Doctors as fiduciaries: do medical professionals have the right not to treat?

In the first part of the paper, the author discusses the origin and obligation of the medical profession and argues that the duty of fidelity in the context of a patient–professional relationship (PPR) is the central obligation of medical professionals. The duty of fidelity entails seeking the patient’s best interests even at the expense of the professional’s own, and refusing to treat a “risk-patient” infected by SARS is a breach of fidelity because the medical professional is involved in a situation of conflict of interests and places his/her own health interests ahead of the patient. The author attributes the failure to the fact that professional ethical codes are not legally enforceable, and this failure at the microethical level damages the integrity of the profession at the macroethical level. The author argues that professional autonomy must be subordinated to professional fidelity for the medical profession to survive as a social institution. In the second part of the paper, the author shows that the PPR has most of the important attributes of a fiduciary relationship, and analyzes several important court cases in some common law jurisdictions to illustrate the increasing importance of fiduciary law in adjudicating disputes between patients and medical professionals, and appeals to law courts and legislatures to apply more stringent fiduciary principles on the medical profession to ensure that the professional duty of fidelity is enforced and the goal of medicine fulfilled for the interests of members of the community who has established the medical profession in the first place.

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Zusammenfassung  Im ersten Teil dieses Beitrags diskutiert der Autor den Ursprung und die Verpflichtung des ärztlichen Berufsstands und argumentiert für die Treuepflicht in der patient-professional relationship (PPR) als zentrale Verpflichtung des Arztes. Zu dieser Treuepflicht gehören der absolute Vorrang des besten Patienteninteresses auch auf Kosten der Interessen des Arztes. Die Weigerung, einen an SARS erkrankten „Risikopatienten” zu behandeln ist also ein Bruch dieser Treuepflicht, da der Arzt/die Ärztin hier einer Konfliktsituation gegenübersteht und seine/ihre eigenen Gesundheitsinteressen über die des Patienten stellt. Der Autor führt dieses Versagen auf den Umstand zurück, dass die Einhaltung von Berufsethikleitlinien rechtlich nicht erzwingbar ist. Dieses Versagen auf mikroethischer Ebene schädigt die Integrität des Berufsstands auf makroethischer Ebene. Der Autor argumentiert, für den Ärztestand sei die professionelle Autonomie der professionellen Treue unterzuordnen, wenn der Ärztestand als gesellschaftliche Institution überleben soll. Im zweiten Teil des Beitrags zeigt der Autor, dass die PPR die meisten der wesentlichen Attribute eines Treuhänderverhältnisses aufweist, und analysiert einige wichtige Rechtsfälle vor Gerichtsbarkeiten bürgerlichen Rechts („common law jurisdictions”), um die wachsende Bedeutung des Treuhänderrechts bei Entscheidungen in Disputen zwischen Patienten und Ärzten aufzuzeigen. An Gerichte und Gesetzgeber wird appelliert, auf den Ärztestand strengere treuhänderische Prinzipien anzuwenden, um sicherzustellen, dass die professionelle Treuepflicht Geltung erhält und der Zweck ärztlicher Tätigkeit im Interesse der Mitglieder eben der Gemeinschaft erfüllt wird, die den Ärztestand ursprünglich ins Leben gerufen hat.

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Résumé  Dans la première partie de cette article, l’auteur discute de l’origine et des obligations de l’ordre des médecins, et soutient que le devoir de loyauté dans la relation patient-professionnel (RPP) est l’obligation centrale des professionnels de la médecine. Ce devoir de loyauté comprend la recherche du meilleur intérêt du patient, même aux dépens des intérêts du médecin, et le refus de traiter un « patient à risque » infecté par le SARS constitue une rupture de ce devoir de loyauté, puisque le professionnel de la santé se trouve dans une situation de conflit d’intérêts et place ses propres intérêts en matière de santé avant ceux du patient. L’auteur attribue cette défaillance au fait que le respect des codes d’éthique professionnelle ne peut être légalement imposé. Une telle défaillance au niveau micro-éthique porte préjudice à l’intégrité de la profession au niveau macro-éthique. L’auteur soutient que l’autonomie professionnelle doit être subordonnée à la loyauté professionnelle dans la profession médicale si celle-ci veut survivre en tant qu’institution sociale. Dans la deuxième partie de l’article, l’auteur montre que la RPP possède la plupart des caractéristiques majeures de la relation fiduciaire, et analyse quelques grands cas juridiques passés devant des juridictions de droit civil, pour illustrer l’importance croissante de la législation fiduciaire dans la sanction de litiges entre patients et médecins. Il en appelle aux tribunaux et aux législateurs pour appliquer des principes fiduciaires plus sévères à la profession médicale, afin que soit renforcée la valeur du devoir de loyauté professionnelle et que le but de la médecine soit rempli dans l’intérêt des membres de la communauté qui a précisément placé la profession médicale au sommet de sa hiérarchie.

