that he makes little or no net revenue for some of the work that he does. A colleague recommends that he use different labs for different patients, with labs matched to each patient's dental plan and coverage. Offshore labs are used for managed care patients. Three knowledgeable experts comment on the case, two with many years of private practice experience, two who are dental educators holding master's degrees in philosophy and bioethics.

Reasons on the similarity of objections with regards to gambling and speculation in Islamic finance and conventional finance.

Gambling and speculation which leads to zero-sum outcomes are prohibited in Islamic finance and condemned in conventional finance. This article explores the reasons for the similarity of objections towards gambling and speculation. Three probable reasons are explored namely the concept of stewardship in conventional thought and the concept of khalifa in Islam, Christianity and morality's influence on conventional law and finance and the concept of ethics of sacrifice and ethics of tolerance.

Industry funding of patient and health consumer organisations: systematic review with meta-analysis.

OBJECTIVE: To investigate pharmaceutical or medical device industry funding of patient groups. DESIGN: Systematic review with meta-analysis. DATA SOURCES: Ovid Medline, Embase, Web of Science, Scopus, and Google Scholar from inception to January 2018; reference lists of eligible studies and experts in the field. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Observational studies including cross sectional, cohort, case-control, interrupted time series, and before-after studies of patient groups reporting at least one of the following outcomes: prevalence of industry funding; proportion of industry funded patient groups that disclosed information about this funding; and association between industry funding and organisational positions on health and policy issues. Studies were included irrespective of language or publication type. REVIEW METHODS: Reviewers carried out duplicate independent data extraction and assessment of study quality. An amended version of the checklist for prevalence studies developed by the Joanna Briggs Institute was used to assess study quality. A DerSimonian-Laird estimate of single proportions with Freeman-Tukey arcsine transformation was used for meta-analyses of prevalence. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) was used to assess the quality of the evidence for each outcome. RESULTS: 26 cross sectional studies met the inclusion criteria. Of these, 15 studies estimated the prevalence of industry funding, which ranged from 20% (12/61) to 83% (86/104). Among patient organisations that received industry funding, 27% (175/642; 95% confidence interval 24% to 31%) disclosed this information on their websites. In submissions to consultations, two studies showed very different disclosure rates (0% and 91%), which appeared to reflect differences in the relevant government agency's disclosure requirements. Prevalence estimates of organisational policies that govern corporate sponsorship ranged from 2% (2/125) to 64% (175/274). Four studies analysed the relationship between industry funding and organisational positions on a range of highly controversial issues. Industry funded groups generally supported sponsors' interests. CONCLUSION: In general, industry funding of patient groups seems to be common, with prevalence estimates ranging from 20% to 83%. Few patient groups have policies that govern corporate sponsorship. Transparency about corporate funding is also inadequate. Among the few studies that examined associations between industry funding and organisational positions, industry funded groups tended to have positions favourable to the sponsor. Patient groups have an important role in advocacy, education, and research, therefore strategies are needed to prevent biases that could favour the interests of sponsors above those of the public. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017079265.

Financial relationships between institutional review board members and industry.

BACKGROUND: Little is known about the nature, extent, and consequences of financial relationships between industry and institutional review board (IRB) members in academic institutions. We surveyed IRB members about such relationships. METHODS: We surveyed a random sample of 893 IRB members at 100 academic institutions (response rate, 67.2%). The questionnaire focused on the financial relationships that the members had with industry (e.g., employment, membership on boards, consulting, receipt of royalties, and paid speaking). RESULTS: We found that 36% of IRB members had had at least one relationship with industry in the past year. Of the respondents, 85.5% said they never thought that the relationships that another IRB member had with industry affected his or her IRB-related decisions in an inappropriate way, 11.9% said they thought this occurred rarely, 2.4% thought it occurred sometimes, and 0.2% thought it occurred often. Seventy-eight respondents (15.1%) reported that at least one protocol came before their IRB during the previous year that was sponsored either by a company with which they had a relationship or by a competitor of that company, both of which could be considered conflicts of interest. Of these 78 members (62 voting members and 16 nonvoting members), 57.7% reported that they always disclosed the relationship to an IRB official, 7.7% said they sometimes did, 11.5% said they rarely did, and 23.1% said they never did. Of the 62 voting members who reported conflicts, 64.5% reported that they never voted on the protocol, 4.8% said they rarely did, 11.3% said they sometimes did, and 19.4% said they always did. Most respondents reported that the views of IRB members who had experience working with industry were beneficial in reviewing industry-sponsored protocols. CONCLUSIONS: Relationships between IRB members and industry are common, and members sometimes participate in decisions about protocols sponsored by companies with which they have a financial relationship. Current regulations and policies should be examined to be sure that there is an appropriate way to handle conflicts of interest stemming from relationships with industry.

