Medical Professionals

Conflicts and Quandaries in Medical Practice

Kathleen Montgomery, Wendy Lipworth

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351362306
• Edition: 1
• Topic: Business
• Subtopic: Business Ethics
• Index: Business

Medical Professionals: Conflicts and Quandaries in Medical Practice offers a fresh approach to understanding the role-related conflicts and quandaries that pervade contemporary medical practice. While a focus on professional conflicts is not new in the literature, what is missing is a volume that delves into medical professionals' own experience of the conflicts and quandaries they face, often as a result of inhabiting multiple roles. The volume explores the ways in which these conflicts and quandaries are exacerbated by broader societal forces, including changing scientific and technological paradigms, commercialization, and strengthened consumer movements, which simultaneously expand the scope of roles and responsibilities that medical professionals are expected to fulfill, and make it more difficult to do so.

Several empirical chapters analyze data from qualitative interview studies with clinicians and other stakeholders. The studies highlight the burdens on clinicians who are expected to make informed and justified judgments and decisions in the midst of competing pressures; authors describe the methods that clinicians use to address the associated tensions within specific contexts. Two conceptual chapters follow and offer some innovative ways to think about the challenges facing medical professionals as they strive to make sense of the changing landscape within healthcare. The first reflects on the challenges to clinical practice in the midst of shifting and often competing definitions of disease and associated ideologies of care. The second reflects more broadly on the utility of value pluralism as a framework for conceptualizing and working through moral and professional quandaries. The book concludes with a chapter containing suggestions for how members of the medical profession might reframe their thinking about their roles, responsibilities, and decision-making in the midst of inevitable quandaries such as those presented here.

This book will be of vital reading for academics, researchers, educators, postgraduate students, and interested health care practitioners and administrators.

Part I
Overview

1
Role-Related Conflicts and Value-Laden Quandaries Confronting Today’s Medical Professionals

Kathleen Montgomery and Wendy Lipworth

This book is designed to offer a fresh approach to understanding the role-related conflicts and quandaries that pervade contemporary medical practice, including problems of conflicts of interest, resource allocation, experimental medical practices, and determinations of futility. The volume also explores the ways in which these conflicts and quandaries are exacerbated by broader social forces, including changing scientific and technological paradigms, commercialization, and strengthened consumer movements, all of which simultaneously expand the scope of roles and responsibilities that medical professionals are expected to fulfil and make it more difficult to do so.

There exist many publications examining the medical profession, from the early work of Talcott Parsons (1939) and Eliot Freidson (1970a, 1970b) to more recent volumes such as The Healthcare Professional Workforce (Hoff, Sutcliffe, and Young 2016). Whereas Parsons and others of his generation (e.g. Carr-Saunders and Wilson 1933) defended the lofty status and power of the medical profession as functionally necessary for the good of society, Freidson introduced a new perspective that critically examined the profession’s power and the strategies the profession adopts to develop and reinforce its status and legitimacy in the eyes of the state and the general public. Much of the work that has followed has explored the various conflicts confronting health professionals, primarily emanating from intra- and inter-professional jurisdictional battles (introduced in Abbott’s classic The System of Professions, 1988) and from professional–organizational struggles to reconcile claims to professional autonomy and bureaucratic control (e.g. Starr 1982; Montgomery 1992; Scott et al. 2000; Currie et al. 2012).

Thus, a focus on professional conflicts is not new in the literature. What has been missing, however, is a volume that delves into medical professionals’ own experiences of, ways of thinking about, and ways of responding to the challenges that they confront as they are expected to make informed and justified decisions in the face of competing professional roles and responsibilities. While such conflicts might be managed with relatively little cognitive dissonance, they can also generate quandaries—commonly understood to be states of perplexity or uncertainty over what to do in difficult situations where there is, by definition, no straightforward resolution. Quandaries are often value-laden—a feature that, in the context of value pluralism, makes them particularly intractable.

