Thesis (MPhil)--University of Stellenbosch, 2001. / ENGLISH ABSTRACT: This evaluation serves the purpose of illuminating concepts and ideas behind the moral impact of business values in healthcare and to establish a framework for the analysis of moral dilemmas found in the sphere ofbio-medical ethics. The historic developments of business in healthcare are examined, looking at how and why business became an integral part of the health care system. The concept of "managed healthcare" is introduced and used as the context in which the different institutional role-players are brought together. Managed healthcare is defined by a discussion of the different organisational structures through which it manifests itself. The policies, procedures and regulations that managed healthcare organisations implement and control to fulfil their general function are also examined. Some normative aspects pertaining to the concept of managed health care are explored, including the institutional values of business and that of medicine. A brief discussion of the economic system in which the business agents or role players function are included in the evaluation of the institutional values of business. Further arguments are made to show how the healthcare system with all its role players displays the characteristics of a complex system. Discussions on the fundamental values of medicine concentrate on the basic ideas behind virtues and principles of medical ethics. It is argued that the development of these virtues and principles are important foundations on which the medical profession stands. The moral impact of combining these institutional values within the context of managed healthcare relationships is examined and some important moral dilemmas or conflicts are identified. It is further argued that the fundamental relationships between all the role players in the health care system have changed as all the agents function within a complex system, giving rise to new organisational structures and relationships, with new conceptual roles, ideals, values and practices. / AFRIKAANSE OPSOMMING: Hierdie evaluasie het dit ten doelom sekere konsepte en idees agter die morele impak van besigheidswaardes in gesondheidsorg te illumineer en om 'n raamwerk daar te stel vir die verdere analise van morele dilemmas in die sfeer van bio-mediese etiek. Die historiese ontwikkeling van besigheid in gesondheidsorg word verken deur die redes aan te voer waarom besigheid deel van die gesondheidsorgsisteem geword het. Die konsep "bestuurde gesondheidsorg" word gebruik as die konteks waarin die verskillende institusionele rolspelers bymekaar gebring word. Bestuurde gesondheidsorg word gedefinieer deur die verskillende organisatoriese strukture waardeur dit manifesteer. Die prosedures, regulasies en bereid wat bestuurde gesondheidsorgorganisasies implementeer om hul funksies te vervul word ook verken. Normatiewe aspekte van bestuurde gesondheidsorg word verken, waarby ingesluit word die institusionele waardes van besigheid sowel as dié van medisyne. 'n Kort beskrywing van die ekonomiese sisteem waarin die besigheidsagente, of rolspelers funksioneer word ingesluit by die evaluasie van die institusionele waardes van besigheid. Verdere argumente word gevoer om te wys daarop hoe die gesondheidsorgsisteem met al sy rolspelers die karakter toon van 'n komplekse sisteem. Die basiese idees agter deugsaamheid en morele beginsels van bio-mediese etiek word bespreek om die fundamentele waardes van medisyne te beskryf. Daar word geargumenteer dat die ontwikkeling van hierdie waardes 'n belangrike fondament is waarop die mediese professie staan. Die morele impak van die kombinasie tussen die institusionele waardes van besigheid en medisyne binne die konteks van bestuurde gesondheidsorg word geevalueer en belanrike morele dilemmas en konflikte word geidentifiseer. Verder word geargumenteer dat die fundamenrele verhouding tussen al die rol spelers in die gesondheidsisteem verander het danksy die funksionering van die agente binne hierdie komplekse sisteem. Dit lei op sy beurt na veranderinge in organisatoriese strukture en verhoudinge met nuwe konsepsuele rolle, idiale, waardes en praktyke.

