abstract: American Indian literature is replete with language that refers to broken or hollow promises the US government has made to American Indians, one of the most prominent being that the US government has not kept its promises regarding health services for American Indians/Alaska Natives (AI/AN). Some commenters refer to treaties between tribes and the US government as the origin of the promise for health services to AI/AN. Others point to the trust relationship between the sovereign nations of American Indian tribes and the US government, while still others assert that the Snyder Act of 1921 or the Indian Health Care Improvement Act (IHCIA) contained the promise for health care. While the US has provided some form of health care for AI/AN since the country was in its infancy, and continues to do so through the Indian Health Service, the promise of health services for AI/AN is not explicit. Philosophers have articulated that a promise contains a moral obligation to fulfill it because of others’ expectations created by that promise. As the US government made its first promises in early treaties with AI/AN tribes and subsequently made promises in the years since, it is morally obligated to fulfill those promises, be they lying promises or not, because of resulting expectations. Yet, the US government has historically acted to restrict the rights of AI/AN—rights that include access to health services—through assimilation, separation, or termination policies. Further, the policies of the US government have kept the AI/AN populations socioeconomically impoverished, dependent on the US government for basic needs, and susceptible to health-compromising conditions. Using case studies, this dissertation looks not only at the policies and events that directly affected health services and health status, but also at how those policies and events contributed to health outcomes and the expectations of AI/AN. Given the history of the US government in fulfilling (or not fulfilling) its promises, this dissertation examines the expectations of AI/AN for their own future health outcomes under the policy of self-governance. / Dissertation/Thesis / Doctoral Dissertation Biology 2016

Made available in DSpace on 2016-06-07T17:12:21Z (GMT). No. of bitstreams: 0 Previous issue date: 2015-08-24. Added 1 bitstream(s) on 2016-06-07T17:17:00Z : No. of bitstreams: 1 000863909_20180224.pdf: 325393 bytes, checksum: 95ca34210c9db4738d343025bcdf6381 (MD5) Bitstreams deleted on 2018-03-02T12:39:59Z: 000863909_20180224.pdf,. Added 1 bitstream(s) on 2018-03-02T12:40:55Z : No. of bitstreams: 1 000863909.pdf: 2682582 bytes, checksum: 0b5e6d136a0d6c28d1ab8d892cc82aab (MD5) / Há uma demanda crescente por melhorias na formação médica tanto em aspectos técnicos como humanísticos. O internato se configura como um período central à aquisição e desenvolvimento de habilidades para os estudantes de medicina. Compreender a forma como as escolas médicas avaliam este importante período de formação pode apontar melhorias no ensino médico com repercussões sobre a Saúde Coletiva. Tivemos como objetivo analisar os instrumentos utilizados por escolas médicas para avaliar os estágios de internato por seus alunos. A hipótese principal é a de que muitos instrumentos não incorporam questões destinadas à avaliação de conflitos éticos durante o internato. Estudo seccional baseado na análise documental dos instrumentos utilizados por escolas médicas brasileiras para avaliação dos estágios de internato por seus alunos. Foram selecionadas aleatoriamente 121 escolas médicas brasileiras públicas ou privadas de quaisquer regiões do país. Foram excluídas escolas médicas que ainda não possuíam alunos cursando estágios de internato durante o primeiro semestre de 2014. Dois pesquisadores examinaram os instrumentos de avaliação obtidos e extraíram informações padronizadas de cada instrumento de forma independente. Quaisquer divergências entre os investigadores foram dirimidas por intermédio de um terceiro pesquisador. Das 121 instituições contatadas, 46 aceitaram participar na pesquisa, entre essas, 23 afirmaram que adotavam algum instrumento formal para avaliação dos estágios de internato por seus alunos. Apenas 12 escolas possuíam instrumentos que abordavam de alguma forma a dimensão ética. Na maioria dos casos as questões éticas examinadas se relacionavam à atitude dos preceptores quanto aos alunos. Nenhum dos instrumentos abordou a questão ética relacionada à equipe em suas relações de maneira geral, com o paciente ou com os alunos. Somente dois instrumentos questionavam os alunos... / There is a growing demand for improvements in medical education in both technical and humanistic domains. The internship is a crucial period for the acquisition and development of skills by medical students. Efforts to understand how medical schools assess this important period of training may point out directions for improvement in medical education with implications for Public Health. Hence we aimed to analyze the instruments used by medical schools to evaluate the internship rotations from the point of view of their students. Our main hypothesis was that many instruments do not incorporate questions directed at the assessment of ethical conflicts occurring during that period. We conducted