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Table Of Contents
Letter From the Editor
Letter From The Editor

In December of 2008, in my capacity as editor of JLME, I moderated a webinar on President-Elect Barack Obama's proposals for health reform. The webinar was led by an acknowledged expert in the field of health reform, and the speaker spent much of her allotted time answering nervous questions from listeners who openly wondered how their health system would change and how these changes would be paid for. One memorable questioner asked if the U.S. health system would become like Canada's, overly expensive with incredibly long wait-times. The host laughingly corrected her examiner, reminding the audience that both costs and wait times were badly exaggerated in Canada and actually compared very favorably to those in the United States. The American public, she added, was too savvy to fall for such foolish rhetoric. Clear thinking and a bit of judicious research would prove, she argued, that health reform was the most sensible path.
Larry R. Churchill and Joshua E. Perry - [PDF]

The ethical tensions between market forces in health care and professional claims about the priority of service are long-standing. Many readers may think of Arnold Relman's New England Journal of Medicine article as a convenient beginning point for the contemporary debate about how to manage these tensions. In the more than three decades since Relman's article, "the medical-industrial complex" has become even more pervasive and the tensions between a business model for health care and a professional service model have increased proportionately.
Symposium Articles
Commercial Pressures on Professionalism in American Medical Care: From Medicare to the Affordable Care Act
Theodore R. Marmor and Robert W. Gordon - [PDF]

This essay describes how longstanding conceptions of professionalism in American medical care came under attack in the decades since the enactment of Medicare in 1965 and how the reform strategy and core provisions of the 2010 Affordable Care Act (ACA) illustrate the weakening of those ideas and the institutional practices embodying them.
When Worlds Collide: Medicine, Business, the Affordable Care Act and the Future of Health Care in the U.S.
Andrew C. Wicks and Adrian A. C. Keevil - [PDF]

Many observers claim that business has become a powerful force in medicine and that the future of health care cannot escape that reality, even though some scholars lament it. The U.S. recently experienced the most devastating recession since the Great Depression. As health care costs rise, we face additional pressure to rein in health care spending. We also have important new legislation that could well mark a significant shift in how health care is provided and who has access to care, namely the Affordable Care Act (ACA). These changes underscore the need to bring new thinking to the conversation about health care and to move beyond conceptual and practical obstacles that inhibit our progress.
Between Liberal Aspirations and Market Forces: Obamacare's Precarious Balancing Act
Jonathan Oberlander - [PDF]

The American health care system long has been distinctive in its embrace of market forces. For-profit private insurers play a major role in providing coverage, though they operate alongside public insurance programs that cover over one-third of the population. Historically, federal and state governments' regulation of insurance markets was limited, leaving insurers to set premiums and coverage rules largely as they saw fit.
Selling Hospice
Sam Halabi - [PDF]

Hospice care in the United States has undergone a remarkable transformation since it assumed its modern form in the late 1960s. It began as a movement driven by small organizations staffed with many volunteer providers focusing on comprehensive spiritual, palliative, and mental health services for a relatively small number of terminally ill patients, typically suffering from cancer. The idea behind hospice during its early days was that a terminally patient and his or her family made a decision to focus on easing a patient's pain and anxiety, making him or her more comfortable, rather than pursuing additional curative treatment. Because these objectives required a wide range of professional and non-professional skills, hospice care involved not only physicians and nurses, but clergy, social workers, volunteer caretakers, homemakers, and, of course, family members. The process of decision-making by the patient and his or her family was never uniform and never systematically studied. Early experiments in hospice coverage noted the complex considerations at work during the hospice election process, including a patient's informed consent when he or she was in pain or heavily sedated, and the need to incorporate opinions from an attending physician, nurse, clergymember, social worker, and family member, among other constellations of participants. As a result, hospice care in the United States before 1983 was characterized by small providers who worked within the limits of prevailing institutional norms, tight budgets and diverse approaches to the care of terminally ill patients. Matching terminally ill patients and their families with available and appropriate hospice providers was accomplished through the loose and inchoate network of participating physicians, nurses, clergy, social workers, and volunteers who, early on, saw value in the alternative hospice care provided.
Beyond the Market: The Role of Constitutions in Health Care System Convergence in the United States of America and the United Kingdom
Jamie Fletcher and Jane Marriott - [PDF]

