Ethical and Professionalism Implications of Physician Employment and Health Care Business Practices: A Policy Paper From the American College of Physicians.

The environment in which physicians practice and patients receive care continues to change. Increasing employment of physicians, changing practice models, new regulatory requirements, and market dynamics all affect medical practice; some changes may also place greater emphasis on the business of medicine. Fundamental ethical principles and professional values about the patient-physician relationship, the primacy of patient welfare over self-interest, and the role of medicine as a moral community and learned profession need to be applied to the changing environment, and physicians must consider the effect the practice environment has on their ethical and professional responsibilities. Recognizing that all health care delivery arrangements come with advantages, disadvantages, and salient questions for ethics and professionalism, this American College of Physicians policy paper examines the ethical implications of issues that are particularly relevant today, including incentives in the shift to value-based care, physician contract clauses that affect care, private equity ownership, clinical priority setting, and physician leadership. Physicians should take the lead in helping to ensure that relationships and practices are structured to explicitly recognize and support the commitments of the physician and the profession of medicine to patients and patient care.

La pandemia de la covid-19, la fuerza mayor y la alteración de las circunstancias en materia contractual / The covid-19 pandemic, force majeure and changed contractual circumstances / A pandemia da covid-19, a força maior e a alteração das circunstâncias em matéria contratual

La declaratoria del estado de emergencia, a causa de la pandemia de la covid-19, exige un análisis de la vigencia de las relaciones contractuales y cómo estas pueden verse afectadas por eventos extraordinarios, imprevisibles e irresistibles que impidan el cumplimiento de las prestaciones, así como aquellos casos en los que la alteración de las circunstancias puede llevar a que una de las partes exija al juez recomponga el contenido de la prestación pactada o la resolución del contrato.

The declaration of a state of emergency due to the covid-19 pandemic requires an analysis of the validity of the contractual relations and how these may be affected by extraordinary, unforeseeable and irresistible events that prevent the performance of the services, as well as those cases in which the alteration of circumstances may lead one of the parties to demand that the judge recompose the content of the agreed service or terminate the contract.

A declaração de estado de emergência, devido à pandemia da covid-19, exige uma análise da vigência das relações contratuais e como estas podem ser afetadas por eventos extraordinários, imprevisíveis e irresistíveis que impeçam o cumprimento das prestações, assim como aqueles casos em que a alteração das circunstâncias podem levar a que uma das partes exija que o juiz recomponha o conteúdo da prestação acordada ou a rescisão do contrato.

Bridging the Breach: Using Positive Affectivity to Overcome Knowledge Hiding after Contract Breaches.

With a basis in conservation of resources theory, this study investigates the relationship between employees' exposure to perceived contract breaches and their job performance, while also considering the mediating role of knowledge hiding and the moderating role of positive affectivity. Multisource, three-wave data from employees and their peers in Pakistani organizations reveal that breaches in the psychological contract hinder job performance, because employees respond with an unwillingness to contribute valuable knowledge to execute their job tasks. This mediating role of knowledge hiding is mitigated if employees can draw from their own positive affectivity trait. This study accordingly identifies a key factor, intentional attempts to conceal knowledge requested by other members, that can backfire and make employees suffer doubly: from unfulfilled organizational promises and from lower performance. It also reveals how this risk might be contained, that is, by encouraging employees' positive affect.

Perceptions of Work-Related Stress and Ethical Misconduct Amongst Non-tenured Researchers in Italy.