This is not to say that physicians have no guidance in the management of conflicts and quandaries. Medical education and advanced training provide physicians with a foundation of knowledge about clinical decision-making, professional associations develop and promote codes to guide normative choices, and healthcare organizations draw up policies and protocols that mandate particular kinds of physician behaviour. However, the kinds of conflicts and quandaries that today’s medical professionals encounter all too often fall outside their educational backgrounds, professional codes, organizational policies, and standard operating procedures. Contributions in this volume expose some very real, but under-discussed, conflicts and quandaries, with the goal of encouraging deeper discussion among health professionals, policymakers, and consumers.

The core of the volume consists of five empirical chapters that describe the results of qualitative research undertaken by researchers based at, or affiliated with, the University of Sydney, Sydney Health Ethics (SHE— formerly, the Centre for Values, Ethics and the Law in Medicine or VELiM). The centre, founded in 1995, is the leading centre in Australia for social science and ethics research in health and medicine. The centre’s work is distinguished by its interdisciplinarity and strong tradition of both national and international collaboration. The qualitative studies reported here involved interviews with individuals in Sydney and elsewhere in New South Wales. Nevertheless, the kinds of conflicts and quandaries that health professionals wrestle with have implications for health professionals in many Western societies, despite variations in healthcare systems.

The first three empirical chapters examine the conflicts and quandaries that present themselves at the micro level of patient care, while the next two focus on the macro level of policy and regulation. However, the reality is that all of these conflicts and quandaries span both micro and macro levels of concern. This is because it can be impossible to isolate challenging decisions that occur at the bedside from the broader meso and macro organizational, health system, and societal influences that both enable and constrain clinical decisions and actions.

The complexities of relationships across the micro, meso, and macro levels have been elucidated by institutional theorists (Scott 2008). A central premise of institutional theory is that the norms, beliefs, and rules espoused by actors in a particular environment play a key role in shaping behaviours of others in the environment. To depict these effects (following Leahey and Montgomery 2011), one can envision a set of actors within concentric rings, with permeable boundaries across the rings.

The innermost ring is the personal relationship between a particular doctor and a particular patient. This core relationship—the foundation of healthcare—is nested within a wider set of actors who may have a direct, indirect, or distant relationship with the doctor and patient. For example, actors in the adjacent ring are the patient’s family and members of the healthcare team, who may interact with, and whose actions may directly affect, the doctor–patient relationship. That is, beliefs of family members may strongly influence a patient’s decisions about treatment, and practice norms among the healthcare team may facilitate or otherwise affect the clinician’s behaviour in a particular doctor–patient interaction. The next ring includes those with a more indirect, but still influential, impact upon the doctor and patient, including professional associations and professional peers, healthcare organizations, medical researchers, and academic publishers. Pressures from actors at this meso level can take the form of informal peer expectations of appropriate professional behaviour, more formal professional codes of ethics and health service policies, and broader norms and guidelines governing the generation, dissemination, and translation of biomedical research. The outermost ring includes those with the most distant connection to a particular doctor–patient relationship but whose influence nonetheless can be far-reaching. These include regulators, accrediting bodies, the courts, health-related industries, the media, and consumer advocacy groups.

The result of this complex environment, with behavioural expectations and pressures from multiple actors, is that adhering to even the most taken-for-granted principles of patient care in Western medicine today—for example, respecting patient autonomy, giving priority to patients’ interests and needs, ensuring that patients have access to and receive the highest quality treatment available—can generate conflicts and, in some cases, quandaries for clinicians. Indeed, many of the respondents interviewed for the studies in this volume speak passionately about their efforts to satisfy the expectations of multiple, and often conflicting, role responsibilities; they also reflect on their frustrations and discomfort when unable to do so, along with their strategies for managing associated cognitive dissonance.