The use of legal guardians and financial powers of attorney among home-dwellers with Alzheimer's disease living with their spousal caregivers.

We conducted a cross-sectional survey of a random sample of 1943 spouses of home-dwellers with Alzheimer's disease (AD) to examine the prevalence of court-appointed guardians or financial powers of attorney for persons with AD, related factors and the need for information about these issues among caregiving families. The questionnaire consisted questions on variables of demographic characteristics, disability, symptoms and care needs of the person with dementia, the strain of caregiving, the use of court-appointed legal guardians or powers of attorney, as well as discussions about these issues -- and the need for them -- with a doctor. The response rate was 77% and the mean ages of those with AD and caregivers were 80.2 and 78.2 years, respectively. The use of legal guardians was rare (4.3%), while the use of financial powers of attorney was more common (37.8%). Only 9.9% of the couples had discussed these issues with their doctor, whereas 47.9% expressed a need for it. The factors associated with the use of these legal arrangements were related to the severity of dementia, including experiencing dementia symptoms for more than 3 years, poor functioning, incontinence and behavioural symptoms. There is a clear need for information on medico-legal issues related to dementia among caregivers of AD patients. If held soon after the diagnosis, such discussions could support the autonomy of these persons in spite of AD and enable them to plan for the future as they wish.

Do firms with unique competencies for rescuing victims of human catastrophes have special obligations? Corporate responsibility and the AIDS catastrophe in sub-Saharan Africa.

Firms possessing a unique competency to rescue the victims of a human catastrophe have a minimum moral obligation to devote substantial resources toward best efforts to aid victims. The minimum amount that firms should devote to rescue is the largest sum of their most recent year's investment in social initiatives, their five-year trend, their industry's average, or the national average. Financial exigency may justify a lower level of investment. Alternative social investments may be continued if they have an equally compelling rationale. These duties apply to the global pharmaceutical companies in the context of the AIDS pandemic in sub-Saharan Africa.

What's a business for?

In the wake of the recent corporate scandals, it's time to reconsider the assumptions underlying American-style stock-market capitalism. That heady doctrine--in which the market is king, success is measured in terms of shareholder value, and profits are an end in themselves--enraptured America for a generation, spread to Britain during the 1980s, and recently began to gain acceptance in Continental Europe. But now, many wonder if the American model is corrupt. The American scandals are not just a matter of dubious personal ethics or of rogue companies fudging the odd billion. And the cure for the problems will not come solely from tougher regulations. We must also ask more fundamental questions: Whom and what is a business for? And are traditional ownership and governance structures suited to the knowledge economy? According to corporate law, a company's financiers are its owners, and employees are treated as property and recorded as costs. But while that may have been true in the early days of industry, it does not reflect today's reality. Now a company's assets are increasingly found in the employees who contribute their time and talents rather than in the stockholders who temporarily contribute their money. The language and measures of business must be reversed. In a knowledge economy, a good business is a community with a purpose, not a piece of property. If, like many European companies, a business considers itself a wealth-creating community consisting of members who have certain rights, those members will be more likely to treat one another as valued partners and take responsibility for telling the truth. Such a community can also help repair the image of business by insisting that its purpose is not just to make a profit but to make a profit in order to do something better.

How to restore the fiduciary relationship. An interview with Eliot Spitzer. Interview by Louise O'Brien.

Eliot Spitzer's investigations into the mutual fund and investment-banking industries have made the New York State attorney general the de facto flag bearer of corporate reform. His exposure of conflicts of interest between investment bankers and research analyst in Wall Street firms led to the $1.4 billion global settlement between regulators and banking houses in 2003. In this interview, Spitzer describes the challenge of protecting public markets from conflicts of interest, paying particular attention to how such conflicts get institutionalized in an industry. "The cases that have gotten me and my fellow regulators most upset are the ones where we've seen senior management being tolerant of rank abuses," he says. "Because then you know that the entire structure is rotten." He also points the finger squarely at boards, maintaining that board members are drawn from pools of company and industry insiders. He cites "a void in values in a lot of boardrooms," holding up executive compensation as a powerful example. "Board compensation committees ... are self-selected and interwoven--it's a rigged marketplace." He continues, "It would be interesting to see what the world would look like if CEO pay packages had to be submitted to shareholder votes." Spitzer suggests that what's really needed is for all business leaders to reinstill throughout their organizations the critical notion of a fiduciary duty--whether it is to the shareholder or to the customer. Using the mutual fund industry as an example, he also contrasts the value of enforcement with that of regulation and articulates an important--and surprisingly limited--role for government in protecting free markets.