a cross-sectional study based on documentation analysis of the instruments used by Brazilian medical schools for evaluation of the internship rotations by their own students. We randomly selected 121 Brazilian medical schools. We excluded medical schools that still did not have students enrolled in any internship rotation as of the first semester of 2014. Two independent researchers examined the assessment instruments obtained and extracted standardized information for each instrument. Any disagreements between the reviewers will be solved through the assessment of a third researcher. Of the 121 institutions contacted, 46 agreed to participate in the survey. Among these, 23 stated that they some formal instrument for evaluation of the internship rotations by their students. Only 12 medical schools had instruments that addressed the ethical dimension in some way. In most cases the ethical issues examined were related to the attitude of preceptors. None of the instruments addressed the ethical issues related to the healthcare. Only two instruments questioned the students about negative ethical experiences and conflicts during the rotations and only one sought to find positive ethical experiences. We argue that assessment instruments based on the ...

Dentre as diversas questões éticas vivenciadas por pacientes terminais destacam-se a eutanásia e a distanásia, ambas consideradas imorais pelo personalismo ontológico proposto por Elio Sgreccia. O objetivo desta dissertação é verificar se o pensamento de Sgreccia pode ser justificado racionalmente de forma objetiva e se possui critérios de necessidade e universalidade. O método utilizado foi a análise dos próprios textos do autor e de suas fontes, tendo como técnica de abordagem a revisão histórica da ética médica desde o tempo de Hipócrates e a comparação do personalismo ontológico com as principais éticas dando ênfase aos conceitos de vida, pessoa, saúde, doença e corpo humano. Apresenta-se o personalismo ontologicamente fundamentado, com os princípios de defesa da vida, liberdade-responsabilidade, totalidade e subsidiariedade, comparando-o ao principialismo, com seus princípios de autonomia, beneficência, não maleficência e justiça. Descreve-se a proposta de Sgreccia para a solução de dilemas com o uso dos princípios secundários do mal menor e do duplo efeito, bem como a necessidade de hierarquização dos princípios primários. Destaca-se a hierarquia do benefício sobre a autonomia, demonstrando o valor intrínseco e inalienável da vida, bem como a subordinação da liberdade a esse valor. Conclui-se que, segundo o autor, os principais dilemas éticos do fim da vida em pacientes terminais são decorrentes de uma não uniformidade de termos, sendo a confusão entre eutanásia passiva e distanásia a principal. O esclarecimento ocorre com a aplicação dos conceitos iniciais que o autor busca na fonte aristotélico-tomista, bem como uma compreensão de autonomia semelhante à proposta por Kant e da morte não mais como um evento, mas como um processo que se inicia com a doença terminal. / Submitted by Ana Guimarães Pereira (agpereir@ucs.br) on 2016-06-27T16:38:10Z No. of bitstreams: 1 Dissertacao Franco Scariot.pdf: 1853889 bytes, checksum: a7f6e9903b14737aeb71a0224798ea1a (MD5) / Made available in DSpace on 2016-06-27T16:38:10Z (GMT). No. of bitstreams: 1 Dissertacao Franco Scariot.pdf: 1853889 bytes, checksum: a7f6e9903b14737aeb71a0224798ea1a (MD5) Previous issue date: 2016-06-27 / Among the many ethical issues experienced by terminal patients, both euthanasia and dysthanasia stand out as being considered immoral by the ontological personalism proposed by Elio Sgreccia. The aim of this paper is to verify if Sgreccia’s theory can be rationally justified in an objective way and if it has necessity and universality criteria. The method used was the analysis of the author's own texts and sources, taking the historical review of medical ethics since Hippocrates as an approach technique, as well as comparing the ontological personalism with the main ethical theories, emphasizing the concepts of life, person, health, disease and the human body. The study presents the ontologically based personalism with the principles of protection of life, freedom-responsibility, totality and subsidiarity, in a comparison with the principlism and its principles of autonomy, beneficence, nonmaleficence and justice. Sgreccia’s theory is reported as a solution to dilemmas when using its secondary principles of less harm and double effect, and also presents the need to create a hierarchy system for its primary principles. The hierarchy of benefit stands out from autonomy, thus demonstrating the intrinsic and inalienable value of life, as well as the subordination of freedom to that value. Therefore, it is possible to conclude that, according to the author, the main ethical dilemmas concerning the end of life in terminal patients are due to the lack of standard expressions, especially between passive euthanasia and dysthanasia. The elucidation is given when applying the initial concepts which the author collects in the Aristotelian-Thomistic source, as well as in an understanding of autonomy similar to that proposed by Kant, and of death not as an event but as a process which starts with terminal illness.