Two narratives have emerged to describe recent health care reforms in the United States of America (US) and the United Kingdom (UK). One narrative speaks of revolution, that the adoptions of the Affordable Care Act 2010 (ACA) in the US, and the Health and Social Care Act 2012 (HSCA) in the UK, have resulted in fundamental, large-scale philosophical, political and legal change in the jurisdictions' respective health care systems. The other narrative evokes evolution, identifying each new legislative scheme as a natural development of existing governance structures. Policymakers in both the US and UK face the problem of a health care system which, as traditionally envisaged, cannot offer universal access to health care at a reasonable, or politically acceptable, price. In an attempt to solve this problem, those policymakers shop around, with the result that each of the two jurisdictions' reformed health care systems includes features normally associated with a free market health care model, as this has been seen to increase quality and lower costs, but both also demonstrate characteristics of a state-run model, which provides a safety net for citizens and a buffer against the commodification of health.
Trust and Transparency: Patient Perceptions of Physicians' Financial Relationships with Pharmaceutical Companies
Joshua E. Perry, Dena Cox, and Anthony D. Cox - [PDF]

Financial relationships and business transactions between physicians and the health care industry are common. These relationships take a variety of forms, including payments to physicians in exchange for consulting services, reimbursement of physician travel expenses when attending medical device and pharmaceutical educational conferences, physician ownership in life science company stocks, and the provision of free drug samples. Such practices are not intrinsic to medical practice, but as the Institute of Medicine described in its 2009 report, these relationships have the potential to produce positive collaborations that improve patient care and public health, and most physicians view it as "ethically proper to accept items ranging from drug samples to a lucrative consultantship."
Curing the Disobedient Patient: Medication Adherence Programs as Pharmaceutical Marketing Tools
Matt Lamkin and Carl Elliott - [PDF]

About a week after Maran Wolston was prescribed Copaxone, a drug for multiple sclerosis (MS), she got a phone call from a nurse at an organization called Shared Solutions. The organization was familiar to Wolston; when her neurologist had asked permission to share her health information with Shared Solutions, Wolston had agreed, assuming it was connected to her health insurance.
Economism and the Commercialization of Health Care
Howard Brody - [PDF]

Pay-for-performance (P4P) represents an effort to improve the quality of health care by paying physicians more if they meet specified target measures. There are both empirical and theoretical reasons to be deeply suspicious of P4P schemes applied at the level of the individual physician or health provider. Most P4P programs were implemented before there were any good data to demonstrate that they achieved the desired results. Once such schemes were in use, the available data are far from reassuring. Common findings are that providers may do more of the specific procedure that is being measured, but in the process may neglect to do other things that equally affect quality of care. Payers often find that the cost of implementing a P4P program far exceeds the value of the very modest resulting improvements; and payments may unfairly benefit providers who are already meeting quality targets while disadvantaging those who make the most strenuous efforts to improve. There are also recurring signs of providers gaming the system by (for example) refusing to take care of the sickest and most difficult patients.
The Hair Stylist, the Corn Merchant, and the Doctor: Ambiguously Altruistic
Lois Shepherd - [PDF]

The AHP Code of Ethics requires members to serve the best interests of their clients, be clear and honest with them, and keep their secrets confidential. Members pledge to represent their skills and qualifications honestly and to make appropriate referrals to others more qualified when out of their depth.
Medical Versus Fiscal Gatekeeping: Navigating Professional Contingencies at the Pharmacy Counter
Elizabeth Chiarello - [PDF]

Commercialization of medicine is a growing trend that threatens to undermine physicians' commitments to patient care in favor of personal financial interests. Bemoaned by Arnold Relman as early as 1980, growing for-profit sectors of health care have been reshaping medicine from a profession into a business, forming the foundation of what he terms a "medical-industrial complex" that threatens to undermine professional identity and reshape health care funding. Commercialization poses new ethical challenges for health care providers who have a financial stake in their health care decisions and may undermine their fiduciary duties to patients.
Upstream Health Law
William M. Sage and Kelley McIlhattan - [PDF]

Medicine and health are surprisingly separate. In the introduction to his 1963 master work on medical economics, Kenneth Arrow acknowledged that "the subject is the medical-care industry, not health." In the 50 years that followed, researchers, policymakers, and public health professionals generated valuable and varied insights into health, impacting both behaviors and environments while addressing social determinants and demographic trends. Yet medical care has followed an even steeper upward trajectory, growing rapidly in scientific precision, public esteem, and technical sophistication.
Independent Articles
All Together Now: Developing a Team Skills Competency Domain for Global Health Education
Virginia Rowthorn and Jody Olsen - [PDF]