The undertreatment of chronic pain and the prevention of drug abuse and diversion of pain medications (i.e., opioids) have been identified as public health issues in the United States. In this domain, the Drug Enforcement Administration (D.E.A.) faces challenges when enforcing the Controlled Substance Act because it is tasked with regulating the dispensing of opioids by physicians in the treatment of chronic pain, while also attempting to prevent their abuse and diversion. Thus, the D.E.A. must use discretion in how it enforces the C.S.A. because intentional actions to prevent opioid abuse and diversion could also unintentionally affect the willingness of primary care physicians to prescribe them in the treatment of chronic pain. As an initial step in clarifying the boundaries between the D.E.A. and the medical profession, it was necessary to assess physician perceptions about the D.E.A. 's use of enforcement discretion. A total of 205 Oregon primary care physicians completed a web-based survey examining three domains: concern about D.E.A. enforcement discretion; autonomy related to use of opioids in the treatment of chronic pain; and prescribing of opioids in the treatment of chronic pain. Results indicated that some physicians perceive a concern about D.E.A. enforcement discretion, and those who have concern are more likely to perceive having reduced autonomy related to the use of opioids in the treatment of chronic pain. The results do not support previous research that showed that such concerns directly affects physician prescribing of opioids. Instead, results reveal that concern about D.E.A. enforcement discretion is associated with reduced perceived autonomy, and reduced perceived autonomy is associated with less willingness to prescribe opioids in the treatment of chronic pain. This research takes the study on this topic one step further in identifying physician perceptions about D.E.A. enforcement discretion, and how these perceptions were associated with physician autonomy and prescribing of opioids in the treatment of chronic pain. In doing so, this research provides important scholarly contributions to the enforcement discretion literature, specific to the D.E.A., and medical professionalism as it pertains to physician autonomy related to the use of opioids in the treatment of chronic pain.

Thesis (LLD (Public Law))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: The unique and intimate relationship that exists between a medical practitioner and his/her client is possibly one of the most important relationships that can come into being between any two people. This relationship is characterised and influenced by the qualities and attributes specific to the nature and historical development of medical care, as well as medical science in general. The doctor-patient relationship is also influenced by the social dynamics of a particular community, environmental factors, technological advances and the general social and commercial evolution of the human race. With regard to medical care and health service delivery, the doctor-patient relationship is furthermore vital to the quality of the care provided, as well as to the outcomes and relative success of the specific medical intervention or treatment. One of the distinct characteristics of the doctor-patient relationship is the power imbalance inherent in this relationship. The medical practitioner has expert knowledge and skill, while the patient finds himself or herself in an unusually dependent and vulnerable position. It is because of this important role that the doctor-patient relationship still plays in health service delivery today; the susceptibility of the relationship to a variety of influences, and the characteristic power imbalances inherent in this relationship, that a study of the doctor-patient relationship in South African medical- and health law is necessary. The characteristic power imbalances will be considered from a legal perspective in this dissertation. This study provides a comprehensive source of the doctor-patient relationship from a legal perspective. Where relevant, references are made to theories and principles from other disciplines, including sociology, economy and medical ethnomethodology. The prevalence and consequences of power imbalances in the doctor-patient relationship are identified and discussed with the aim of bringing these to the attention of both the legal fraternity, and medical practitioners. Specific problem areas are identified and solutions are offered, including the following: • The adverse consequences of power imbalances inherent in the doctor-patient relationship on the medical decision-making process are considered from various perspectives. With regard to these adverse consequences, the doctrine of informed consent is analysed