Jeremy Simon

In September 2013, the American Board of Obstetrics and Gynecology (ABOG) revised its definition of obstetrician-gynecologist. With few exceptions, gynecologists risked losing their board certification if they treated men. Anoscopy (on men) and vasectomy were explicitly prohibited (1). Pressure from the public and media (1), National Institutes of Health (NIH), and private letter-writing campaigns (2) resulted in the ABOG's reversing its stance step by step until it fully reversed itself in January 2014 (24). Although it may seem that restricting specialists in women's medicine to treating only women should create neither hardship nor protest, it is in fact a problem. Gynecologists often provide essential treatment that men cannot easily obtain from other practitionersfor example, high-resolution anoscopy (HRA). The incidence of anal cancer is increasing in both women and men and is especially high in HIV-infected men who have sex with men (5). High-resolution anoscopydirected biopsy is an important part of the diagnostic evaluation for anal cancer and its precursors. A relatively new procedure, HRA utilizes advanced colposcopic skills and requires significant training and experience. Gynecologists, with their expertise in colposcopy, have been the quickest to master HRA and thus make up a large percentage of the limited number of clinicians qualified to perform the procedure in this country (1). Gynecologists also play an important role in performing vasectomies. Although it is one of the safest and most cost-effective methods of contraception, vasectomy accounts for only 1 in 3 sterilizations in this country and is utilized preferentially by high-income white men (6). In rural and low-income areas, insufficient access to providers is one of the primary barriers to vasectomy. Gynecologists trained in the procedure during a family planning fellowship may be the only qualified, accessible providers in these areas (7). There are other situations as well in which gynecologists are the most appropriate physicians for men. For example, debilitating pelvic pain can affect men (albeit less prevalently than women). With their wider exposure to this problem, gynecologists are often the only practitioners able to properly diagnose and treat pelvic pain in men (8). Although, as noted, the ABOG has reversed all of these restrictions, we are troubled by the fact that a specialty board would attempt to limit the otherwise lawful and ethical practice of its diplomates. These restrictions raise ethical problems that go well beyond a simple public relations failure. Indeed, it is only in the context of an ethical failure that the ABOG's attempted policy initiative can be fully understood. First, the restrictions relied on an untenable distinction between men and women. A division of humans into 2 sexes or genders is perforce arbitrary. Any such classification must account for at least 4 factors: chromosomal sex, genitalia present at birth, genitalia currently present, and lived identity (which may or may not be made to conform to expected appearances with hormones or other means). It is not necessary to list all of the possible combinations of these factors to see that only 2 unequivocally fit the malefemale dichotomy the ABOG's edict createdintersexuality and transsexuality are completely unaccounted for. Although this may seem to be only an intellectual or practical problem, it is also an ethical one. By ignoring intersexual and transsexual persons when limiting the practice of gynecology, the ABOG ensured that such patients would be treated, or not treated, arbitrarilyin other words, unfairly. That the ABOG's policy had an exception for the treatment of transgender conditions (Web page no longer active) did not solve the problem. This exception was sufficiently vague that it was unclear who could be treated for what. Moreover, it did not seem to cover intersexual or transgender persons who may feel more comfortable with a gynecologist treating matters not related to their transgender conditions. By failing to account for these groups, the ABOG betrayed the trust of a vulnerable group of patients, who often receive their care from gynecologic endocrinologists. Second, the ABOG's restrictions compelled individual practitioners to abandon active patients who may not have had adequate alternatives for care (1, 8). This violates the heart of the physicianpatient relationship and harms identifiable patients. In addition to being unethical (9), it could be considered malpractice (10). Third, the restrictions discriminated against specific disadvantaged groups. As noted, gynecologists are especially important providers of vasectomy in underserved areas. In the case of HRA, those at greatest risk for anal cancer, and thus most in need of skilled HRA providers, are HIV-infected men who have sex with men. A fourth issue is that the ABOG's action could have interfered with important NIH-sponsored research. Although HRA has been…

In Science, Truth, and Democracy, Philip Kitcher challenges the view that science has a single, context‐independent, goal, and that the pursuit of this goal is essentially immune from moral critique. He substitutes a context‐dependent account of science’s goal, and shows that this account subjects science to moral evaluation. I argue that Kitcher’s approach must be modified, as his account of science ultimately must be explicated in terms of moral concepts. I attempt, therefore, to give an account of science’s goal that is free of direct moral entanglements but still makes this goal context‐dependent and leaves the choice of which projects to pursue subject to moral scrutiny.

