Behind closed doors: accountability and responsibility in patient care.

In this paper, I examine the notion of accountability and its historical evolution in health care. Using medical mistakes and adverse patient outcomes as my focus, I examine the interests served by particular models of accountability and argue for a model of collective fiduciary responsibility in U.S. health care today.

The implications of affiliations between Catholic and non-Catholic health care organizations for availability of reproductive health services.

Four case studies of successfully negotiated affiliations between Catholic and non-Catholic organizations reveal the strategies employed to address a range of reproductive health services.

PIP: This article summarizes multiple case studies on decision-making with regard to reproductive health services in affiliations between Catholic and non-Catholic organizations. A database on the number and types of affiliations was compiled during 1990-1996 to provide a national profile of such organizations. Findings of case studies revealed that affiliations between Catholic and non-Catholic health care organizations are diverse in structure, motivated by market and financial issues, and display diverse strategies with regards to reproductive health services. In addition, strategies for providing more comprehensive women's health care were evident in 3 of the 4 case studies. Availability of contraceptive services, female and male sterilization, and infertility services generally was unchanged as a result of affiliations. This shows that affiliations themselves did not significantly affect policies or practices with regards to their provision. Successful negotiations between Catholic and non-Catholic partners involve explicit strategies concerning reproductive health services, some of which curtail specific services and some of which enhance services. Finally, policy-makers have an important role in ensuring that communities receive full disclosure of the nature of affiliations and their possible impact on availability of services.

Medical ethics in the courtroom: a reappraisal.

Following up on a 1989 paper on the subject, this essay revisits the question of ethical expertise in the court room. Informed by recent developments in the use of ethics experts, the authors argue 1) that the adversarial nature of court proceedings challenges the integrity of the ethicist's pedagogical role; 2) that the use of ethics experts as normative authorities remains dubious; 3) that clarification of the State's interest in "protecting the ethical integrity of the medical profession" is urgently required; and 4) that the expertise of the ethicist may be more appropriately used in advising the legislature that in influencing the court.

Why "do no harm"?

Edmund Pellegrino has argued that the dramatic changes in American health care call for critical reflection on the traditional norms governing the therapeutic relationship. This paper offers such reflection on the obligation to "do no harm." Drawing on work by Beauchamp and Childress and Pellegrino and Thomasma, I argue that the libertarian model of medical ethics offered by Engelhardt cannot adequately sustain an obligation to "do no harm." Because the obligation to "do no harm" is not based simply on a negative duty of nonmaleficence but also on a positive duty of beneficence, I argue that it is best understood to derive from the fiduciary nature of the healing relationship.

Appropriateness in patient care: a new conceptual framework.

In recent years the focus for the evaluation of health services has shifted from unnecessary treatment--specifically, unnecessary surgery--to appropriateness research. This new emphasis constitutes a shift in the burden of proof, indicating increased attention to the evidentiary basis of medical and surgical practice. The evaluation of the appropriateness of health services is also seen as integral to the reforming drive to contain health care costs and improve quality. Because of its pivotal role as a criterion in health care decision-making, the concept of appropriateness requires clarification. Three sources of value are defined that give meaning to "appropriateness" in patient care: the clinical point of view, the point of view of the individual patient, and the societal point of view. The framework is also used to shed light on the issue of medical futility.

Justice and care: the implications of the Kohlberg-Gilligan debate for medical ethics.

Carol Gilligan has identified two orientations to moral understanding; the dominant 'justice orientation' and the under-valued 'care orientation'. Based on her discernment of a 'voice of care', Gilligan challenges the adequacy of a deontological liberal framework for moral development and moral theory. This paper examines how the orientations of justice and care are played out in medical ethical theory. Specifically, I question whether the medical moral domain is adequately described by the norms of impartiality, universality, and equality that characterize the liberal ideal. My analysis of justice-oriented medical ethics, focuses on the libertarian theory of H.T. Engelhardt and the contractarian theory of R.M. Veatch. I suggest that in the work of E.D. Pellegrino and D.C. Thomasma we find not only a more authentic representation of medical morality but also a project that is compatible with the care orientation's emphasis on human need and responsiveness to particular others.