The relationship between stress and unethical behaviour amongst non-tenured research staff in academia is a relatively unexplored phenomenon. The research reported herein was therefore carried out with the aim of exploring the relationship(s) between stress, the socio-organisational factors which contribute to it, job satisfaction, perceptions of job instability, and the occurrence of unethical behaviour in research. 793 Italian researchers participated in the research-all of whom were working on fixed-term contracts-after being individually requested to complete an online questionnaire. The data indicate that unethical behaviours occur with alarming frequency. The stress level reported is quite high, as is the level of perceived job insecurity, both of which impact upon levels of job satisfaction. Perceived stress levels also seem to play a role in the commission of unethical behaviours, but this relationship is irrelevant when one considers the role of social and organisational factors that are known to induce it. Indeed, it seems that there are various socio-organisational determinants of stress that have an obvious direct negative influence on the commission of unethical behaviours more than the stress level per se. This research paints a worrying picture in relation to the psycho-physical state of non-tenured researchers as a result of the working conditions in which they find themselves in Italian universities.

Distinguishing Characteristics of Corruption Risks in Iranian Construction Projects: A Weighted Correlation Network Analysis.

The construction industry consistently ranks amongst the highest contributors to global gross domestic product, as well as, amongst the most corrupt. Corruption therefore inflicts significant risk on construction activities, and overall economic development. These facts are widely known, but the various sources and nature of corruption risks endemic to the Iranian construction industry, along with the degree to which such risks manifest, and the strength of their impact, remain undescribed. To address the gap, a mixed methods approach is used; with a questionnaire, 103 responses were received, and these were followed up with semi-structured interviews. Results were processed using social network analysis. Four major corruption risks were identified: (1) procedural violations in awarding contracts, (2) misuse of contractual arrangements, (3) neglect of project management principles, and, (4) irrational decision making. While corruption risks in Iran align with those found in other countries, with funds being misappropriated for financial gain, Iran also shows a strong inclination to champion projects that serve the government's political agenda. Root cause identification of corruption risks, namely, the noticeable impact of authoritarianism on project selection in Iran, over criterion of economic benefit or social good, is a significant outcome of this study.

So not mothers: responsibility for surrogate orphans.

The law ordinarily recognises the woman who gives birth as the mother of a child, but in certain jurisdictions, it will recognise the commissioning couple as the legal parents of a child born to a commercial surrogate. Some commissioning parents have, however, effectively abandoned the children they commission, and in such cases, commercial surrogates may find themselves facing unexpected maternal responsibility for children they had fully intended to give up. Any assumption that commercial surrogates ought to assume maternal responsibility for abandoned children runs contrary to the moral suppositions that typically govern contract surrogacy, in particular, assumptions that gestational carriers are not 'mothers' in any morally significant sense. In general, commercial gestational surrogates are almost entirely conceptualised as 'vessels'. In a moral sense, it is deeply inconsistent to expect commercial surrogates to assume maternal responsibility simply because commissioning parents abandon children for one reason or another. We identify several instances of child abandonment and discuss their implications with regard to the moral conceptualisation of commercial gestational surrogates. We conclude that if gestational surrogates are to remain conceptualised as mere vessels, they should not be expected to assume responsibility for children abandoned by commissioning parents, not even the limited responsibility of giving them up for adoption or surrendering them to the state.

Implicaciones éticas y jurídicas de la maternidad subrogada: aproximación a una visión europea / Ethical and juridical implications relating to surrogate pregnancy: an overview from a european perspective / Implicações éticas e jurídicas da maternidade por substituição: aproximação de uma visão europeia

Resumen: avances biotecnológicos son abrumadores y la realidad social cambia con ellos. En efecto, la nueva ley en España sobre los matrimonios homosexuales ha propiciado que parejas de mujeres y de hombres que se casan puedan procrear no solo mediante la adopción, sino también por la fecundación in vitro. Así, la gestación por sustitución se está convirtiendo en la vía preferente para que parejas heterosexuales u homosexuales con problemas específicos, parejas de hombres y para el varón sin pareja puedan tener descendencia. Esta situación crea múltiples conflictos éticos y jurídicos difíciles de resolver: filiación del menor, mercantilización de la mujer, instrumentalización y compraventa de niños, etc. En este artículo se analizarán los aspectos bioéticos en conflicto, sin olvidar la regulación jurídica que existe al respecto.

