Dual Obligations Research Articles

The risk of complaints against occupational physicians to the medical regulatory body in Ireland.

Complaints against doctors to regulators are increasing in all jurisdictions. Occupational physicians (OPs) are at increased risk of complaint due to the unique doctor–patient relationship and the dual obligations of the role. OPs may become embroiled in third-party disputes and must be clear that their role is an advisor to the decision-maker, but not the decision-maker. OPs require training in how to reduce, cope with and defend against complaints to regulators.

The Exclusion Clause in Canada: Prioritizing Practical Expediency

Abstract Applying the Canadian legal framework for refugees in compliance with binding international instruments has entailed significant challenges. In order to fulfil its dual obligations of protecting people under threat of torture and persecution, while denying refugee status to those responsible for such atrocities, Canada relies on the exclusion clause of the 1951 Convention relating to the Status of Refugees as a practical and expedient solution. This article provides a comprehensive review of the jurisprudence related to Canada’s exclusion system, examining the judicial reasoning of decisions issued by the Immigration and Refugee Board, the Federal Court, the Federal Court of Appeal, and the Supreme Court of Canada. The analysis endorses the position that Canada’s continuing prioritization of security trumps humanitarian aims by an overly broad application of article 1F of the Refugee Convention. The interpretation of Canadian judiciary can lead to the improper application of international law, prompting the need for a reassessment of the Canadian exclusion system 70 years after the adoption of the Refugee Convention.

Covidaze Juggle: Undergraduate Teaching Assistants (TAs) with a Large Online Freshmen Course

As undergraduate students in a Health Sciences Program we were selected as teaching assistants (TAs) in a freshman introductory Cellular and Molecular Biology course that we had all taken in a standard format. The course was tightly focused on cell communication (Adv Physiol Educ 36: 13–19, 2012, Biochem Mol Biol Educ. 2013 May-Jun;41(3):145-55). The new version was offered synchronously on-line to 273 students who were in different time zones (within Canada and abroad, Africa, Asia). Didactic sessions (both flipped/non-flipped) were followed by TA sessions (60-90 mins.) designed to help students consolidate content and prepare them for active assessments used (The FASEB Journal, 31: 575.2-575.2.). Each tutorial Group had on the average, twenty students. For the tutorials, we met them in virtual break-out rooms where we had considerable flexibility to organize our sessions. Larger groups were reconvened to meet the instructors either on the same day or on a separate session. These sessions served to further consolidate their learning. In addition, we had the options of organizing office hours on our own to deal with our students. We were taking several of our own on-line courses in parallel. These dual obligations as teachers in one course and learners for several others posed many challenges. As teachers, we had to foster engagement, promote interactions, gauge comprehension, maintain enthusiasm, identify individual learning needs despite lack of verbal, non-verbal cues as many students remained both silent and invisible and also deal with technical glitches. To prepare for our own courses we faced similar technical issues, maintained enthusiasm, battled online fatigue, engaged with our Professors and TAs, dealt with conflicting schedules, found resources, remained flexible, and stayed focused as the lack of a distinct campus environment blurred boundaries between home and academia. We adapted rapidly to cope with these concurrent contrary demands.

The Ethical Conflict of Dual Obligations Amongst Social Workers: The Role of Organisational Affiliation and Seniority

AbstractThe purpose of the current study was to examine the frequency of ethical conflicts amongst social workers, deriving from dual obligations to clients and employers, as associated with their organisational affiliation and professional seniority. The sample included 723 social workers from three organisational sectors in Israel: the government sector, the third sector and the for-profit sector. Two-way analysis of variance (ANOVA) was conducted to examine the main and interaction effects of organisational affiliation and seniority on the frequency of ethical conflicts amongst social workers. Social workers in the for-profit and third sectors experienced a significantly higher frequency of ethical conflicts than those in the government sector. In addition, social workers with moderate seniority were found to experience ethical conflicts more frequently than those with low and high seniority. These findings have an important contribution to the ongoing public debate on the privatisation of social services, by pointing to the difficulties encountered by social workers employed in partially privatised social services in meeting their obligations to clients. Better public monitoring and adequate supervision of social workers are recommended. In addition, it is suggested that partial privatisation processes be reconsidered in the case of vulnerable populations.