Orientador: Edison Iglesias de Oliveira Vidal / Banca: Sergio Tavares de Almeida Rego / Banca: Sigisfredo Luis Brenelli / Resumo: Há uma demanda crescente por melhorias na formação médica tanto em aspectos técnicos como humanísticos. O internato se configura como um período central à aquisição e desenvolvimento de habilidades para os estudantes de medicina. Compreender a forma como as escolas médicas avaliam este importante período de formação pode apontar melhorias no ensino médico com repercussões sobre a Saúde Coletiva. Tivemos como objetivo analisar os instrumentos utilizados por escolas médicas para avaliar os estágios de internato por seus alunos. A hipótese principal é a de que muitos instrumentos não incorporam questões destinadas à avaliação de conflitos éticos durante o internato. Estudo seccional baseado na análise documental dos instrumentos utilizados por escolas médicas brasileiras para avaliação dos estágios de internato por seus alunos. Foram selecionadas aleatoriamente 121 escolas médicas brasileiras públicas ou privadas de quaisquer regiões do país. Foram excluídas escolas médicas que ainda não possuíam alunos cursando estágios de internato durante o primeiro semestre de 2014. Dois pesquisadores examinaram os instrumentos de avaliação obtidos e extraíram informações padronizadas de cada instrumento de forma independente. Quaisquer divergências entre os investigadores foram dirimidas por intermédio de um terceiro pesquisador. Das 121 instituições contatadas, 46 aceitaram participar na pesquisa, entre essas, 23 afirmaram que adotavam algum instrumento formal para avaliação dos estágios de internato por seus alunos. Apenas 12 escolas possuíam instrumentos que abordavam de alguma forma a dimensão ética. Na maioria dos casos as questões éticas examinadas se relacionavam à atitude dos preceptores quanto aos alunos. Nenhum dos instrumentos abordou a questão ética relacionada à equipe em suas relações de maneira geral, com o paciente ou com os alunos. Somente dois instrumentos questionavam os alunos... / Abstract: There is a growing demand for improvements in medical education in both technical and humanistic domains. The internship is a crucial period for the acquisition and development of skills by medical students. Efforts to understand how medical schools assess this important period of training may point out directions for improvement in medical education with implications for Public Health. Hence we aimed to analyze the instruments used by medical schools to evaluate the internship rotations from the point of view of their students. Our main hypothesis was that many instruments do not incorporate questions directed at the assessment of ethical conflicts occurring during that period. We conducted a cross-sectional study based on documentation analysis of the instruments used by Brazilian medical schools for evaluation of the internship rotations by their own students. We randomly selected 121 Brazilian medical schools. We excluded medical schools that still did not have students enrolled in any internship rotation as of the first semester of 2014. Two independent researchers examined the assessment instruments obtained and extracted standardized information for each instrument. Any disagreements between the reviewers will be solved through the assessment of a third researcher. Of the 121 institutions contacted, 46 agreed to participate in the survey. Among these, 23 stated that they some formal instrument for evaluation of the internship rotations by their students. Only 12 medical schools had instruments that addressed the ethical dimension in some way. In most cases the ethical issues examined were related to the attitude of preceptors. None of the instruments addressed the ethical issues related to the healthcare. Only two instruments questioned the students about negative ethical experiences and conflicts during the rotations and only one sought to find positive ethical experiences. We argue that assessment instruments based on the ... / Mestre