In Chapter 2, Jordens and Montgomery demonstrate the difficulties in adhering to ever-growing ethical expectations and legal requirements for respecting patient autonomy. They observe that early paternalistic models of patient care have been replaced by newer approaches that emphasize greater patient involvement through informed consent, shared-decision making, and patient education. Such innovations are often subsumed under the rubric of “patient-centred care,” an appealing mantra adopted by healthcare organizations around the globe, espoused as the antidote to paternalism by giving priority to patient values, preferences, and decisions. Drawing on studies of clinicians and participants in the context of bone marrow transplantation, Jordens and Montgomery demonstrate the difficulties and frustrations for clinicians that arise when the ethical principles and ideal models of care do not readily translate into practice. One consequence is what the authors call the “paradox of autonomy,” where clinicians go to great lengths to educate patients about the proposed treatment prior to obtaining a patient’s consent, but patients make limited efforts to become educated about what they are consenting to. Ironically, by choosing to disregard key elements of the consent process, patients autonomously short-circuit a process that is designed to protect and increase their autonomy. A related observation from the study is the recognition of limits of shared decision-making, bounded on one side by patients’ unilateral refusals to consent to potentially beneficial treatment and on other side by clinicians’ unilateral refusal to offer interventions that they believe would be futile.

In Chapter 3, Ghinea and colleagues investigate the practice of “off-label” prescribing—that is, prescribing in a manner that is inconsistent with the indications approved by a medicines regulatory body. The authors begin by discussing the ambiguity surrounding the phrase and the resulting controversy about whether off-label prescribing constitutes inappropriate experimentation of an unlicensed investigational product or whether it is a legitimate extrapolation from approved uses of a medicine. They review the policies and politics involved in regulating medicines, along with the existing literature that reports that off-label prescribing appears to be a common practice, especially for certain groups of patients such as children and the elderly. The authors point out the potential quandary for clinicians, who may have good reason for prescribing off label but risk being placed in legal jeopardy for deviating from evidence-based and approved uses of certain medicines. Drawing from interviews with clinicians, the authors show how doctors balance the need for evidence about a medicine’s efficacy with their own expertise and tacit knowledge about how patients respond to various treatments, in a way that allows them to defend their prescribing decisions. The authors conclude with reference to two case studies that reveal the limitations of efforts to arrive at formalized definitions of “evidence,” “experimentation,” and “expertise” in the context of prescribing behaviour.

Chapter 4 also is concerned with access to medicines, in this case cancer medicines. Pace and colleagues provide examples of several new cancer medicines which have therapeutic value but which have not been proven to be entirely safe and effective and/or come at huge cost. The authors explore several challenges facing clinicians as they consider therapy options for their patients. At the micro level, clinicians face the need to provide their patients with hope and compassionate care while ensuring that the medicines they prescribe are sufficiently safe and effective. This is particularly challenging when medicines are new and may not have a substantial evidence base but to which patients are nonetheless demanding access. At the macro level, clinicians have to contend with a duty to the broader community to use scarce resources responsibly while still advocating for individual patients. Pace and colleagues provide data from interviews with clinicians to illustrate their recognition of and, in some cases, discomfort with, these challenges. They conclude with some examples of ways in which clinicians avoid or manage the cognitive dissonance such quandaries generate, including a variety of possibilities for making medicine more affordable and accessible.

In Chapter 5, Lipworth and Montgomery continue the investigation of conflicts and quandaries involving pharmaceuticals. In this chapter, however, the focus shifts from patient care and resource allocation to the relationships that clinicians have with the pharmaceutical industry—in this case as collaborators with, or employees of, the industry. Many observers argue that professional–industry relationships place clinicians in a position of conflict of interest. To explore the different positions taken by key actors regarding these relationships, the authors first discuss a case study of a controversial debate about academic–industry collaboration that played out in the pages of premier academic journals. This case illustrates divergent and strongly held opinions about the appropriate role for clinicians who engage in research with pharmaceutical firms and who seek to publish review articles in academic journals. Next, the authors present interview data from clinicians who are employees of pharmaceutical companies. Using the framework of professional regulation, Lipworth and Montgomery compare the attitudes of practicing clinicians to those of health professionals employed by industry. They find that the former group tends to view regulation through an adversarial lens. In contrast, those in the latter group embrace multiple levels of regulation as facilitators of their roles and as potential ways to navigate the quandaries posed by potential conflicts of interest.