Surgeon as Double Agent: Perception of Conflicting Expectations of Patient Care and Stewardship of Resources

Physicians must satisfy 2 competing expectations: advocate for patients and serve as stewards of resources. No guidelines exist for surgeons on resolving this conflict. We surveyed surgeons' perceptions about these dual obligations. We conducted our study at 2 large university hospitals in 3 distinct steps, each built on the previous one. First, we surveyed 40 surgery residents and medical students using a 10-question assessment tool as the quantitative portion of our analysis. Next, a focus group of attending surgeons was surveyed to identify themes for the qualitative part of our study. Based on these, 5 attending surgeons from varying specialties were interviewed in a semi-structured format. We used the Wilcoxon signed rank test for quantitative analysis and content analysis to report our qualitative findings. Students and residents did not think that they faced resource allocation decisions; however, they observed attending surgeons face them regularly (p= 0.0003). Attending surgeons from various specialties agreed that they thought they were obligated to both provide excellent care and serve as a steward of resources. All surgeons agreed these obligations can conflict. Individual practices varied with all erring on the side of patient care. Concern about being an outlier in one's section was a greater motivator to alter practice than was fear of litigation. No surgeon thought that patients had an adequate understanding of surgeons' dual agency. Surgeons balance the responsibilities of patient care and stewardship of resources with great variability. Diverse practices likely add to inequalities in healthcare delivery and increase mistrust. Surgeons' social contract with patients calls for transparent strategies to address their dual agency.

Dual Obligations of Military Healthcare Providers

Healthcare providers serving as military officers are placed in a position of balancing their professional obligations against the obligations as a military officer. The military’s primary objectiv...

Balancing Operative Efficiency and Surgical Education: A Functional Neurosurgery Model.

Attending surgeons have dual obligations to deliver high-quality health care and train residents. In modern healthcare, lean principles are increasingly applied to processes preceding and following surgery. However, surgeons have limited data regarding variability and waste during any given operation. To measure variability and waste during the following key functional neurosurgery procedures: retrosigmoid craniectomy (microvascular decompression [MVD] and internal neurolysis) and deep brain stimulation (DBS). Additionally, we correlate variability with residents' self-reported readiness for the surgical steps. The aim is to guide surgeons as they balance operative safety and efficiency with training obligations. For each operation (retrosigmoid craniectomy and DBS), a standard workflow, segmenting the operation into components, was defined. We observed a representative sample of operations, timing the components, with a focus on variability. To assess perceptions of safety and risk among surgeons of various training levels, a survey was administered. Survey results were correlated with operative variability, attempting to identify areas for increasing value without compromising trainee experience. A sampling of each operation (n=36) was observed during the study period. For MVD, craniectomy had the highest mean duration and standard deviation, whereas the MVD itself had the lowest mean duration and standard deviation. For DBS, the segments with largest standard deviation in duration were registration and electrode placement. For many steps of both procedures, there was a statistically significant relationship between increasing level of training and increasing perception of safety. This proof-of-concept study introduces an educational and process-improvement tool that can be used to aid surgeons in increasing the efficiency of patient care.

Institutional Maintenance Work as a Response to the Introduction of Inspections in Swedish Schools 2003-2008

This paper focuses on a national governmental school inspections program that was reintroduced in the Swedish school system in 2003. The program included controls conducted by governmental inspectors whose task was to strictly inspect, ignoring activities such as consulting and advice-giving. In the article, we show that while the reintroduced school inspections pointed to the contours of a stricter audit regime in Sweden, studies of micro-level processes provided a more complex picture. Based on an interview study including inspectors, teachers, principals and public employees in the Swedish school system, our results show that the practices of the inspectors did not change dramatically. The inspectors participated in institutional maintenance work that kept institutionalised practices more or less intact. The paper contributes to the discussion on institutional maintenance work by investigating the role of hybrid professionals (inspectors with dual loyalties and obligations both to the state and to their professional peers) and how their interdependent relationship to stakeholders affected the conditions and character of institutional work activities.