Global health is by definition and necessity a collaborative field; one that requires diverse professionals to address the clinical, biological, social, and political factors that contribute to the health of communities, regions, and nations. For universities with global health programs, the interprofessional nature of global health presents both vast opportunities and distinct challenges. In addition to helping students develop mastery within their chosen fields, universities must also ensure that students learn to collaborate with other professionals to address complex global health needs. While much work has been done in recent years to define the field of global health and set forth discipline- specific competencies, less has been done in the area of interdisciplinary or interprofessional global health education. This gap in scholarship is troubling given the clear and well-acknowledged need for professionals across a broad spectrum of disciplines to take part in global health initiatives.
Medical Innovation Then and Now: Perspectives of Innovators Responsible for Transformative Drugs
Shuai Xu and Aaron S. Kesselheim - [PDF]

The discovery and development of new therapeutics has always been central to improving health worldwide. However, there is ongoing concern regarding the current state of medical innovation. Output from the pharmaceutical industry has been criticized for not being "transformative," that is, offering substantial improvements in patient outcomes over existing therapeutics. While the cost of drug development continues to rise, breakthrough therapies remain elusive and one half of Phase 3 studies fail. Venture capital, a traditional source of funding for new breakthrough biomedical innovations, has decreased investment by 30% in the biotechnology and medical device sectors from 2007 to 2013. Stakeholders question whether the new drugs approved each year by the FDA -many criticized as marginal improvements over existing therapies - justify the enormous investment.
The Fiduciary Relationship Model for Managing Clinical Genomic "Incidental" Findings
Gabriel Lazaro-Munoz - [PDF]

The physician-patient relationship has a long history and is rich in deeply held traditions, yet it is one of the principal destinations for many of society's most innovative technological advances. The implementation of scientific innovations, such as genomic sequencing, forces the physician-patient relationship to continuously confront difficult ethical and legal dilemmas. The way the physician-patient relationship responds to the implementation of genomics is a crucial aspect of the success of these technologies as catalysts for the improvement of human health. Therefore, it is important to identify frameworks that can guide the sustainable implementation of genomics in clinical care. One promising alternative is to apply legal fiduciary principles to guide the generation, use, and handling of genomic information in the clinic.
Autonomy and Paternalism in Health Policy
Mark A. Rothstein - [PDF]

In the United States the delivery of health care traditionally has been hierarchical and strictly controlled by physicians. Physicians typically provided patients with little information about their diagnosis, prognosis, and treatment plan; patients were expected to follow their physicians' orders and ask no questions. Beginning in the 1970s, with the widespread adoption of the doctrine of informed consent to treatment, the physician-patient relationship began to be more collaborative, although the extent of the change has been subject to debate. At a minimum, physicians began to give patients more information and asked them to consent to recommended treatment, the therapeutic privilege to withhold information from patients lost support and eventually was repudiated, and physicians embraced - at least in theory - a more patient-centered conception of health care.
Public Health and the Law: Global Emergency Legal Responses to the 2014 Ebola Outbreak
James G. Hodge, Jr., Leila Barraza, Gregory Measer, and Asha Agrawal - [PDF]

From their relative obscurity over the past three decades, varied strains of Ebola disease have emerged as a substantial global biothreat. The current outbreak of Ebola, beginning in March 2014 in Guinea, is projected to infect tens of thousands of people before being brought under control. Some estimate the outbreak could exceed 100,000 cases and extend another 12-18 months. Ebola's spread has the potential to extend across the globe, but is concentrated in several African countries (e.g., Democratic Republic of Congo, Sierra Leone, Liberia, Guinea, Nigeria, and Senegal). Collectively, these countries are home to nearly 290 million people. Among Liberia's population of 4.1 million, over 1,100 people have already died from Ebola in less than 6 months; by comparison, if this same outbreak and death rate occurred in the United States, over 88,000 Americans would perish. With the numbers of infected still expanding and reported mortality rates exceeding 40% of those infected, international, national, and regional governments have launched various states of emergency authorizing a plethora of public health powers.
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