NSHEN has developed this educational resource called Featured Articles. We will be choosing articles from recent health ethics literature that we think will be of interest to ethics committee members as well as others working in our health care system.
We will create a summary of each article we feature for those too busy to read it in its entirety.
by Howard, M. and K Hutchinson (2022) Industry Technicians Embedded in Clinical teams: Impacts on Medical Knowledge. The Hastings center Report; 52 (2):41-48.
In this article, Howard and Hutchinson discuss the ethical issues associated with industry technicians, also referred to as ‘industry employed allied professionals’ (IEAP), working as part of a medical team in the hospital setting. Dialogical practice, where all members of the health care team work together towards a common goal, is essential for clinical communities, as it is a way of sharing knowledge and identifying gaps in that knowledge that are relevant to patient care. The authors argue that by mediating expertise about medical devices on behalf of the manufacturer while also working as part of the health care team, IEAPs potentially limit opportunities for independent learning and for dialogical education practices. In keeping with their role, IEAPs are protecting the commercial interests of the medical device manufacturer, and true knowledge exchange is therefore limited. This may negatively affect clinical knowledge and patient outcomes.
Advances in development of implantable medical devices, increases the dependence on IEAPs to provide service, support and training to health care team members. Embedding IEAPs in the clinical team as non-physician members of the team is associated with conflict of interest. In this paper, Howard and Hutchinson demonstrate how the claim that IEAPs disrupt medical knowledge is based on epistemology. They describe how the reliance on IEAPs to provide service, support and training can negatively impact or even undermine the norms of clinical knowledge sharing.
Key discussion points
Clinical knowledge and epistemic communities
Clinical learning and knowledge derive from physicians and/or interdisciplinary health care teams working together toward shared understanding of diagnoses or shared decisions around treatment. As such, the clinical knowledge system relies on collaboration between members of the clinical community communicating and sharing their expertise in a transparent and open manner. The knowledge sharing may be disrupted if some of the members within the clinical community attain unwarranted epistemic privilege. Medical device manufacturers have commercial interest in protecting knowledge about their products, and IEAPs are essentially functioning as a gatekeeper for medical teams or health care professionals to access this knowledge. The paper argues that this way of controlling knowledge for commercial benefits is an example how IEAPs exploit clinical hierarchies.
- Impact of IEAPs on Clinical Epistemic Communities
The technological complexity of some implantable medical devices increases the demand for IEAPs in hospitals. Moreover, IEAPs are often relied on to alleviate the clinical knowledge gap created by rapid technological advances. This means that the IEAPs may have more knowledge about a medical device than the surgeon who is using it. The role of IEAPs can vary depending on the situation, and can include primarily sales-oriented activities, training in use of devices, proctors to train others, support to use equipment and/or provision of technical support. In these roles the medical device manufacturers and IEAP are in a position of power to practice knowledge management, for example by controlling training resources, technical information, and the like. Physicians may be entirely dependent on IEAPs to gain knowledge and expertise with new equipment if no independent training option or knowledge source about new devices is available. The paper notes that many members of the health care community underestimate the impact the presence of IEAPs has on decision-making, which is a problem. It argues that more attention should be paid to the fact that decisions around purchasing and use of medical devices are often made without adequate independence from those who stand to profit from their use.
- Industry Employees, the Knowledge Economy, and Clinical Knowledge
IEAPs are often the to knowledge about whether, when and how to use specific medical devices. This is for example often the case with implantable medical devices. The authors argue that industry-based training and education provided by IEAPs contribute to shaping epistemic communities in the clinic, and that this is a concern because they may provide suboptimal training. The knowledge offered by IEAPs is specific to the medical device/devices produced by the company they work for. Irrespective of the IEAP’s good intentions, it is a fact that the knowledge that the IEAP has is provided by the company, and that this knowledge is generated for the sake of profiting from the product. IEAPs are therefore not able to provide comparable knowledge around medical devices produced by competing companies.
- Competing Norms of Exchange in the Clinic
Influence on knowledge production and sharing is not limited to individual clinics. Knowledge exchange is also affected at a broader system level, as hospitals engage with IEAPs in purchasing practices. The authors flag the importance of paying attention to how medical device companies interact with health care institutions and use knowledge management procedures at this level. Norms of knowledge exchange in public institutions and/or clinics are fundamentally different from those of the medical device industry. The former is founded on knowledge sharing, whereas the latter builds on commercial interest. That means that for IEAPs ,patient needs in hospitals are secondary to industrial profit, and may in some cases be overridden by the IEAPs’ primary goal. Howard and Hutchinson flag the importance of paying attention to the difference in interests and highlight that the IEAPs’ advice first and foremost is provided to service commercial interests. IEAPs’ knowledge and advice is product specific, which limits the IEAPs ability to provide advice around which device would be best for a specific type of surgery or in a specific patient case. Moreover, it may skew recommendations in situations where the medical team is seeking advice around whether to proceed with a device-based versus a non-device-based intervention.