“For of those to whom much is given…”

On January 9, 1961, some weeks before being inaugurated the 35th President of the United States, John F. Kennedy exhorted the Massachusetts State Legislature, “For of those to whom much is given, much is required.” His words, internationally distributed, gave new platform and audience to the Biblical message from Luke (KJV, 12:48) from whence it came. Kennedy would often return to versions of this ancient missive in speeches during his all‐too‐brief time as President.This historical admonition speaks not only to those benefited by material wealth or comfort; he was pointedly addressing those placed at the nexus of sacred opportunities and those they would influence. Indeed, a theme throughout Kennedy's life was his passionate transmission of the existential need for giving and giving back. The most well known of his quotes, forcefully spoken through the cold January air at his inauguration,“…ask not what your country can do for you, but what you can do for your country,” epitomizes his world‐view of the centrality of service to your home and the greater good.We in the academic world, particularly those of us given the gift of sharing the core science of anatomy sensu lato, have much: we have learned from caring teachers who stimulated our careers; have been afforded great freedom to explore science without many limitations; have unfettered openness through our journals and forums; and have been allowed to share our thoughts with bright, eager, and pure minds at the outset of their journey. The pressures of our daily world ‐ grants, curricular changes, a seemingly never‐ending ladder of administrators – can at times jade our spirit and dull our senses to the dual obligations we hold: to serve our science and mentor those who have knocked at our door. To paraphrase President Kennedy, perhaps we should focus a bit more on what we can do for the future of our discipline and those who will carry the torch then sit in expectation or disappointment of what we should have received. We have, indeed, been given much; good service to our next generation is a blessing in return, not a burden.(American Association of Anatomists A.J. Ladman Award Symposium Lecture).This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Services in the Trans-Pacific Partnership: What Would Be Lost?

As the fate of the Trans-Pacific Partnership (TPP) hangs in balance, an evaluation of what it offers could inform current decisions and shape future negotiations. The TPP’s services component has been hailed as one of the agreement’s major accomplishments. To assess the agreement’s impact on national policy in the major services sectors, we created a new public database. This database reveals that TPP commitments seldom go beyond countries’ applied policies, suggesting the explicit liberalization resulting from the agreement is limited only to a few countries and a few areas. However, the TPP enhances transparency and policy certainty because parties’ services commitments cover more trading partners, more sectors and are in some cases closer to applied policies than their commitments under previous agreements. Furthermore, new TPP rules, including on state-owned enterprises, government procurement and competition policy, could enhance services market access. In particular, the TPP breaks new ground in prohibiting restrictions on international data flows, while at the same time creating unprecedented obligations on all parties to protect consumers from fraud and protect privacy. These dual obligations on importing and exporting countries represent a model for regulatory cooperation that could elicit greater market opening if applied to other areas.

Clinician-Investigator Training and the Need to Pilot New Approaches to Recruiting and Retaining This Workforce.

Clinician–investigators, also called physician–scientists, offer critical knowledge and perspectives that benefit research on basic science mechanisms, improved diagnostic and therapeutic approaches, population and outcomes medicine, health policy, and health services, yet few clinically trained health professionals pursue a research career. Sustaining this workforce requires attention to the unique challenges faced by investigators who must achieve clinical and research competence during training and their careers. These challenges include the duration of required clinical training, limited or discontinuous research opportunities, high levels of educational debt, balancing the dual obligations and rewards of clinical care and research, competition for research funding, and the need for leadership development after training. Women and individuals from underrepresented racial and ethnic groups comprise a small percentage of this workforce.The authors summarize the recent literature on training for clinician–investigators, emphasizing approaches with encouraging outcomes that warrant broader implementation. Using this overview as background, they convened three workshops at the National Institutes of Health in 2016 to identify and refine key priorities for potential new pilot programs to recruit and retain the clinician–investigator workforce. From these workshops emerged three priorities for future pilot programs: (1) support for research in residency, (2) new research on-ramps for health professionals at multiple career stages, and (3) national networks to diversify and sustain clinician–investigator faculty. Implementation of any pilot program will require coordinated commitment from academic health centers, medical licensing/certification boards, professional societies, and clinician–investigators themselves, in addition to support from the National Institutes of Health.