The dynamics of corruptogenic organizations.

Corruptogenic organizational dynamics have been largely ignored in reporting about recent corporate scandals. Using a large group framework, the author identifies factors within an organization that create a breeding ground for unethical or illegal behavior and attract individuals unconsciously looking for ways to damage themselves or others. An organizational culture that promotes questionable attitudes and behaviors along with subgroups that produce powerful corruptive forces can destroy a firm and damage the economy. Enron and the Madoff investment group are identified as corruptogenic organizations put together by founders and a leadership core bent on self-destruction and traumatizing the community-outcomes beyond that which are usually linked to greed. Suggestions are provided to organizational consultants and policy makers as to how to determine the potential for corruption hidden in their midst and to implement countervailing structures and processes.

Ethics, rhetoric, and expectations: responsibilities and obligations of health care systems.

Health care organization foundations and other fund-raising departments often function at an arm's length from the system at large. As such, operations related to their mandate to raise funds and market the organization do not receive the same level of ethical scrutiny brought to bear on other arms within the organization. An area that could benefit from a more focused ethics lens is the use of language and rhetoric employed in order to raise funds and market the organization. Such departments and divisions often utilize overblown promises of miracles and extraordinary advances to convince donors to contribute and to persuade the general public. The result can be a heightened sense of expectation on the part of patients, their families, and the general public as to what can realistically be achieved by the health care system, leading to disappointment and conflict when these expectations are not or cannot be met. This article suggests that such advertising and marketing be subject to the same advertising standards as other businesses.

Masters of the universe: how power and accountability influence self-serving decisions under moral hazard.

This article provides an answer to the question of why agents make self-serving decisions under moral hazard and how their self-serving decisions can be kept in check through institutional arrangements. Our theoretical model predicts that the agents' power and the manner in which they are held accountable jointly determine their propensity to make self-serving decisions. We test our theory in the context of financial investment decisions made under moral hazard using others' funds. Across 3 studies, using different decision-making tasks, different manipulations of power and accountability, and different samples, we show that agents' power makes them more likely to behave in a self-serving manner under moral hazard, but only when the appropriate accountability mechanisms are not in place. Specifically, we distinguish between outcome and procedural accountability and show that holding agents accountable for their decision-making procedure reduces the level of self-serving decisions under moral hazard and also curbs the negative consequences of power. Implications for decisions under moral hazard, the psychology of power, and the accountability literature are discussed.

Guideline funding and conflicts of interest: article 4 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report.

INTRODUCTION: Professional societies, like many other organizations around the world, have recognized the need to use more rigorous processes to ensure that healthcare recommendations are informed by the best available research evidence. This is the fourth of a series of 14 articles prepared to advise guideline developers in respiratory and other disease. It focuses on commercial funding of guidelines and managing conflict of interest effectively in the context of guidelines. METHODS: In this review, we addressed the following topics and questions. (1) How are clinical practice guidelines funded? (2) What are the risks associated with commercial sponsorship of guidelines? (3) What relationships should guideline committee members be required to disclose? (4) What is the most efficient way to obtain complete and accurate disclosures? (5) How should disclosures be publicly shared? (6) When do relationships require management? (7) How should individual conflicts of interest be managed? (8) How could conflict of interest policies be enforced? The literature review included a search of PubMed and other databases for existing systematic reviews and relevant methodological research. Our conclusions are based on available evidence, consideration of what guideline developers are doing, and workshop discussions. RESULTS AND DISCUSSION: Professional societies often depend on industry funding to support clinical practice guideline development. In addition, members of guideline committees frequently have financial relationships with commercial entities, are invested in their intellectual work, or have conflicts related to clinical revenue streams. No systematic reviews or other rigorous evidence regarding best practices for funding models, disclosure mechanisms, management strategies, or enforcement presently exist, but the panel drew several conclusions that could improve transparency and process.