Entrenched biases and structural incentives limit the influence of interdisciplinary research.

Due to unequal funding streams and leadership structures, dominant frameworks emerge within interdisciplinary departments. Elizabeth Dzeng shares her experience in the field of medical social science where the drive to publish in high impact journals pushes researchers to conform to predominantly objectivist definitions of quality, rather than more interpretive frameworks. Cross-fertilization of ideas will remain limited unless we redefine quality to include all relevant modes of inquiry

The Influence of Hospital Policies and Culture on Do-Not-Resuscitate Decision-Making at the End of Life: A Sociological and Ethical Analysis

Author has submitted with a minor correction to the appendix.The aim of this thesis is to explore how institutional cultures and policies relating to patient autonomy influence physicians’ clinical and ethical approaches to do-notresuscitate (DNR) decision-making at the end of life. I explore this in the context of the evolution of the American medical profession that shifted medical decision-making power from paternalism to patient autonomy. Decades ago, the “doctor knows best” attitude prevailed. Since then, the pendulum has swung towards honouring patient autonomy. This thesis explores the implications of these changes and considers the tensions between the principle of beneficence and patient autonomy. I conducted 58 semi-structured in-depth interviews with internal medicine physicians, sampled by years of experience and medical subspecialty. These interviews were conducted at three academic medical centres in the United States (University of Washington, Johns Hopkins, Columbia New York Presbyterian) and one in the United Kingdom (Addenbrooke’s Hospital). It emerged during the research process that two of these four hospitals had policies that prioritised patient autonomy whereas the other two hospitals had policies that prioritised making decisions in the patient’s best interest. The main focus of this dissertation is on the United States, where three of the hospital sites are located. The UK serves as an additional site as there are no hospitals in the United States that permit unilateral physician decision-making in the way that the UK allowed at the time of the study. The focus on autonomy in American medicine today highlights the importance of freedom and choice to make one’s own decision. However, to truly honour patient autonomy, the patient or surrogate must have an adequate understanding of his situation and choices. Although the shift away from paternalism was a necessary positive step, I argue that the way in which autonomy is practiced reflects a reductionist notion of autonomy that disempowers rather than empowers patients, as patients are asked to make choices without the understanding or guidance necessary to make informed choices. Particularly at hospitals where autonomy is prioritised over other ethical principles such as best interest, trainee physicians equate autonomy with giving a menu of choices. They are uncomfortable giving a recommendation based on clinical knowledge as they worry that would be infringing upon patient autonomy. However, trainee physicians feel ethically compromised and experience significant moral distress when they are asked to provide therapies that they perceive to be futile. Despite that, doctors are still power brokers in the physician patient relationship and are able to manipulate conversations in other ways to sway patients towards a decision that they believe is in the patient’s best interest. Through a Habermasian approach, I explore how trainee communication practices of using purposefully graphic descriptions of resuscitation to discourage that choice are pathologic and disempowering. Physicians are fully inculcated in their respect for autonomy but unintentionally resort to strategic forms of communication because they feel constrained to resist recommendations in the name of autonomy. Rather than focusing on an ideology of autonomy, the American medical system needs to move towards practices that embrace a more nuanced and empathetic form of autonomy that fosters a more open form of communication that allows for cocreation of consensus between doctors and patients

Ethical Issues in the Design and Implementation of Population Health Programs

Spurred on by recent health care reforms and the Triple Aim’s goals of improving population health outcomes, reducing health care costs, and improving the patient experience of care, emphasis on population health is increasing throughout medicine. Population health has the potential to improve patient care and health outcomes for individual patients. However, specific population health activities may not be in every patient’s best interest in every circumstance, which can create ethical tensions for individual physicians and other health care professionals. Because individual medical professionals remain committed primarily to the best interests of individual patients, physicians have a unique role to play in ensuring population health supports this ethical obligation. Using widely recognized principles of medical ethics—nonmaleficence/beneficence, respect for persons, and justice—this article describes the ethical issues that may arise in contemporary population health programs and how to manage them. Attending to these principles will improve the design and implementation of population health programs and help maintain trust in the medical profession

Moral Distress Amongst American Physician Trainees Regarding Futile Treatments at the End of Life: A Qualitative Study.

BACKGROUND: Ethical challenges are common in end of life care; the uncertainty of prognosis and the ethically permissible boundaries of treatment create confusion and conflict about the balance between benefits and burdens experienced by patients. OBJECTIVE: We asked physician trainees in internal medicine how they reacted and responded to ethical challenges arising in the context of perceived futile treatments at the end of life and how these challenges contribute to moral distress. DESIGN: Semi-structured in-depth qualitative interviews. PARTICIPANTS: Twenty-two internal medicine residents and fellows across three American academic medical centers. APPROACH: This study uses systematic qualitative methods of data gathering, analysis and interpretation. KEY RESULTS: Physician trainees experienced significant moral distress when they felt obligated to provide treatments at or near the end of life that they believed to be futile. Some trainees developed detached and dehumanizing attitudes towards patients as a coping mechanism, which may contribute to a loss of empathy. Successful coping strategies included formal and informal conversations with colleagues and superiors about the emotional and ethical challenges of providing care at the end of life. CONCLUSIONS: Moral distress amongst physician trainees may occur when they feel obligated to provide treatments at the end of life that they believe to be futile or harmful.This study was funded by the Health Resources and Service Administration T32 HP10025-20 Training Grant, the Gates Cambridge Scholarship, Society of General Internal Medicine Founders Grant, and the Ho-Chiang Palliative Care Research Fellowship at the Johns Hopkins School of Medicine.This is the author accepted manuscript. The final version is available from Springer via http://dx.doi.org/10.1007/s11606-015-3505-

Habermasian communication pathologies in do‐not‐resuscitate discussions at the end of life: manipulation as an unintended consequence of an ideology of patient autonomy

The focus on patient autonomy in American and increasingly British medicine highlights the importance of choice. However, to truly honour patient autonomy, there must be both understanding and non-control. Fifty-eight semi-structured in-depth interviews were conducted with internal medicine physicians at three hospitals in the US and one in the UK. At hospitals where autonomy was prioritised, trainees equated autonomy with giving a menu of choices and felt uncomfortable giving a recommendation based on clinical knowledge as they worried that that would infringe upon patient autonomy. Employing Habermas's Theory of Communicative Action, this paper explores how physician trainees' communication practices of using purposefully graphic descriptions of resuscitation to discourage that choice prevent greater understanding and compromise non-control. Central to this problem are also issues of colonisation of the life-world by the system. Physicians are fully inculcated in their respect for autonomy but unintentionally resort to strategic forms of communication that prevent patients from adequately understanding their situation because trainees feel constrained against making recommendations. However, if the ideal of autonomy is to be realised, physicians might have to move towards practices that embrace a more authentic autonomy that fosters open communication that allows for co-creation of consensus between doctors and patients

How Should Physicians Care for Dying Patients with Amyotrophic Lateral Sclerosis?

We discuss physician aid in dying, euthanasia, and other dimensions of palliative care decision making and define relevant terms raised by this case of a dying patient with amyotrophic lateral sclerosis in Washington State who is unable to self-administer a lethal prescription. We then present a concrete framework that clinicians can directly apply when faced with difficult cases such as this one. We outline how exploring motivations, obtaining informed consent, defining goals, and examining alternatives can help guide physicians like the one in this case. We conclude by summarizing one way in which physicians might balance these issues while still remaining within the constraints of the law