Workplace bullying has been recognized as a major occupational stressor since the mid 1980s. A number of different terms have been used to describe it, including employee abuse, emotional abuse, mistreatment and neglect at work, mobbing, and harassment. In the United Kingdom, a number of reports from trades unions illustrating the pain, psychological distress, physical illness, and career damage suffered by the victims of bullying first drew attention to the issue. However, academic interest in the issue began only recently, and there are still few empirical studies. The most systematic research comes from Scandinavia, where there is strong public awareness and antibullying legislation.

Margaret Brazier has argued that, in the literature on reproductive technology, women's “right” to reproduce is privileged, pushed, and subordinated to patriarchal values in such a way that it amounts to women's old “duty” to reproduce, dressed up in modern guise. I agree that there are patriarchal assumptions made in discussions of whether women have a right to select which embryos to implant or which fetuses to carry to term. Forcing ourselves to see women as active, rational decisionmakers tends to counteract any lingering patriarchal assumptions. But rational decisionmaking requires information. Voting wisely requires information about the candidates. Taking women's reproductive rights seriously means taking seriously women's need for relevant information to make rational decisions, including decisions about which embryos to implant or alter. I argue that preimplantation genetic profiles and prenatal test information should be made available to prospective parents, especially prospective mothers, unless doing so threatens to harm the resulting child or the larger society in specifiable and important ways.

These CQ Sources were compiled by Bette Anton.

Over the past decade or so, the predominant patient-centered ethos in American bioethics has come under attack by critics who claim that it is morally deficient in certain respects, particularly when viewed in the context of acute-care decisionmaking. One line of criticism has been that the current ethic of patient autonomy gives an individual competent patient far too much decisional authority over the terms of his own treatment so that the patient is at complete liberty to neglect the ways in which his medical decisions can drastically and negatively affect the lives of other family members. Given that family members must help shoulder the financial, emotional, and rehabilitative burdens involved in the patient's care, it has been argued that they too have a legitimate interest in choosing what sort of medical treatment the patient eventually receives. Another closely related line of criticism is that the prevailing focus on patient autonomy gives short shrift to the moral significance of the family as a genuine community. Echoing a view of the person advanced by most communitarian political theorists, some commentators have argued that the patient comes to the clinic so thoroughly embedded in a complex web of familial relationships and obligations that it does not make sense to identify him as the only person in the family to make decisions about treatment.

The belated but formal acknowledgment of medical errors and their impact has been well documented. Curiously, the topic of management or executive mistakes in healthcare is not raised in professional meetings nor, until recently, addressed by an article in health administration journals.

It is a rare patient who always does everything healthcare providers advise. Sometimes no harm comes from this; sometimes good does. But occasionally, great harm comes from not listening, as when it results in patients returning time and again for costly and invasive treatments of, say, infections, valve replacements, pressure ulcers, and so forth. No class of patients arouses more anger and resentment in healthcare providers, who often put out a call to invoke some version of the three strikes rule and refuse care. And if the patients are also unemployed substance abusers who live in a local park, impolite or dangerous to staff, disruptive to other patients, and have intimidating visitors, the call to say “No” is louder. Can care ever be refused? If so, when? These are the questions we take up in this article. The answers we provide were developed as part of a Paraplegics and Quadriplegics with Pressure Ulcers Project carried out at Vancouver Hospital and Health Sciences Centre. Following an established usage, we refer to patients who exhibit a cluster of the above characteristics, the dominant one of which is a reluctance to heed medical advice, as “noncompliant patients.” This term is offensive to some, but the politically correct lexicon does not provide any alternative which is as short and clear or substantially different. We use the term as a convenient way of referring to a familiar class of patients and without any imputation of blame.

Ethicists in American medical schools feel increasingly discouraged these days. In the 1960s, 1970s, and 1980s, society's enthusiasm for teaching about medical ethics flourished as new medical technologies posed new ethical perplexities. Americans eagerly sought ethics advice and looked to medical schools to provide it. As the sites where many of the new technologies were developed and future physicians were trained, medical schools were the logical place for medical ethicists to work and teach. A few schools recognized society's need and instituted explicit medical ethics teaching—allocating funds, hiring ethicists, creating departments, and trumpeting their accomplishments. But most schools responded to the need with indifference or even hostility. They distrusted outside “experts” and feared a zealous reform movement aimed at the character or practices of modern medicine. Yet even those schools were forced to create ethics programs to meet powerful accreditation requirements adopted around 1990. Complying reluctantly, these schools allocated few personnel and minimal budgets. The resulting programs struggled.

In an effort to create a mechanism for addressing a critical need of providing medicines for economically developing countries, the Chiron Corporation and the Global Alliance for TB Drug Development have entered into an innovative public-private partnership. In the following interview, Craig Wheeler discusses the origins and nature of this agreement that could set a pattern for how corporations and nonprofit organizations can work together in drug development.

These CQ Sources were compiled by Bette Anton.

Clinicians, operating within complex systems, make mistakes, as people do in every human endeavor, and when they do, patients are sometimes harmed. One important question is how we as clinicians can find resolution in the wake of an error. The published literature has divided errors into those caused by “systems” and by “individuals.” But whereas both “systems” and “individual” approaches are important in understanding the cause of an error, neither alone can fully lead to resolution once an error has occurred. Instead, both are necessary to understand, resolve, and prevent errors.