abstract: ABSTRACT Whole genome sequencing (WGS) and whole exome sequencing (WES) are two comprehensive genomic tests which use next-generation sequencing technology to sequence most of the 3.2 billion base pairs in a human genome (WGS) or many of the estimated 22,000 protein-coding genes in the genome (WES). The promises offered from WGS/WES are: to identify suspected yet unidentified genetic diseases, to characterize the genomic mutations in a tumor to identify targeted therapeutic agents and, to predict future diseases with the hope of promoting disease prevention strategies and/or offering early treatment. Promises notwithstanding, sequencing a human genome presents several interrelated challenges: how to adequately analyze, interpret, store, reanalyze and apply an unprecedented amount of genomic data (with uncertain clinical utility) to patient care? In addition, genomic data has the potential to become integral for improving the medical care of an individual and their family, years after a genome is sequenced. Current informed consent protocols do not adequately address the unique challenges and complexities inherent to the process of WGS/WES. This dissertation constructs a novel informed consent process for individuals considering WGS/WES, capable of fulfilling both legal and ethical requirements of medical consent while addressing the intricacies of WGS/WES, ultimately resulting in a more effective consenting experience. To better understand components of an effective consenting experience, the first part of this dissertation traces the historical origin of the informed consent process to identify the motivations, rationales and institutional commitments that sustain our current consenting protocols for genetic testing. After understanding the underlying commitments that shape our current informed consent protocols, I discuss the effectiveness of the informed consent process from an ethical and legal standpoint. I illustrate how WGS/WES introduces new complexities to the informed consent process and assess whether informed consent protocols proposed for WGS/WES address these complexities. The last section of this dissertation describes a novel informed consent process for WGS/WES, constructed from the original ethical intent of informed consent, analysis of existing informed consent protocols, and my own observations as a genetic counselor for what constitutes an effective consenting experience. / Dissertation/Thesis / Ph.D. Biology 2013

abstract: Lung Cancer Alliance, a nonprofit organization, released the "No One Deserves to Die" advertising campaign in June 2012. The campaign visuals presented a clean, simple message to the public: the stigma associated with lung cancer drives marginalization of lung cancer patients. Lung Cancer Alliance (LCA) asserts that negative public attitude toward lung cancer stems from unacknowledged moral judgments that generate 'stigma.' The campaign materials are meant to expose and challenge these common public category-making processes that occur when subconsciously evaluating lung cancer patients. These processes involve comparison, perception of difference, and exclusion. The campaign implies that society sees suffering of lung cancer patients as indicative of moral failure, thus, not warranting assistance from society, which leads to marginalization of the diseased. Attributing to society a morally laden view of the disease, the campaign extends this view to its logical end and makes it explicit: lung cancer patients no longer deserve to live because they themselves caused the disease (by smoking). This judgment and resulting marginalization is, according to LCA, evident in the ways lung cancer patients are marginalized relative to other diseases via minimal research funding, high- mortality rates and low awareness of the disease. Therefore, society commits an injustice against those with lung cancer. This research analyzes the relationship between disease, identity-making, and responsibilities within society as represented by this stigma framework. LCA asserts that society understands lung cancer in terms of stigma, and advocates that society's understanding of lung cancer should be shifted from a stigma framework toward a medical framework. Analysis of identity-making and responsibility encoded in both frameworks contributes to evaluation of the significance of reframing this disease. One aim of this thesis is to explore the relationship between these frameworks in medical sociology. The results show a complex interaction that suggest trading one frame for another will not destigmatize the lung cancer patient. Those interactions cause tangible harms, such as high mortality rates, and there are important implications for other communities that experience a stigmatized disease. / Dissertation/Thesis / M.S. Biology 2013