Abstract: We find ourselves in a time of far reaching biotechnological breakthroughs and alongside with this, society is also experiencing changes. In this sense, new regulations regarding homosexual marriage have opened an scenario where same sex couples of men or women, may "procreate", not only by means of adoption - not permitted for homosexual couples in many countries - but also through in vitro fertilization. For this reason, surrogate pregnancy is becoming the option of choice enabling heterosexual couples with specific problems, male couples, and males without a female partner to have a child. Indeed, as surrogate pregnancy techniques proliferates, ethical conflicts arise: the possibility of men to have their own children, problems relating filiation, instrumentalization of women and babies, legal solutions given by different European countries. In this article, both bioethical and legal issues regarding surrogate pregnancy will be analyse looking for the best interest of the minors.

Resumo: Os avanços biotecnológicos são avassaladores e a realidade social se transforma com eles. Com efeito, a nova lei espanhola sobre o casamento homossexual tem propiciado que casais de mulheres e de homens que se casam possam procriar não só através da adoção, mas também por fertilização in vitro. Assim, a gestação por substituição está se tornando a alternativa preferida para que casais heterossexuais ou homossexuais com problemas específicos, casais de homens e homens solteiros possam ter filhos. Esta situação cria vários conflitos éticos e jurídicos que são difíceis de resolver: filiação da criança, mercantilização da mulher, instrumentalização e compra e venda de crianças, etc. Este artigo irá analisar os aspectos bioéticos, sem esquecer a regulação jurídica a este respeito.

A Trust-Based Pact in Research Biobanks. From Theory to Practice.

Traditional Informed Consent is becoming increasingly inadequate, especially in the context of research biobanks. How much information is needed by patients for their consent to be truly informed? How does the quality of the information they receive match up to the quality of the information they ought to receive? How can information be conveyed fairly about future, non-predictable lines of research? To circumvent these difficulties, some scholars have proposed that current consent guidelines should be reassessed, with trust being used as a guiding principle instead of information. Here, we analyse one of these proposals, based on a Participation Pact, which is already being offered to patients at the Istituto Europeo di Oncologia, a comprehensive cancer hospital in Milan, Italy.

One mum too few: maternal status in host surrogate motherhood arrangements.

In a host surrogate motherhood arrangement, the surrogate agrees to be implanted with, and carry to term, an embryo created from the commissioning couple's gametes. When the surrogate child is born, it is the surrogate mother who, according to UK law, holds the legal status of mother. By contrast, the commissioning mother possesses no maternal status and she can only attain it once the surrogate agrees to the completion of the arrangement. One consequence of this is that, in the event that a host arrangement fails, the commissioning mother is left without maternal status. In this paper, I argue that this denial of maternal status misrepresents the commissioning mother's role in the host arrangement and her relationship with the surrogate child. Consequently, I suggest that commissioning mothers participating in host surrogacy arrangements ought to be granted the status of mother in the event that the arrangement fails.

A comparison of justice frameworks for international research.

Justice frameworks have been developed for international research that provide guidance on the selection of research targets, ancillary care, research capacity strengthening, and post-trial benefits. Yet there has been limited comparison of the different frameworks. This paper examines the underlying aims and theoretical bases of three such frameworks--the fair benefits framework, the human development approach and research for health justice--and considers how their aims impact their guidance on the aforementioned four ethical issues. It shows that the frameworks' underlying objectives vary across two dimensions. First, whether they seek to prevent harmful or exploitative international research or to promote international research with health benefits for low and middle-income countries. Second, whether they address justice at the micro level or the macro level. The fair benefits framework focuses on reforming contractual elements in individual international research collaborations to ensure fairness, whereas the other two frameworks aim to connect international research with the reduction of global health inequities. The paper then highlights where there is overlap between the frameworks' requirements and where differences in the strength and content of the obligations they identify arise as a result of their varying objectives and theoretical bases. In doing so, it does not offer a critical comparison of the frameworks but rather seeks to add clarity to current debates on justice and international research by showing how they are positioned relative to one another.