and evaluated in great detail. • The influence of paternalistic notions in health service delivery; the business model of health service delivery and the effects of managed care and consumer-directed health care on the doctor-patient relationship and health service delivery in general are also analysed from a legal perspective, and specifically with regard to the power imbalances inherent in this relationship. • The role of autonomy, self-determination and dignity, as well as the principles of beneficence in medical practice, are reconsidered in an attempt to provide a solution for redressing the power imbalances inherent in the doctor-patient relationship. • The fiduciary nature of the doctor-patient relationship and the special role of trust in the relationship are emphasised throughout the dissertation as the focal point of departure in the doctor-patient relationship and the main constituent in any legal endeavor to redress the power imbalances inherent in it. / AFRIKAANS OPSOMMING: Die unieke en intieme verhouding wat bestaan tussen ‘n mediese praktisyn en ‘n pasiënt is wêreldwyd waarskynlik een van die belangrikste verhoudings wat tussen twee persone tot stand kan kom. Hierdie verhouding word gekenmerk en beïnvloed deur kwaliteite en eienskappe eie aan die besonderse aard en historiese ontwikkeling van gesondheidsorg, sowel as die mediese wetenskap in die algemeen. Die dokter-pasiënt verhouding word verder beïnvloed deur die sosiale dinamika van ‘n bepaalde gemeenskap, omgewingsfaktore, tegnologiese vooruitgang en die algemene sosiale en kommersiële ontwikkeling van die mensdom. Op die terrein van gesondheidsorg en mediese dienslewering is die dokter-pasiënt verhouding voorts ook sentraal tot die kwaliteit van die mediese sorg wat verskaf word, sowel as die uitkomste en relatiewe sukses van die spesifieke mediese behandeling. Een van die kenmerkende eienskappe van die dokter-pasiënt verhouding is die magswanbalans wat daar tussen dokter en pasiënt bestaan. Die mediese praktisyn beskik oor deskundige kennis en vaardighede, terwyl die pasiënt hom- of haarself in ‘n ongewone, afhanklike en kwesbare posisie bevind. Dit is dan veral weens die besondere rol wat hierdie verhouding steeds in hedendaagse gesondheidsorg speel, die beïnvloedbaarheid van hierdie verhouding deur ‘n verskeidenheid faktore, sowel as die kenmerkende magswanbalans inherent in die verhouding, dat ‘n ondersoek na die dokter-pasiënt verhouding in die Suid-Afrikaanse mediese reg noodsaaklik is. Hierdie kenmerkende magswanbalans sal vanuit ‘n regsperspektief verder in hierdie proefskrif ondersoek word. Hierdie studie bied ‘n omvattende bron van die dokter-pasiënt verhouding benader vanuit ‘n regsperspektief, terwyl verwysings na teorieë en beginsels van ander dissiplines soos die sosiologie, ekonomie en mediese etnometodologie ook waar nodig ingesluit word. Die voorkoms en gevolge van ‘n magswanbalans in die dokter-pasiënt verhouding word verder geïdentifiseer en bespreek ten einde dit onder die aandag te bring van beide regslui en medici. Spesifieke probleemareas wat geïdentifiseer is en die oplossings wat daarvoor aan die hand gedoen is sluit die volgende in: • Die nadelige gevolge van die bestaan van ‘n magswanbalans in die dokter-pasiënt verhouding op die mediese-besluitnemingsproses word bespreek vanuit verskillende persepktiewe. Met betrekking tot hierdie nadelige gevolge, word die leerstuk van ingeligte toestemming in besonder geanaliseer en geëvalueer. • Die invloed van ‘n paternalistiese benadering tot gesondheidsorg, die besigheids-model van gesondheidsorg, en die effek van bestuurde- en verbruikersgedrewe gesondheidsorg inisiatiewe op die dokter-pasiënt verhouding en die verskaffing van gesondheidsdienste in die algemeen word ook vanuit ‘n regsperspektief ge-analiseer. Spesifieke aandag word in dié verband gegee aan die invloede van hierdie benaderings en perspektiewe op die magswanbalans inherent aan die dokter-pasiënt verhouding. • Die besondere rol van autonomie, selfbeskikking en menswaardigheid, asook die beginsels van weldadigheid in gesondheidsorg, word heroorweeg in ‘n poging om ‘n meer gelyke distribusie van mag in die dokter-pasiënt verhouding te verseker. • Die fidusiêre aard van die dokter-pasiënt verhouding en die besondere rol wat vertroue in hierdie verhouding speel, word in hierdie proefskrif beklemtoon en word voorts as die basis van die dokter-pasiënt verhouding beskou. Vertroue, as ‘n kenmerk van die dokter-pasiënt verhouding, behoort ook die fokuspunt te wees van enige poging om die magswanbalans in die dokter-pasiënt verhouding aan te spreek.

Typescript (Photocopy) / Bibliography: leaves 307-320 / vii, 320 leaves ; 30 cm. / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Thesis (Ph.D.)--Dept. of Community Medicine, University of Adelaide, 1992