Dentre as diversas questões éticas vivenciadas por pacientes terminais destacam-se a eutanásia e a distanásia, ambas consideradas imorais pelo personalismo ontológico proposto por Elio Sgreccia. O objetivo desta dissertação é verificar se o pensamento de Sgreccia pode ser justificado racionalmente de forma objetiva e se possui critérios de necessidade e universalidade. O método utilizado foi a análise dos próprios textos do autor e de suas fontes, tendo como técnica de abordagem a revisão histórica da ética médica desde o tempo de Hipócrates e a comparação do personalismo ontológico com as principais éticas dando ênfase aos conceitos de vida, pessoa, saúde, doença e corpo humano. Apresenta-se o personalismo ontologicamente fundamentado, com os princípios de defesa da vida, liberdade-responsabilidade, totalidade e subsidiariedade, comparando-o ao principialismo, com seus princípios de autonomia, beneficência, não maleficência e justiça. Descreve-se a proposta de Sgreccia para a solução de dilemas com o uso dos princípios secundários do mal menor e do duplo efeito, bem como a necessidade de hierarquização dos princípios primários. Destaca-se a hierarquia do benefício sobre a autonomia, demonstrando o valor intrínseco e inalienável da vida, bem como a subordinação da liberdade a esse valor. Conclui-se que, segundo o autor, os principais dilemas éticos do fim da vida em pacientes terminais são decorrentes de uma não uniformidade de termos, sendo a confusão entre eutanásia passiva e distanásia a principal. O esclarecimento ocorre com a aplicação dos conceitos iniciais que o autor busca na fonte aristotélico-tomista, bem como uma compreensão de autonomia semelhante à proposta por Kant e da morte não mais como um evento, mas como um processo que se inicia com a doença terminal. / Among the many ethical issues experienced by terminal patients, both euthanasia and dysthanasia stand out as being considered immoral by the ontological personalism proposed by Elio Sgreccia. The aim of this paper is to verify if Sgreccia’s theory can be rationally justified in an objective way and if it has necessity and universality criteria. The method used was the analysis of the author's own texts and sources, taking the historical review of medical ethics since Hippocrates as an approach technique, as well as comparing the ontological personalism with the main ethical theories, emphasizing the concepts of life, person, health, disease and the human body. The study presents the ontologically based personalism with the principles of protection of life, freedom-responsibility, totality and subsidiarity, in a comparison with the principlism and its principles of autonomy, beneficence, nonmaleficence and justice. Sgreccia’s theory is reported as a solution to dilemmas when using its secondary principles of less harm and double effect, and also presents the need to create a hierarchy system for its primary principles. The hierarchy of benefit stands out from autonomy, thus demonstrating the intrinsic and inalienable value of life, as well as the subordination of freedom to that value. Therefore, it is possible to conclude that, according to the author, the main ethical dilemmas concerning the end of life in terminal patients are due to the lack of standard expressions, especially between passive euthanasia and dysthanasia. The elucidation is given when applying the initial concepts which the author collects in the Aristotelian-Thomistic source, as well as in an understanding of autonomy similar to that proposed by Kant, and of death not as an event but as a process which starts with terminal illness.