Managing Conflicts of Interest in Industry-Sponsored Clinical Research

Companies engaged in health care research and development share, with health professionals, academic health centers, patient advocacy organizations, and other medical and health-related institutions, the mission to improve human health. Companies play indispensable roles in advancing almost all aspects of this mission, including sponsoring clinical research and generating clinical data that serve as the basis for drug and device approvals, guidelines, and prescribing information. Clinical research must be conducted with the utmost scientific rigor, integrity, and compassion. It has long been recognized that the dual obligations companies have to both patients and shareholders create real and perceived conflicts of interest (COIs). If not properly managed, COIs can undermine physician and patient trust in industry-supported development of drugs and devices

Ethical challenges experienced by clinical research nurses:: A qualitative study.

Clinical investigation is a growing field employing increasing numbers of nurses. This has created a new specialty practice defined by aspects unique to nursing in a clinical research context: the objectives (to implement research protocols and advance science), setting (research facilities), and nature of the nurse-participant relationship. The clinical research nurse role may give rise to feelings of ethical conflict between aspects of protocol implementation and the duty of patient advocacy, a primary nursing responsibility. Little is known about whether research nurses experience unique ethical challenges distinct from those experienced by nurses in traditional patient-care settings. The purpose of the study was to describe the nature of ethical challenges experienced by clinical research nurses within the context of their practice. The study utilized a qualitative descriptive design with individual interviews. Participating nurses (N = 12) self-identified as having experienced ethical challenges during screening. The majority were Caucasian (90%), female (83%), and worked in outpatient settings (67%). Approximately 50% had > 10 years of research experience. The human subjects review board approved the study. Written informed consent was obtained. Predominant themes were revealed: (1) the inability to provide a probable good, or/do no harm, and (2) dual obligations (identity as a nurse vs a research nurse). The following patterns and subthemes emerged: conflicted allegiances between protocol implementation, needs of the participant, desire to advance science, and tension between the nurse-patient therapeutic relationship versus the research relationship. Participants described ethical challenges specific to the research role. The issues are central to the nurse-participant relationship, patient advocacy, the nurse's role in implementing protocols, and/or advancing science. Ethical challenges related to the specialized role of clinical research nurses were identified. More research is warranted to fully understand their nature and frequency and to identify support systems for resolution.

Moral Obligations: Actualist, Possibilist, or Hybridist?

ABSTRACTDo facts about what an agent would freely do in certain circumstances at least partly determine any of her moral obligations? Actualists answer ‘yes’, while possibilists answer ‘no’. We defend two novel hybrid accounts that are alternatives to actualism and possibilism: Dual Obligations Hybridism and Single Obligation Hybridism. By positing two moral ‘oughts’, each account retains the benefits of actualism and possibilism, yet is immune from the prima facie problems that face actualism and possibilism. We conclude by highlighting one substantive difference between our two hybrid accounts.

Prevalence and compensation of academic leaders, professors, and trustees on publicly traded US healthcare company boards of directors: cross sectional study

Objective To identify the prevalence, characteristics, and compensation of members of the boards of directors of healthcare industry companies who hold academic appointments as leaders, professors, or trustees.Design Cross sectional...

