The Medical Cosmology of Halakha: The Expert, the Physician, and the Sick Person on Shabbat in the Shulchan Aruch

One of the best-known principles of halakha is that Shabbat is violated to save a life. Who does this saving and how do we know that a life is in danger? What categories of illness violate Shabbat and who decides? A historical-sociological analysis of the roles played by Jew, non-Jew, and physician according to the approach of “medical cosmology” can help us understand the differences in the approach of the Shulchan Aruch compared to later decisors (e.g., the Mishnah Berurah). Such differences illuminate how premodern medical triage coexisted with a different halakhic understanding than that of the biomedical age

Communication behaviors and patient autonomy in hospital care: A qualitative study.

BACKGROUND: Little is known about how hospitalized patients share decisions with physicians. METHODS: We conducted an observational study of patient-doctor communication on an inpatient medicine service among 18 hospitalized patients and 9 physicians. A research assistant (RA) approached newly hospitalized patients and their physicians before morning rounds and obtained consent. The RA audio recorded morning rounds, and then separately interviewed both patient and physician. Coding was done using integrated analysis. RESULTS: Most patients were white (61%) and half were female. Most physicians were male (66%) and of Southeast Asian descent (66%). All physicians explained the plan of care to the patients; most believed that their patient understood. However, many patients did not. Physicians rarely asked the patient for their opinion. In all those cases, the decision had been made previously by the doctors. No decisions were made with the patient. Patients sometimes disagreed. CONCLUSIONS: Shared decision-making may not be the norm in hospital care. Although physicians do explain treatment plans, many hospitalized patients do not understand enough to share in decisions. When patients do assert their opinion, it can result in conflict. PRACTICE IMPLICATIONS: Some hospitalized patients are interested in discussing treatment. Improving hospital communication can foster patient autonomy

Patient Autonomy in Talmudic Context: The Patient’s ‘‘I Must Eat’’ on Yom Kippur in the Light of Contemporary Bioethics

In contemporary bioethics, the autonomy of the patient has assumed considerable importance. Progressing from a more limited notion of informed consent, shared decision making calls upon patients to voice the desires and preferences of their authentic self, engaging in choice among alternatives as a way to exercise deeply held values. One influential opinion in Jewish bioethics holds that Jewish law, in contradistinction to secular bioethics, limits the patient's exercise of autonomy only in those instances in which treatment choices are sensitive to preferences. Here, we analyze a discussion in the Mishna, a foundational text of rabbinic Judaism, regarding patient autonomy in the setting of religiously mandated fasting, and commentaries in the Babylonian and Palestinian Talmuds, finding both a more expansive notion of such autonomy and a potential metaphysical grounding for it in the importance of patient self-knowledge

Prior Authorization as a Potential Support of Patient-Centered Care.

We discuss the role of prior authorization (PA) in supporting patient-centered care (PCC) by directing health system resources and thus the ability to better meet the needs of individual patients. We begin with an account of PCC as a standard that should be aimed for in patient care. In order to achieve widespread PCC, appropriate resource management is essential in a healthcare system. This brings us to PA, and we present an idealized view of PA in order to argue how at its best, it can contribute to the provision of PCC. PA is a means of cost saving and as such it has mixed success. The example of the US demonstrates how implementation of PA has increased health inequalities whereas best practice has the potential to reduce them. In contrast, systems of universal coverage, like those in Europe, may use the cost savings of PA to better address individuals' care and PCC. The conclusion we offer therefore is an optimistic one, pointing towards areas of supportive overlap between PCC and PA where usually the incongruities are most evident