L’article 2 de la loi n°94-43 du 18 janvier 1994, transférant l’organisation des soins en milieu carcéral du ministère de la Justice au service public hospitalier, a souvent été présenté comme une réforme de santé publique s’imposant au vu de l’état des prisons françaises. L’épidémie de sida et le volontarisme des ministres de la Santé suffiraient à rendre compte de ce qui a été qualifié de « révolution sanitaire ». Pourtant au-delà de ces facteurs conjoncturels, les conditions de possibilité de cette réforme s’inscrivent plus largement au croisement d’une double dynamique, professionnelle et carcérale, que cette recherche propose de retracer. En effet, la loi du 18 janvier 1994 est également la réforme d’une profession et d’un secteur d’action publique tous deux fortement contestés. La réforme de l’organisation des soins en prison marque l’échec d’une stratégie de spécialisation médicale, entendue comme la tentative opérée par certains praticiens d’occuper une position spécifique au sein du secteur médical.Initiée au début des années soixante par le premier Médecin-inspecteur des prisons, Georges Fully, l’affirmation d’une « médecine pénitentiaire » spécifique avait alors pour but de conférer aux praticiens une plus grande légitimité, et ainsi autonomie, à l’égard de leur employeur, l’Administration pénitentiaire. La spécialisation était ainsi conçue comme une ressource supplémentaire afin de mettre fin au tiraillement auquel étaient confrontés les praticiens travaillant en détention entre leur statut de vacataire du ministère de la Justice et celui de médecin-traitant des détenus. Toutefois, après la violente contestation des prisons survenue durant les années soixante-dix, l’affirmation d’une médecine pénitentiaire devient pour le nouveau Médecin-inspecteur, Solange Troisier, le moyen de légitimer un secteur d’action publique discrédité : l’organisation des soins en milieu carcéral. La consécration d’une médecine spécifique aux détenus est également pour elle le moyen de faire prévaloir les exigences du Code de procédure pénale sur celles issus du Code de déontologie. La spécialisation de la médecine pénitentiaire devient ainsi un moyen de s’autonomiser non pas du ministère de la Justice mais du secteur médical. La réforme de 1994 marque l’échec de cette tentative de spécialisation médicale. Elle résulte de la rencontre entre un « segment » de praticiens défendant l’idée d’une médecine non-spécifique avec quelques magistrats-militants, issus du Syndicat de la magistrature, en poste à l’Administration pénitentiaire favorables à un « décloisonnement » de l’institution carcérale. La loi du 18 janvier 1994 marque l’aboutissement de cette stratégie et l’échec de la tentative de spécialisation. A la « médecine pénitentiaire », désormais rattachée à un passé stigmatisant révolu, succéderait une « médecine exercée en milieu carcéral ».L’enjeu de cette thèse est par conséquent de retracer la sociogenèse d’une réforme à partir des dynamiques qui traversent un groupe professionnel, d’une part, et des transformations qui affectent un secteur d’action publique, d’autre part. On montrera également que la spécialisation de la médecine ne peut être comprise que si elle est articulée à d’autres logiques et qu’elle ne peut ainsi être réduite à sa seule dimension médicale. / Article 2 of French law No 94-43 of January 18, 1994, which concerns the transfer of the organization of health care in prisons from the Ministry of Justice to the public hospital service, has often been presented as a necessary public health reform considering the state of French prisons. The AIDS epidemic and the voluntary work of the Ministry of Health and the Ministry of Justice have revealed the need for what has been called a “sanitary revolution”. However, the conditions required for this reform would seem to require a dual approach: both professional and institutional, which this study will underline. Indeed, The French law of January 18, 1994 is also the reform of a profession, and of a sector of action, that is strongly criticized publicly. The reform of organization of health care in prisons underlines the failure of a strategy for a medical specialty, and is viewed by a few observers as an attempt by some practitioners to establish a particular position within the medical sector.Launched in the early sixties by the very first Doctor-inspector for prisons, Georges Fully, the assertion of specific “ health care in prison” was designed to give more legitimacy to the practitioners and therefore to allow them a greater level of autonomy from their employer, the prison administration. The specialization was designed to be an additional resource to help to put an end to the tension that the practitioners working in prison had to face, between their contract status at the Ministry of Justice and their status as general practitioners working in prisons . However, after the violent protests in prisons during the seventies, the organisation of “ health care in prisons” became for the new Doctor-inspector, Solange Troisier, a means of legitimizing the work of a discredited public service. The consecration of a specific medical practice for prisoners was also for her a means of asserting the requirements of the Code of Criminal Procedure over those of the Code of Medical Ethics. Thus the specialization of health care in prison became a means of empowerment not for the Ministry of Justice but for the medical sector.The reform of 1994 marks the failure of this attempt of medical specialization. It results from interactions between a group of practitioners defending the idea of a non-specific medical care and several militant magistrates, coming from the trade union of magistrates, working in the prison administration who were in favour of a opening-out of the penitentiary institution. The French law of January 18, 1994, highlights the accomplishment of this type of strategy and the failure to create a specialized health care in prison, the latter being then attached to a stigmatized and outdated past.The issue of this thesis is consequently to explore the sociogenesis of a reform from the dynamics which guide a professional group, on the one hand, and the evolutions which affect a public sector of action, on the other hand. We will also show that the specialization of medicine can be understood only if it is apprehended differently and subsequently cannot be reduced only to its medical dimension.

