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This broadly titled topic is essential to the description and resolution of a case in clinical ethics. It addresses the ways in which professional, familial, religious, financial, legal, and institutional factors influence clinical decisions. These factors are the context in which the case occurs and so we call this topic Contextual Features. Although clinical ethics focuses on medical indications, patient preferences, and quality of life in particular cases of patient care, medical decisions are not simply individual choices by two autonomous agents (the physician and the patient). Choices are influenced and constrained by contextual considerations.


Today, the encounter between patient and physician occurs in more complex institutional and economic structures than ever before. Only occasionally does the traditional private relationship exist in which a patient chooses and consults a physician in private practice and pays a fee out of pocket for service. More often, doctors have multiple relationships with other physicians, nurses, allied health professionals, health care administrators, insurers, professional organizations, and state and federal agencies, in addition to their own families. 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 burden patients and 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.


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 are, or should be, of little or no relevance in an ethical decision about patient care: his or her duties are narrowly focused on the patient. We consider this view obsolete and theoretically incorrect. Many of the factors mentioned previously impose responsibilities and duties on both patients and physicians. The ethical task is to determine how correctly to assess the importance of these contextual features in a particular case.


These contextual features can be viewed from the large perspective of social policy. Indeed, the serious discussions about reform of the health care system takes place at this level. Many bioethicists address questions of health policy, which are subjected to ethical analysis under the rubric of justice. Certainly, the currently distorted organization of American health care does contribute to ethical complexities that arise in patient care, and, often, these complexities cannot be resolved apart from institutional reform. Still, the focus of this book is on clinical cases that arise and must be managed medically and ethically within extant structures. Those who desire to learn more about the ethics of health policy may consult the large bioethical literature on justice and health care.

Daniels N, Sabin J.Setting Limits ...

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