Wrong-Doing, Truth-Telling: The Function of Avowal in Justice. By Michel Foucault. Edited by Fabienne Brion and Bernard E. Harcourt. Translated by Stephen W. Sawyer (University of Chicago Press, 2014, 344pp. $35.00 hb)

Wrong-Doing, Truth-Telling: The Function of Avowal in Justice is a collection of seven lectures delivered by French philosopher and historian Michel Foucault at the Catholic University of Louvain in 1981. Compiled from audiovisual recordings and Foucault’s original manuscripts, these lectures explore the notion of avowal and its place within criminal justice processes. Accompanied by three contemporaneous interviews given by Foucault (only one of which has previously been available in English), and a preface and concluding essay by the editors contextualizing these lectures in Foucault’s oeuvre, this volume contributes much to Foucaultian scholarship, particularly when considered alongside the recently published volumes of Foucault’s lecture courses at the Collège de France. However, while the book promises to offer some insights of relevance to criminology, it is important to remember that this is not its key purpose, and criminologists should read it with this caveat in mind. These lectures chart a genealogy of avowal from the Greeks through the medieval period and Christianity to the modern period. Avowal aligns with Foucault’s interest in the connections between subjectivity and truth—specifically the dual obligations of accepting particular truths and telling the truth about ourselves—which became the focus of the last volumes of his History of Sexuality and his lecture courses of the period. For Foucault, avowal is ‘…a verbal act through which the subject affirms who he [sic] is, binds himself to this truth, places himself in a relation of dependence with regard to another, and modifies at the same time his relationship to himself’ (17). Through the avowal of a crime, i.e., one commits oneself to being the author of the crime, which also entails subjecting oneself to a particular authority (such as a legal authority) to which the avowal is offered, and which alters the relationship between oneself and the status avowed. After all, an offender who avows is treated in a different way to one whose guilt has been determined through other legal processes—and they are often seen as more open to reform. In this sense, an exploration of avowal adds another dimension to Foucault’s interest in the exercise of power and the fashioning of subjectivity, specifically in understanding one’s relationship to truth.

Models of occupational medicine practice: an approach to understanding moral conflict in “dual obligation” doctors

In the United Kingdom (UK), ethical guidance for doctors assumes a therapeutic setting and a normal doctor-patient relationship. However, doctors with dual obligations may not always operate on the basis of these assumptions in all aspects of their role. In this paper, the situation of UK occupational physicians is described, and a set of models to characterise their different practices is proposed. The interaction between doctor and worker in each of these models is compared with the normal doctor-patient relationship, focusing on the different levels of trust required, the possible power imbalance and the fiduciary obligations that apply. This approach highlights discrepancies between what the UK General Medical Council guidance requires and what is required of a doctor in certain roles or functions. It is suggested that using this modelling approach could also help in clarifying the sources of moral conflict for other doctors with "dual obligations" in their various roles.

What Physician-Investigators Owe Patients Who Participate in Research

VIDENCE-BASED MEDICINE PRESCRIBES THAT CLINICAL practice should be guided by the results of rigorous research. The close connection between clinical research and patient care, coupled with the need for researchtobeconductedbyphysician-investigatorswithpatients who participate in research (patient-participants), makes it difficult to appreciate how the ethical obligation of investigators differ from those of physicians. Moreover, clinicalresearchcreatesethicaltensionsbyexposingpatientparticipants to risks of harm for the sake of generating scientific knowledge. This has been obscured and assuaged by the prominent tendency to view the ethics of clinical research through the lens of the patient-physician relationship. 1 According to this therapeutic orientation, physicianinvestigatorsretainafiduciarydutyofloyaltytothemedical best interests of patients, characteristic of clinical practice, in the context of conducting clinical research. In contrast, this fiduciary loyalty does not cohere with the socially valuable enterprise of clinical research. To be sure, researchers owe significant and extensive ethical obligation to patientparticipants. However, the ethics of clinical practice does not provide an accurate account of the dual obligations of investigators to promote valuable science and protect human research participants. Unquestionably, research participants place trust in physician-researchers. For example, patient-participants trust investigators to assess their eligibility for a protocol, to explain clearly the study’s risks and potential benefits, to keep private information confidential, and to monitor their wellbeing. Moreover, some patients who participate in research are especially vulnerable to exploitation because of illness. Accordingly, physician-researchers owe these patients significant duties, although the scope of these duties must be evaluated. Can these duties to patients be defined by fiduciary loyalty, akin to the physician’s relationship to patients, requiring the researcher to promote each patientparticipant’s best interests? Or do these duties need separate elucidation? Widelyacceptedaspectsofclinicalresearchwouldbeunethical if physician-researchers’ duties to patientparticipants were identical to those of physicians in clinical care. These research practices are tied to the distinctive goal of research, ie, producing generalizable knowledge. In the medical care setting, treatments and diagnostics must beprescribedbasedoneachpatient’sindividualneeds.However, because controlled experimentation is necessary for valid scientific results, treatments within clinical trials are limited by protocols, not personalized. Moreover, valid scientific results often require that nontherapeutic procedures pose some risk to patient-participants without being offset by individual benefits. For example, performing a biopsy, lumbar puncture, and imaging procedure is justified in clinical care only if the procedure contributes to diagno