This thesis seeks to examine the ethical basis for occupational medicine, as it is practised in the United Kingdom (UK). There is empirical evidence of occupational physicians being confused with regard to confidentiality and consent, and variations in their practice. It is argued that the ethical guidance from the General Medical Council and the Faculty of Occupational Medicine on these matters, contributes significantly to such confusion. The doctor-patient relationship, consent for disclosure of a medical report, and medical confidentiality, all in the context of occupational medicine practice, are explored. These issues are addressed in the core part of this thesis in the form of the three published papers. In the first paper, the doctor-patient relationship in occupational medical practice is reviewed, and it becomes apparent that in the UK, the occupational physician carries out different roles and functions, ranging from duties that mirror those of a therapeutic encounter, to those that require the occupational physician to be completely independent for the purposes of a particular type of assessment (for ill-health retirement). The former is compatible with the assumption of a fiduciary relationship between doctor and patient, whereas in the latter situation, it would be incongruous to expect the doctor to be independent and owe the patient a “duty of undivided loyalty” simultaneously. In the second paper, consent for disclosure of information, in particular a medical report, is distinguished from the “informed consent” for treatment or interventional research, and the phrase “permission to disclose” is proposed for the disclosure situations. Although this distinction may not have much significance in therapeutic practice, the output of virtually all occupational physician activities results in the writing of a report, so this difference between the two “consents” has greater relevance. The third paper reviews the ethical, and in particular, legal basis for medical confidentiality with reference to an independently commissioned report. In such a situation, UK courts have been consistent in stating that disclosure of such a report to the commissioning party does not breach confidentiality, and no further consent for such disclosure is required. This conflicts with ethical guidance to occupational physicians on this matter. Such conflict between the law and ethical guidance are a further, and important, source of ethical confusion for occupational physicians. Indeed, a common theme through the three papers is that ethical guidance to occupational physicians is in parts either incongruent, incoherent, or conceptually flawed. This may not be surprising, as current ethical guidance is predicated on a doctor-patient relationship that exists in the usual setting for most doctor-patient encounters, that is, the therapeutic setting. It seems unreasonable to expect that simply transposing such an ethical paradigm into a different setting, with dissimilar roles and obligations, could work in a seamless manner. The occupational physicians’ ethical confusion thus reflects the confusion in their ethical guidance.

Traditionally, one of the major characteristics of established professions such as medicine and law has been the possession of a Code of Ethics. The last three decades have seen the formulation of Codes of Ethics by many new professions and semi-professions as well as by many of the service occupations. In view of the intense concern of these professions, semi-professions and service occupations with the formation of codes of ethics, we set out to examine the codes of three professions to ascertain their functional significance both to the professions themselves and to the public. The rationale for the choice of the three professions of Medicine, Social Work, and Librarianship lay in their being professions whose codes of ethics were in different stages of development. A theoretical framework formulated in the first chapter was used in the following three chapters to examine the judicial viability of the codes of ethics of these professions. As main features of this analysis, we considered the formulation, promulgation, administration, review and revision procedures, jurisdiction, and implications for social policy of the codes. On the basis of the analysis and discussion of the codes of ethics studied we drew the conclusion that many of the existing codes are, to a great extent, deplorably non-specific and even rhetorical. It would therefore seem to be desirable that some measures should be taken to improve the judicial viability of these Codes; and we have made a number of recommendations calculated to achieve this end. / Arts, Faculty of / Social Work, School of / Hoffmann, Walter Paul Fritz; Humphrey, Patricia McLean; Thompson, Douglas Terrence / Graduate