According to Native American myths, there once roamed an Eye Juggler—a humanoid deity who could detach his eyes and juggle them. His talents were of no special appeal to members of the various tribes, given that it is quite possible to hunt buffalo, prepare meals, or play stickball without tossing around your eyes. However, there was a white man who grew interested in the Eye Juggler. Sensing great utility in detachable eyes—for spying, or looking two ways at once—the white man formulated a deal. He would trade away his wealth in return for the Eye Juggler's gift. To this proposition the Juggler agreed, but also issued a warning. If the eyes stay detached for very long, they rot and cannot be used.

For over a decade, managed care has profoundly altered how healthcare is delivered in the United States. There have been concerns that the patient-physician relationship may be undermined by various aspects of managed care, such as restrictions on physician choice, productivity requirements that limit the time physicians may spend with patients, and the use of compensation formulas that reward physicians for healthcare dollars not spent. We have previously published data on the effects of managed care on the physician-patient relationship from the physician's perspective. In 1999, we collected data on the impact of managed care arrangements on the physician-patient relationship from the patient's perspective. This article discusses our collective findings.

As medical students we were not discouraged from introducing ourselves by saying, “Hello, I'm Dr. So-and-so,” as opposed to identifying ourselves as students. If we happened to be doing rounds with an intern or resident, the physician would introduce himself or herself as “Dr. X and over here is Dr. Y”—indicating a student. When I introduced myself as a medical student, I got the feeling that people thought it was silly or unnecessary.

Researchers tracking social trends have discovered a remarkable labor-saving device called the computer. They sit down before the instrument, call up a search engine, enter a key word that they believe represents the trend, and count the number of articles aroused by that key word. They track these numbers over a period of time and even graph them. Those who dislike a certain concept are happy to report the concept's rise and fall. Such has occurred with two articles, one of which appeared in CQ, reporting the rise and fall of medical futility. We are impressed with the power of this research methodology, which seems capable of eliminating concepts, even when our own more labor-intensive yet apparently less perceptive daily experience finds evidence of their existence all around us.

In their recent article, Glannon and Ross remind us that family members have obligations to help each other that strangers do not have. They argue, I believe correctly, that what creates moral obligations within families is not genetic relationship but rather a sharing of intimacy. For no one are these obligations stronger than they are for parents of young children. This observation leads the authors to the logical conclusion that organ donation by a parent to her child is not optional but rather a prima facie duty. However, Glannon and Ross go a step further by suggesting that because parent-to-child organ donation is a duty, it cannot be altruistic. They assert that “altruistic acts are optional, nonobligatory…supererogatory…. Given that altruism consists in purely optional actions presupposing no duty to aid others, any parental act that counts as meeting a child's needs cannot be altruistic.” Here I think the authors go too far.

These CQ sources were compiled by Judith Schaeffer Young.

When one considers the protracted and continuing struggle of the citizens of Oregon to include physician-assisted suicide (also known as “physician aid in dying”) among the panoply of measures available to dying patients and the physicians who care for them, the depth and breadth of the issue becomes inescapable. The potential intractability of the dispute is illustrated by the very fact, noted in the preceding parenthetical phrase, that consensus eludes us on even the most basic of semantic points—how we are to most aptly characterize the conduct in question? The case featured in this issue's The Caduceus in Court must be examined as the latest battle in a long war of attrition waged by opponents of physician-assisted suicide against the Oregon Death with Dignity Act (“the Oregon Act”). After briefly reviewing that history, I will then consider the details of Oregon v. Ashcroft and the implications of the litigation not only for the care of dying patients but also for the regulation of medical practice in the United States and, more broadly still, the search for resolution of serious medical disputes in a democratic society.

It is inevitable that physicians in training will be exposed to behavior by supervising physicians that the trainees find unethical. By nature these events are rare. It is imperative within any residency training program that resident physicians have immediate access to a meaningful review process in cases of moral conflict with supervising physicians. Here, I discuss the reasons why this issue must be recognized and what it entails. Most important, I discuss the procedural steps that are essential for the training program to make this a meaningful safety mechanism in residency training. This issue is central to promoting conscious development of professionalism in clinical training. Physicians in training, especially resident physicians, need to be taught to value and protect their own professional integrity. The responsibility for fulfilling this ethical duty falls on the individual residency programs as well as the administrative organizations that regulate residency training. Thus, ensuring this process of review is an organizational ethical imperative. Availability of this process is fundamental to promoting and ensuring ethical behavior by all participants in residency training.

The challenge of determining that therapeutic intervention is futile is a recurrent ethical theme in critical care medicine. The process by which that determination is reached often involves demanding collaborative and interdisciplinary conversation and deliberation within the context of hospital policy, including ethics committee guidelines. The subsequent decision as to what happens next depends on resources, such as palliative care services, hospice, other hospital protocols, and, of course, family support.

I think that utilitarianism is a good moral theory, and definitely better than its rivals, deontology and teleology. For practical purposes in multicultural contexts, at least, I think that no one should overlook a theory that is able to take into account a variety of ethical views and accommodate the ever-changing facts of the material world. But utilitarianism has a bad reputation in bioethics. It is often seen as the inhumane theory that allows the sacrifice of minorities, the killing of the innocent, and simplistic calculations on the value of life. Hardly anyone cares to remember that most formulations of the theory do not allow these actions. The economic doctrine sometimes labeled as utilitarianism could be guilty as charged, but ethics and economy are not interchangeable words. Also as a theory that can actually propose answers to no-win situations, utilitarianism has been an easy target for criticism.