Do institutional logics predict interpretation of contract rules at the dental chair-side?

In quasi-markets, contracts find purchasers influencing health care providers, although problems exist where providers use personal bias and heuristics to respond to written agreements, tending towards the moral hazard of opportunism. Previous research on quasi-market contracts typically understands opportunism as fully rational, individual responses selecting maximally efficient outcomes from a set of possibilities. We take a more emotive and collective view of contracting, exploring the influence of institutional logics in relation to the opportunistic behaviour of dentists. Following earlier qualitative work where we identified four institutional logics in English general dental practice, and six dental contract areas where there was scope for opportunism; in 2013 we surveyed 924 dentists to investigate these logics and whether they had predictive purchase over dentists' chair-side behaviour. Factor analysis involving 300 responses identified four logics entwined in (often technical) behaviour: entrepreneurial commercialism, duty to staff and patients, managerialism, public good.

What's trust got to do with it? Revisiting opioid contracts.

Prescription opioid abuse (POA) is an escalating clinical and public health problem. Physician worries about iatrogenic addiction and whether patients are 'drug seeking', 'abusing' and 'diverting' prescription opioids exist against a backdrop of professional and legal consequences of prescribing that have created a climate of distrust in chronic pain management. One attempt to circumvent these worries is the use of opioid contracts that outline conditions patients must agree to in order to receive opioids. Opioid contracts have received some scholarly attention, with trust and trustworthiness identified as key values and virtues. However, few articles have provided a critical account of trust and trustworthiness in this context, particularly when there exists disagreement about their role in terms of enhancing or detracting from the patient-physician relationship. This paper argues that opioid contracts represent a misleading appeal to patient-physician trust. Assuming the patient is untrustworthy may wrongfully undermine the credibility of the patient's testimony, which may exacerbate certain vulnerabilities of the person in pain. However, misplaced trust in certain patients may render the physician vulnerable to the potential harms of POA. If patients distrust their physician, or feel distrusted by them, this may destabilise the therapeutic relationship and compromise care. A process of epistemic humility may help cultivate mutual patient-physician trust. Epistemic humility is a collaborative effort between physicians and patients that recognises the role of patients' subjective knowledge in enhancing physicians' self-understanding of their theoretical and practice frameworks, values and assumptions about the motivations of certain patients who report chronic pain.

Physicians' strikes and the competing bases of physicians' moral obligations.

Many authors have addressed the morality of physicians' strikes on the assumption that medical practice is morally different from other kinds of occupations. This article analyzes three prominent theoretical accounts that attempt to ground such special moral obligations for physicians--practice-based accounts, utilitarian accounts, and social contract accounts--and assesses their applicability to the problem of the morality of strikes. After critiquing these views, it offers a fourth view grounding special moral obligations in voluntary commitments, and explains why this is a preferable basis for understanding physicians' moral obligations in general and especially as pertaining to strikes.

Beyond altruistic and commercial contract motherhood: the professional model.

It has become common to distinguish between altruistic and commercial contract motherhood (or 'surrogacy'). Altruistic arrangements are based on the 'gift relationship': a woman is motivated by altruism to have a baby for an infertile couple, who are free to reciprocate as they see fit. By contrast, in commercial arrangements both parties are motivated by personal gain to enter a legally enforceable agreement, which stipulates that the contract mother or 'surrogate' is to bear a child for the intending parents in exchange for a fee. She is required to undergo medical examinations and to refrain from behaviour that could harm the foetus. The intending parents are the child's legal parents from the outset. The parties to the contract can, but are not expected to, maintain contact after the transaction is completed. We argue that contract motherhood should not be organized according to the norms of the gift relationship, and that contract mothers should be compensated for their labour. However, we accept that there are good reasons for rejecting the commercial model as a suitable framework for contract pregnancy, and argue, instead, in favour of viewing it as a profession.