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INTRODUCTION

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This topic contains items that are not usually part of a clinical workup. They are, however, essential to the description and resolution of a case in clinical ethics. Contextual features address the ways in which professional, family, religious, financial, legal, and institutional factors influence clinical decisions. These factors are the context in which the clinical case occurs. Although clinical ethics focuses on the medical indications, patient preferences, and quality of life in a particular case of patient care, medical decisions are not simply individual choices by two autonomous agents (the physician and the patient), but choices that are influenced and constrained by the context in which they take place.

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The patient-physician relationship is an intense personal encounter, enclosed in privacy. Yet, that encounter does not take place in a closed world. It occurs within more complex institutional and economic structures than ever before; these structures intrude, sometimes wrongly, sometimes rightfully, on the privacy of the patient-physician relationship. Doctors in their work have multiple relationships with other physicians, nurses, allied health professionals, health care administrators, insurers, professional organizations, and state and federal agencies. Similarly, the relationship between a patient and a physician is surrounded by the patient’s family and friends, other health professionals, and the hospital as an institution. The complex relationships between medicine and the pharmaceutical industry may create conflicts of interest for physicians. Physicians and patients are also subject to the varying influence of community and professional standards, legal rules, governmental and institutional policies about financing and access to health care, computerized methods of storage and retrieval of medical information, the relationship between research and practice, and other factors.

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Physicians often perceive these contextual features as conflicting with their primary commitment to individual patients—and they often do. Some physicians might believe that contextual factors have, or should have, little or no relevance in an ethical decision about patient care in which the doctor’s duties should be narrowly focused on the patient. We consider this view obsolete and theoretically incorrect. Many of the factors mentioned previously impose genuine responsibilities and duties on both patients and physicians. The ethical task is to determine how to correctly assess the importance of these contextual features in a particular case.

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Health policy influences many of the contextual features. The health care system and the complexities of institutional care and its financing have significant impact on the physician-patient relationship. Witness the constant complaint that health reform legislation, up to the Affordable Care Act (ACA) of 2010, will disrupt the personal relationship between individuals and their doctors. The broad field of bioethics does address questions of health policy, which are subjected to ethical analysis under the rubric of justice. This book, devoted to clinical ethics, does not directly deal with health policy.

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Still, clinicians and clinical ethicists will encounter cases in which the structures and policies of existing health or institutional policy create a clinical ethical ...

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