Ethics for Medical Educators: An Overview and Fallacies

Ethics is the rule of right conduct or practice in a profession. The basic principles of ethics are beneficence, justice and autonomy or individual freedom. There is very minor demarcation between ethics and the law. The ethics is promulgated by the professional bodies. All are expected to guide the medical professional in their practice. Medical educators have dual ethical obligations: firstly, to the society at large which expects us to produce competent health professionals, and secondly, to the students under our care. The students observe and copy what their teacher does and his/her role modelling can be a gateway to a student's character building. Due to rapid increase in the number of medical colleges, privatization, and capitalism, ethical issue has become much more relevant and needs to discuss in detail. The present paper discusses the ethics for medical educators in detail with, basic principles, common breaches of ethics and fallacies due to wrong application of ethical principles, and the approach to ethics and methods by which we can prevent and avoid breach of ethics.

Do International Model Drug Control Laws Provide for Drug Availability?

A preliminary review of the United Nations Office on Drugs and Crime (UNODC) model drug control laws was conducted by the Pain & Policy Studies Group (PPSG) to determine whether the models provided governments with language they can use to carry out the obligation to ensure adequate availability of opioid analgesics for the relief of pain and suffering, specified in the Single Convention on Narcotic Drugs, 1961 as amended, and as recommended by the International Narcotics Control Board in 1995. The results showed that current model laws lack the drug availability provisions. Based on initial positive feedback from the International Narcotics Control Board, the UNODC, and the World Health Organization, the PPSG developed preliminary recommendations based on existing provisions in the Single Convention. The PPSG's main recommendation is that updated model laws are needed and that consideration should be given as to how to achieve this objective. The assessment is offered as a starting point for discussion. The World Health Organization (WHO) considers opioid analgesics to be essential for the treatment of pain, but there are great disparities in their availability among countries of the world, leading to needless pain and suffering. Over a period of 15 years of study and efforts to rectify these disparities, the PPSG has found that national narcotics control laws often do not contain provisions that recognize the dual obligation of governments under the international drug control conventions not only to control narcotic drugs but also to make them adequately available for medical and scientific purposes. International drug control organizations develop and publish model narcotics laws and regulations for governments to use. If these models convey the dual obligations of governments, the models would be considered “balanced,” and national governments would have model policy language not only for control of licit drugs, but also for their availability. Most governments have already adopted laws to implement the Single Convention; however, it is not known if they followed the Single Convention itself or model laws. The PPSG conducted this preliminary assessment of whether the models published by the United Nations Office on Drugs and Crime are balanced, using as a guide the 1995 recommendations of the International Narcotics Control Board (www.incb.org/pdf/e/ar/1995/suppl1en.pdf) and the 2000 WHO publication Achieving Balance in National Opioids Control Policies: Guidelines for Assessment (www.painpolicy.wisc.edu/publicat/00whoabi/00whoabi.htm).