COVID-19 presents many challenges, both clinical and philosophical. In this paper we discuss a major lacuna that COVID-19 revealed in our philosophy and understanding of medicine. Whereas we have some understanding of how physician-scientists interrogate the world to learn more about medicine, we do not understand the epistemological costs and benefits of the various ways clinicians acquire new knowledge in their fields. We will also identify reasons this topic is important both when the world is facing a pandemic and when it is not.

On 7 May 2020, Columbia University Global Centers hosted an online international symposium on ethical dilemmas during the COVID-19 pandemic. This interdisciplinary engagement between philosophers and Covid medical professionals reports the challenges as well as the discrepancies between ethical guidelines and reality. This collection of presentations identifies four key ethical dilemmas regarding responsibility, fairness, dignity and honouring death. In looking into accountability and consistency in medical humanities, it examines whether the contextuality of coronavirus across countries and cultures affected the ethical decision-making processes. This work aims to provide a seminal resource for the development of a high-quality roadmap in medical ethics for future health crises.

Metaphysics is an essential part of philosophy of medicine, providing the background for further methodological work. Current accounts of the ontology of particular diseases may be classified as realist or anti-realist. Because strong arguments can be marshaled by both of these positions, an approach to medical ontology that draws support from both sides of this divide would be desirable. Abstract models, as described by Ronald Giere, provide such an approach. After a review of Giere's account of mechanics, I show how abstract models can provide an account of the ontology of diseases.

This chapter discusses the obligations under the Emergency Medical Treatment and Active Labor Act (EMTALA) of both emergency physicians and on-call consultants to patients who present to the emergency department with a medical complaint. Whereas emergency physicians, by the nature of their work, cannot avoid being present to treat patients when they arrive, consultants may be reluctant to fulfill their obligation and come to the emergency department to treat an unstable patient who cannot be discharged without their services. Techniques for avoiding and resolving such impasses are discussed, as well as what to do in the case of true intransigence.

This chapter discusses the appropriate response of emergency physicians to requests to collect evidence, in particular, blood alcohol tests and ingested drugs, from patients for police and other law enforcement officers. The relevant ethical principles, legislation, and case law are reviewed. Recommendations are made regarding when and how it may be ethically appropriate to respond to such requests.

This chapter discusses the appropriate response of emergency physicians to requests by patients or family to provide treatment that the physician considers futile. The term’s meaning and its scope of application in the emergency department are discussed as well.

Futility often serves as a proposed reason for withholding or withdrawing medical treatment, even in the face of patient and family requests. Although there is substantial literature describing the meaning and use of futility, little of it is specific to emergency medicine. Furthermore, the literature does not provide a widely accepted definition of futility, and thus is difficult if not impossible to apply. Some argue that even a clear concept of futility would be inappropriate to use. This article will review the origins of and meanings suggested for futility, specific challenges such cases create in the emergency department (ED), and the relevant legal background. It will then propose an approach to cases of perceived futility that is applicable in the ED and does not rely on unilateral decisions to withhold treatment, but rather on avoiding and resolving the conflicts that lead to physicians' believing that patients are asking them to provide "futile" care.

The term difficult patient refers to a group of patients with whom a physician may have trouble forming a normal therapeutic relationship. The care of these patients can present many ethical dilemmas, ranging from issues of patient autonomy to questions of appropriate use of resources, which the emergency physician must be prepared to handle. Encounters with these patients also challenge physicians to explore and cultivate many of the character traits and virtues necessary to being a humane, caring, and ethical practitioner.