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When do value chains go global? A theory of the spatialization of global value chains

In this article, I synthesize and extend the theoretical literature on global commodity chain (GCC) and global value chain (GVC) governance to generate a theory of the ‘globalness’ of value chains and the spatialization of value chain linkages. Drawing from the original GCC dichotomy of buyer/producer‐driven commodity chains, I emphasize the height of entry barriers to manufacturing and supplier capability differentials across the North–South divide as determinants of the amount and geographic extent of global offshoring behaviour. Using a novel empirical approach to the measurement of global offshoring behaviour at the global industry level, the article shows that the original GCC governance scheme successfully predicts the levels, rates and timing of global production fragmentation across three networked industries. Combining the original GCC governance scheme with the more recent GVC governance types, the theory leads to predictions about the specific types of GVC linkages that might occur given the drivenness of a chain and the geographical location of lead firms and their suppliers. I conclude by drawing out the theory's implications for our understanding of the link between value chain formation and economic development in the global South and suggesting areas for future research.     

When is a bed not a bed? Exploring the interplay of the material and virtual in negotiating home-work boundaries

Working from home is often associated with possibilities of anytime-anyplace working and with a fusion of work and home. In this empirical paper, we explore how the sociomaterial contexts of home-working define and tether what is possible for home-workers in their negotiations with others. Drawing on qualitative data sets, Wengerian concepts are used by exploring the role of boundary objects and brokering in negotiating temporal and spatial boundaries around and across work and home. The home-workers’ bodies are shown to be the key boundary objects, through which technology objects and furniture objects are sometimes fused. Yet, such fusion is shown to be only temporary, always precariously situated and also mediated by identity-regulating norms and values of home-workers. The contribution of the paper is to highlight the limits of what is technologically possible by emphasising the role of the body and material objects in the home-working context.     

What college students do not know: where are the gaps in sexual health knowledge?

Abstract Objective: This study aimed to understand the gaps in college students' knowledge regarding sexual health information. Participants: A sample of 242 participants enrolled in an introductory college course participated in this study in the Fall 2009 semester. Methods: Students participated in 1 of 2 brief interventions and wrote a response paper about their experience. The papers were analyzed using conventional content analysis for information that was new to participants by looking for key words that suggested learning took place. Results: The findings indicated that the majority of participants learned new information. Most learning occurred regarding sexually transmitted infections (ie, types, symptoms, prevalence, treatment, testing) and correct condom use. There were also demographic differences regarding reported new information. Conclusions: Findings can be used to develop future sex education programs for college students by providing college educators with an understanding of where students lack knowledge of sexual health.     

When do scientists become entrepreneurs? The social structural antecedents of commercial activity in the academic life sciences

The authors examine the conditions prompting university-employed life scientists to become entrepreneurs, defined to occur when a scientist (1) founds a biotechnology company, or (2) joins the scientific advisory board of a new biotechnology firm. This study draws on theories of social influence, socialization, and status dynamics to examine how proximity to colleagues in commercial science influences individuals' propensity to transition to entrepreneurship. To expose the mechanisms at work, this study also assesses how proximity effects change over time as for-profit science diffuses through the academy. Using adjusted proportional hazards models to analyze case-cohort data, the authors find evidence that the orientation toward commercial science of individuals' colleagues and coauthors, as well as a number of other workplace attributes, significantly influences scientists' hazards of transitioning to for-profit science.     

Reasons for not reporting victimizations to the police: do they vary for physical and sexual incidents?

Victimization is a significant problem among college students, but it is less likely to be reported to the police than are victimizations in the general population. OBJECTIVE: In this study, the authors examined (1) whether reasons for not reporting varied by type of victimization (sexual or physical) and (2) victim-, offender-, and incident-related predictors of these reasons. PARTICIPANTS: To address these objectives, the authors used data collected from 492 female college students. METHODS: The authors recruited women via flyers placed around campus that asked them to come to the student health center to complete anonymous surveys. RESULTS: Findings from within-subject analyses indicated that women were more likely to cite the following reasons for not reporting a sexual rather than a physical victimization: the incident would be viewed as their fault, they were ashamed, they did not want anyone to know about the incident, or they did not want the police involved. Results from logistic regression analyses indicated that the predictors of not reporting also varied across crime types. CONCLUSIONS: The authors discuss study implications for campus-based prevention strategies.     

Decisions About the “If,” “When,” and “How” of Moving Home: Can a Relocation Service Help? A Welsh Case Study

This small-scale, Welsh qualitative study explores how a new “moving on” service empowered older people to move voluntarily from their home to an extra-care facility. Eighteen older people were interviewed about their experiences of the service, which offered in-person, bespoke information, advice, financial, practical, brokerage, and emotional support about moving. Findings indicate three service use patterns: continuous, partial, and discontinued. It was instrumental in empowering clients to exercise decisional, executional, delegated, and/or consumer autonomies. Recommendations for future developments of a prototype “moving on” service include a multipartner approach and caseworker case management training modeled on social work practice.