The authors conclude that IEAPs placement on medical teams contribute to undermine the norms of clinical knowledge sharing.
by Brudney, D. (2019). Changing the Question. The Hastings Center Report, Volume 49:2; p. 9-16
Disability Rights as a Necessary Framework for Crisis Standards of Care and the Future of Health Care by Guidry-Grimes, L, K. Savin, J.A. Stramondo, J.M. Reynolds, M. Tsaplina, T. Blankmeyer Burke, A. Ballantyne, E.F. Kittay, D. Stahl, J.Leach Scully, R. Garlan-Thomson, A. Tarzian, D. Dorfman, and J. J. Fins. Hastings Center Report 50(3): 28-32.
Pandemic and Beyond: Considerations When Personal Risk and Professional Obligations Converge by Daniel J. Benedetti, Mithya Lewis-Newby, Joan S. Roberts, and Douglas S. Diekema. The Journal of Clinical Ethics, 2021.
Our Next Pandemic Ethics Challenge? – Allocating “Normal” Health Care Services by Jeremy R. Garrett, Leslie Ann McNolty, Ian D. Wolfe, and John D. Lantos. Hastings Center Report, 2020.
Self-Inflicted Moral Distress: Opportunity for a Fuller Exercise of Professionalism by Jeffrey T. Berger, Ann B. Hamric, and Elizabeth Epstein, (2019), The Journal of Clinical Ethics, Volume 30:4; p.314-317.
Family-Centered Culture Care: Touched by an Angel by Jesus A Hernandez, (2019), Journal of Clinical Ethics; 30(4):376-383.
Tho’ Much is Taken, Much Abides: A Good Life Within Dementia in Nancy Berlinger, Kate de Medeiros, and Mildred Z. Solomin (Edts.) What makes a Good Life in Late Life? Citizenship and Justice in Aging Societies, A Hastings Center Special Report, September-October 2018: S71-S74.
Poverty – Not a Justification for Banning Physician-Assisted Death by Lindsey M. Freeman, Susannah L. Rose, and Stuart J. Youngner, The Hastings Center Report, 2018
When Societal Structural Issues Become Patient Problems: The Role of Clinical Ethics Consultation by Aimee Milliken, Martha Jurchak, and Nicholas Sadovnikoff, Hastings Center Report, 2018
Feeling like a burden to others and the wish to hasten death in patients with advanced illness: A systematic review by Andrea Rodriquez-Prat, Albert Balaguer, Iris Crespo, Christina Monforte-Royo, Bioethics, 2019
Nursing Ethics Huddles to Decrease Moral Distress among Nurses in the Intensive Care Unit? by Marianne C. Chiafery, Patrick Hopkins, Sally A. Norton, and Margie Hodges Shaw, The Journal of Clinical Ethics, 2018
Capacity for Preference – Respecting Patients with Compromised Decision-Making by Jason Adam Wasserman and Mark Christopher Navin, The Hastings Center Report, 2018
Narrative Symposium: Doctor in the Family: Stories and Dilemmas Surrounding Illness in Relatives by Joseph J. Fins, Kathleen N.Fenton, Amos Ritter, et al., Narrative Inquiry in Bioethics, 2018 (https://muse.jhu.edu/article/690220)
Can Rationing Through Inconvenience be Ethical? by Nir Eyal, Paul L Romain, and Christopher Robertson, Hastings Center Report, 2018
Workarounds Are Routinely Used by Nurses – But Are They Ethical? by Nancy Berlinger, The American Journal of Nursing, 2017
How Long a Life is Enough Life? by D. Callahan & W. Gaylin, Hastings Center Report, 2017
Development of a Clinical Ethics Committee de Novo at a Small Community Hospital by Addressing Needs and Potential Barriers by Bonnie H. Arzuaga, The Journal of Clinical Ethics, 2017
After the DNR – Surrogates Who Persists in Requesting Cardiopulmonary Resuscitation by Ellen M. Robinson, Wendy Cadge, Angelika A. Zollfrank, M. Cornelia Crement, and Andrew M. Courtwright, The Hastings Centre Report, 2017
Moral Agency, Moral Imagination, and Moral Community: Antidotes to Moral Distress by Terri Traudt, Joan Liaschenko and Cynthia Peden-McAlpine, The Journal of Clinical Ethics, 2016
The Nurse as the Patient’s Advocate: A Contrarian View by Sarah E Shannon, A Hastings Center Special Report, 2016
Doctor Knows Best? Tubal Litigation in Young, Childless Women. Case study with commentaries by Kathryn Goldrath and Lauren B. Smith, The Hastings Center Report, 2016
How Can Clinical Ethics Committees Take on Organization Ethics? Some Practical Suggestions by James E Sabin.
Must We Be Courageous? by Ann B Hamric, John D Arras, and Margaret E Mohrmann.
On Not Taking “Yes” for an Answer by Alexander M. Capron.
Reframing Conscientious Care. Providing Abortion Care When Law and Conscience Collide. By Mara Buchbinder, Dragana Lassiter, Rebecca Mercier, Amy Bryant, and Anne Drapkin Lyerly.
Let’s not Forget about Clinical Ethics Committees! By Franco A. Carnevale.
Patient Satisfaction Surveys on a Scale of 0-10: Improving Health Care, or Leading It Astray? By Alexandra Junewicz and Stuart J. Younger.
The Ethics of Physicians’ Web Searches for Patients’ Information by Nicholas Genes and Jacob Appel.