Fiduciary Principles in Health Care

This chapter examines fiduciary principles in health care law. There is no unanimous agreement when it comes to the precise doctrinal consequences of labeling health care actors as fiduciaries in various contexts, such as personal injury, decisional authority, financial influence, and procedural rules. In the case of patients and physicians, certain attributes are said to constitute an archetypal fiduciary relationship, including agency, dependency, trust, and information asymmetry. Thus, many legal decisions and commentators argue that physicians have fiduciary responsibilities to patients. For courts, however, hospitals are not fiduciaries. They regard private hospitals as ordinary commercial enterprises. This chapter first provides an overview of arguments over whether physicians and non-physicians (for example, hospitals and health insurers) are “fiduciaries” before discussing health care fiduciaries’ duty of loyalty and duty of care, along with their other obligations such as duties of confidentiality and full disclosure. It also explores the ability of health care fiduciaries and patients to waive fiduciary duties, as well as how courts have addressed distinct causes of action for physicians’ breach of fiduciary duty. It shows that courts often invoke fiduciary concepts and terminology in discussing physicians’ obligations to patients, and that physician-patient (and other medical treatment) relationships have classic attributes of fiduciary status.

Effects of Maternal Decisional Authority and Media Use on Vaccination for Children in Asian Countries

Background and objectives: It is now accepted that vaccination is a critical public health strategy in preventing child morbidity and mortality. Understanding factors that promote vaccination is a critical first step. The objective of this study was to investigated associations of maternal decisional authority and media use on vaccination for children in six South and Southeast Asian countries. Materials and Methods: Data come from demographic and health surveys conducted in Bangladesh, Cambodia, Indonesia, Nepal, Pakistan, and the Philippines between 2011 and 2014 (N = 45,168 women). Main outcome variables were four types of basic vaccination for children. Independent variables were maternal decisional authority and media use. Hierarchical multivariable regression analyses were performed to examine associations. Results: Children of mothers who had more decisional authority were more likely to be vaccinated compared to those participants who did not have such authority. The likelihood to have their children vaccinated was higher among women who frequently used media than those who did not use media. Conclusions: Maternal decisional authority and media use are related to improved vaccination for children. To increase vaccination rates in developing countries in South and Southeast Asia, programs and policies that promote maternal decisional authority and the use of media for health need to be implemented to help families and local communities.

A Preliminary Survey Examining Predictors of Burnout in Pain Medicine Physicians in the United States

Background: Burnout is a prolonged response to chronic emotional and interpersonal stressors on the job, defined by 3 dimensions: exhaustion, depersonalization, and reduced personal accomplishment. While there is a growing body of research on burnout in physicians, there is a dearth of literature on burnout in pain medicine physicians. Objective: This study aimed to determine the incidence of burnout amongst pain medicine physicians and whether there are sociodemographic or psychological demand characteristics of the job setting that predict burnout in pain medicine physicians. Study Design and Setting: Cross-section survey of pain medicine physicians across the United States. Methods: Pain medicine physicians were asked questions on sociodemographics and professional characteristics and measures of decisional authority, psychological job demands, job insecurity, perceived coworker support, and job dissatisfaction. Results: Two hundred seven pain medicine physicians’ responses were analyzed, 60.4% reported high emotional exhaustion, 35.7% reported high depersonalization, and 19.3% reported low personal accomplishment. Greater psychological job demands and greater job dissatisfaction predicted greater emotional exhaustion. Younger age and greater job dissatisfaction predicted higher depersonalization. Lastly, lower coworker support and greater job dissatisfaction predicted lower personal accomplishment. There were no statistical violations of assumptions or collinearity. Limitations: Low response rate and potential for response bias limit generalizability of the study. Conclusion(s): Pain medicine physicians in the United States reported high levels of emotional exhaustion, often considered the most taxing aspect of burnout. Job dissatisfaction appeared to be the leading agent in the development of all 3 components of burnout in pain medicine physicians in the United States. Key words: Burnout, pain medicine physicians, job dissatisfaction, decisional authority, psychological job demands

Governing Information Security

Governance of the information security function is critical to effective security. In this paper, the authors present a conceptual model for security governance from the perspective of decision rights allocation. Based on Da Veiga and Eloff’s (2007) framework for security governance and two high-level information security documents published by the National Institute of Standards and Technology (NIST), the authors present seven domains of information security governance. For each of the governance domains, they propose a main decision type, using the taxonomy of information technology decisions defined by Weill and Ross (2004). This framework recommends the selection of decision rights allocation patterns that are proper to those decision types to ensure good security decisions. As a result, a balance can be achieved between decisional authority and responsibility for information security.

Governing Information Security

Governance of the information security function is critical to effective security. In this paper, the authors present a conceptual model for security governance from the perspective of decision rights allocation. Based on Da Veiga and Eloff’s (2007) framework for security governance and two high-level information security documents published by the National Institute of Standards and Technology (NIST), the authors present seven domains of information security governance. For each of the governance domains, they propose a main decision type, using the taxonomy of information technology decisions defined by Weill and Ross (2004). This framework recommends the selection of decision rights allocation patterns that are proper to those decision types to ensure good security decisions. As a result, a balance can be achieved between decisional authority and responsibility for information security.

Decision Making in Pediatric Oncology: Who Should Take the Lead? The Decisional Priority in Pediatric Oncology Model

Decision making in pediatric oncology can look different to the ethicist and the clinician. Popular ethical theories argue that clinicians should not make decisions for patients, but rather provide information so that patients can make their own decisions. However, this theory does not always reflect clinical reality. We present a new model of decision making that reconciles this apparent discrepancy. We first distinguish decisional priority from decisional authority. The person (parent, child, or clinician) who first identifies a preferred choice exercises decisional priority. In contrast, decisional authority is a nondelegable parental right and duty, in which a mature child may join. This distinction enables us to analyze decisional priority without diminishing parental authority. This model analyzes decisions according to two continuous underlying characteristics. One dominant characteristic is the likelihood of cure. Because cure, when possible, is the ultimate goal, the clinician is in a better position to assume decisional priority when a child probably can be cured. The second characteristic is whether there is more than one reasonable treatment option. The interaction of these two complex continual results in distinctive types of decisional situations. This model explains why clinicians sometimes justifiably assume decisional priority when there is one best medical choice. It also suggests that clinicians should particularly encourage parents (and children, when appropriate) to assume decisional priority when there are two or more clinically reasonable choices. In this circumstance, the family, with its deeper understanding of the child's nature and preferences, is better positioned to take the lead.