In Chapter 6, Gallagher explores the conflicts and quandaries that arise for clinicians when they serve as technical expert advisors in decisions about allocation of health resources at the population level. She describes the potential conflicts of interest and problems of dual agency that can arise for individuals in this position. Drawing on interview data from clinicians who occupy such roles, she describes their recognition of the importance of clinician input into resource allocation decisions while recognizing the difficulties of serving simultaneously as dual agents on behalf of their individual patients and on behalf of patient populations. Gallagher also reveals the potential for conflicts of interest should clinicians engage in these roles primarily for personal advancement or for promoting a particular self-serving resource allocation goal. Gallagher describes respondents’ efforts and strategies to navigate the potential tensions inherent in occupying dual roles. In particular, she describes respondents’ confidence that the social processes of macroallocation and priority setting are best viewed not as issues of distributive justice but as ones best resolved by attention to procedural justice.

The five empirical chapters are followed by two conceptual chapters, which bring together and extend the observations presented in the data. While both conceptual chapters draw heavily on the sociological and philosophical literature, they offer fresh and distinctive approaches to understanding professional conflicts. Chapter 7, by Jordens, reflects on the challenges faced by clinicians who find themselves in the midst of shifting and often competing definitions of disease and associated ideologies of care which are, in turn, shaped by complex power dynamics. He emphasizes the inevitable political aspects of healthcare, many of which are reflected in the preceding chapters, including decisions about treatment options and resource allocation. He argues that paradigm shifts in the theory and practice of care can function as positive signs of a medical profession responsive to criticism, while also serving as a source of conflict.

In Chapter 8, Little explores the possibilities of value pluralism as an approach to the kinds of conflicts and quandaries that members of the medical profession encounter in their work. Drawing on empirical material from the preceding chapters, he highlights the (often under-recognized) values that underpin the various conflicts and quandaries, whether they pertain to patient autonomy, conflict of interest, resource allocation, or evidence-based medicine. Little argues that these conflicts and quandaries do not readily lend themselves to satisfactory resolution agreeable to all parties, precisely because of the pluralism of values that actors bring to their understanding of the problems. Instead, Little proposes a mode of discourse informed by value pluralism, a heuristic that enables parties to engage reasonably in dialog, without resorting to absolutism and polemic. As he notes, value pluralism requires scepticism and reflection, along with restrained partisanship in argument. It does not seek end-points that are either right or wrong but suggests pragmatic solutions that may work “for the moment.” In so doing, Little offers a cautious but optimistic approach to thinking about and moving forward in the midst of seemingly intractable, value-laden quandaries.

The editors conclude by drawing together the empirical studies to elucidate commonalities and variation in (1) the types of role-related conflicts that can arise in medical practice, (2) the ways physicians experience these conflicts, and (3) suggestions for managing role-related conflicts that emerge from the studies. The editors then briefly review the contributions of the two conceptual chapters, noting that each offers an innovative framework through which to understand the variety of role-related conflicts and quandaries confronting today’s medical professionals.

References

Abbott, A. 1988. The system of professions: An essay on the division of expert labor. Chicago, IL: University of Chicago Press.

Carr-Saunders, A., and P. Wilson, 1933. The professions. Oxford: Clarendon Press.

Currie, G., A. Lockett, R. Finn, G. Martin, and J. Waring. 2012. Institutional work to maintain professional power: Recreating a model of medical professionalism. Organization Studies 33(7): 937–962.

Freidson, E. 1970a. The profession of medicine: A study of the sociology of applied knowledge. New York, NY: Dodd, Mead.———. 1970b. Professional dominance: The social structure of medical care. New York, NY: Atherton Press.

Hoff, T., K. Sutcliffe, and G. Young, eds. 2016. The healthcare professional work-force: Understanding human capital in a changing industry. Oxford: Oxford University Press.

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Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• List of Illustrations
• Foreword
• PART I Overview
• PART II Empirical Explorations of Conflicts and Quandaries
• PART III Reconceptualization and Concluding Observations
• Contributor Biographies
• Index