Clinical care and complicity with torture

The UN Convention against Torture defines torture as “any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person” by someone acting in an official capacity for purposes such as obtaining a confession or punishing or intimidating that person.1 It is unethical for healthcare professionals to participate in torture, including any use of medical knowledge or skill to facilitate torture or allow it to continue, or to be present during torture.2-7 Yet medical participation in torture has taken place throughout the world and was a prominent feature of the US interrogation practice in military and Central Intelligence Agency (CIA) detention facilities in the years after the attacks of 11 September 2001.8-11 Little attention has been paid, however, to how a regime of torture affects the ability of health professionals to meet their obligations regarding routine clinical care for detainees. The 2016 release of previously classified portions of guideline from the CIA regarding medical practice in its secret detention facilities sheds light on that question. These show that the CIA instructed healthcare professions to subordinate their fundamental ethical obligations regarding professional standards of care to further the objectives of the torturers

Metrics of Patient, Public, Consumer, and Community Engagement in Healthcare Systems: How Should We Define Engagement, What Are We Measuring, and Does It Matter for Patient Care? Comment on “Metrics and Evaluation Tools for Patient Engagement in Healthcare Organization- and System-Level Decision-Making: A Systematic Review”

Abstract In a rigorous systematic review, Dukhanin and colleagues categorize metrics and evaluative tools of the engagement of patient, public, consumer, and community in decision-making in healthcare institutions and systems. The review itself is ably done and the categorizations lead to a useful understanding of the necessary elements of engagement, and a suite of measures relevant to implementing engagement in systems. Nevertheless, the question remains whether the engagement of patient representatives in institutional or systemic deliberations will lead to improved clinical outcomes or increased engagement of individual patients themselves in care. Attention to the conceptual foundations of patient engagement would help make this systematic review relevant to the clinical care of patients

The need for empathetic healthcare systems

Medicine is not merely a job that requires technical expertise, but a profession concerned with making the best decisions and recommendations with reference to, and in consultation with, the patient. This means that the skill set required for healthcare professionals in order to provide good care is a combination of scientific knowledge, technical aptitude, and affective qualities or virtues such as compassion and empathy.publishedVersio

Markedly heterogeneous COVID-19 testing plans among US colleges and universities

As the COVID-19 pandemic worsens in the United States, colleges that have invited students back for the fall are finalizing mitigation plans to lessen the spread of SARS-CoV-2. Even though students have largely been away from campuses over the summer, several outbreaks associated with colleges have already occurred, foreshadowing the scale of infection that could result from hundreds of thousands of students returning to college towns and cities. While many institutions have released return-to-campus plans designed to reduce viral spread and to rapidly identify outbreaks should they occur, in many cases communications by college administrators have been opaque. To contribute to an evaluation of university preparedness for the COVID-19 pandemic, we assessed a crucial element: COVID-19 on-campus testing. We examined testing plans at more than 500 colleges and universities throughout the US, and collated statistics, as well as narratives from publicly facing websites. We discovered a highly variable and muddled state of COVID-19 testing plans among US institutions of higher education that has been shaped by discrepancies between scientific studies and federal guidelines. We highlight cases of divergence between university testing plans and public health best practices, as well as potential bioethical issues

Markedly heterogeneous COVID-19 testing plans among US colleges and universities

As the COVID-19 pandemic worsens in the United States, colleges that have invited students back for the fall are finalizing mitigation plans to lessen the spread of SARS-CoV-2. Even though students have largely been away from campuses over the summer, several outbreaks associated with colleges have already occurred, foreshadowing the scale of infection that could result from hundreds of thousands of students returning to college towns and cities. While many institutions have released return-to-campus plans designed to reduce viral spread and to rapidly identify outbreaks should they occur, in many cases communications by college administrators have been opaque. To contribute to an evaluation of university preparedness for the COVID-19 pandemic, we assessed a crucial element: COVID-19 on-campus testing. We examined testing plans at more than 500 colleges and universities throughout the US, and collated statistics, as well as narratives from publicly facing websites. We discovered a highly variable and muddled state of COVID-19 testing plans among US institutions of higher education that has been shaped by discrepancies between scientific studies and federal guidelines. We highlight cases of divergence between university testing plans and public health best practices, as well as potential bioethical issues