|
A
peer-reviewed electronic journal published by the Institute for Ethics and ISSN
1541-0099 23(1)
– December 2013 |
Pharmaceutically Enhancing Medical Professionals
for Difficult Conversations
Gavin G. Enck
INTEGRIS Baptist Medical Center
Gavin.Enck@integrisok.com
Journal of Evolution and Technology - Vol. 23 Issue 1 – December 2013 - pgs 45-55
Abstract
Conducting “difficult
conversations” with patients and caregivers is one of the most difficult
aspects of the medical profession. These conversations can involve communicating
a terminal prognosis, advance care planning, or changing the goals of
treatment. Although they are challenging, the need for these conversations is
underwritten by the tenets of medical ethics. Unfortunately, medical
professionals lack adequate training in communication skills and overestimate
their abilities in conducting difficult conversations. I suggest that one way
to improve that ability would be the strategic use of pharmaceutical
neuroenhancements. Pharmaceutically augmenting a professional’s capacity for recognizing
masked emotional expressions might conduce to his or her
development of open and responsive communication with
patients and caregivers. I conclude by examining the limitations and objections
to this use of a communication
enhancement by illustrating that it would still require the development of,
and indeed a greater emphasis on, communication skills in medical education and
training.
Conducting difficult
conversations is one of the most challenging aspects of working in the practice
of medicine. As I use the phrase, difficult conversations are discussions with
patients and caregivers that center on terminal prognoses, advance care
planning, or changing the goals of treatment. Not only is it an ethical
necessity that medical professionals have these conversations, but – depending
on the individual’s communication skills – these conversations also directly
impact the outcomes and well-being of patients and caregivers. Yet, medical
professionals are given little education or training relating to communication skills.
Instead, they must rely on mentorship from more experienced professionals. Evidence
indicates that many medical professionals overestimate
their abilities in conducting difficult
conversations.
In this paper, I
suggest that at least one way to improve medical professionals’ skills for conducting
difficult conversations could involve the strategic use of pharmaceutical
neuroenhancements. These “communication enhancements” would augment medical
professionals’ capacities for recognizing patients’
and caregivers’ emotions and emotional concerns, thereby making it more likely for them to develop open and
responsive lines of communication.
Before examining
the use of communication enhancements and difficult conversations with patients
and caregivers, it is important to specify the scope of this paper. My goal is
to offer a way in which the use of pharmaceutical neuroenhancements can be
regarded as an option for medical professionals to improve their communication
skills for difficult conversations. It is beyond the scope of the paper to
engage with general arguments relating to the ethical or legal permissibility
of using pharmaceutical neuroenhancements or issues concerning the potential
risk and harms of side effects. I focus on only one type of pharmaceutical
neuroenhancement, communication
enhancements, and do not address other types of pharmaceutical
neuroenhancements (e.g., cognitive, memory, or moral enhancements). I assume
for the sake of argument that communication enhancements are safe and modestly
effective.
While I contend that
communication enhancements can be regarded as one reasonable option for medical
professionals to use, it is important to note that this is a rather limited
claim. The implication is not that medical professionals have some sort of
professional responsibility to use pharmaceutical neuroenhancements.1
However, they do have a professional responsibility to conduct difficult
conversations with patients and caregivers. In the following section, I examine
the ethical necessity for medical professionals to conduct difficult
conversations and the impact these conversations can have.
The ethical necessity of difficult conversations
The profession of
medicine is underwritten by the patient-physician relationship: a fiduciary
relationship in which a patient and physician are engaged in the process of
healing (Cassell 2012; Pellegrino 2006).
Healing involves acts
aimed at improving a patient’s well-being (Cassell 2012). This is constituted
by the physical, psychological, social, and relational aspects of his or her
life. Accordingly, a nephrologist focusing exclusively on a patient’s kidney
function, a social worker helping patients with social resources and
improvement of familial relationships, and a clinical pharmacologist narrowly
focusing on the indications and counter-indications of a particular
pharmaceutical treatment are all helping to improve a patient’s well-being.
However,
improving a patient’s well-being is not simply about offering restorative or
curative treatments. One fact of the human condition is death.2 It
is crucial to a patient’s well-being to be told when a prognosis is terminal,
when there is a need for advance care planning, or when the goals of care need
to be changed from curative to palliative. Thus, the patient-physician
relationship supports medical professionals upholding certain obligations and
responsibilities that require having difficult conversations.3
The scope and
magnitude of any obligation or responsibility of medical professionals is
governed and guided by certain ethical principles, rules, and ideals (Beauchamp
and Childress 2013; Gert et al. 2006; Jonsen et al. 2010; Oakley and Cocking 2001).
The obligation to have difficult conversations is supported by the biomedical
ethical principles of respect for autonomy, beneficence, and non-maleficence,
and by the ethical ideals of trustworthiness, discretion, and compassion
(Beauchamp and Childress 2013; Oakley and Cocking 2001). The institutions and
practice of medicine impose an ethical and
legal responsibility to discuss terminal prognoses, advance care planning, and
changing goals of treatment.
Nevertheless, it
is important to note that a medical professional’s responsibility for having difficult
conversations with patients and caregivers is contingent on the appropriateness
of the patient’s or caregiver’s situation. The particulars of the situation, including
the information and ethical considerations that are relevant to the circumstances,
determine the appropriateness of having these conversations. For example, disclosing
to a caregiver that a patient has a terminal prognosis while the caregiver is currently
driving to the hospital is, under most conditions, not appropriate. By
contrast, although a patient may have a mental illness, as long as he or she
has decision-making capacity, a healthcare professional has a responsibility to
inform him or her (or the designated caregiver) of a terminal prognosis.
In sum: there is
an ethical necessity, supported by biomedical principles, rules, and ideals, as
well as by the institutions and practice of medicine, for medical professionals
to have discussions with patients or caregivers – when appropriate – regarding terminal
prognoses, advance care planning, or changing goals of treatment.
Impact of difficult conversations on patients and caregivers
These difficult
conversations, whether done well or poorly, greatly impact patients and
caregivers. For example, consider pediatric patients and their adult caregivers.
When difficult conversations are done well, patients’ psychological and
behavioral outcomes are improved in addition to reducing surgical morbidity
(Krahn, Hallum, and Kime 1993; Lynch and Staloch 1988; Quine and Pahl 1987;
Kaplan, Greenfield, and Ware 1989; American Academy of Pediatrics 2001;
American Academy of Pediatrics 2003). However, when these conversations are
done poorly, not only are they likely to result in worse outcomes and cause distress
for both patient and caregiver – they can also lead to an increased risk of
legal action against medical professionals and their institutions. Therefore,
it is of great importance for patients, caregivers, and medical professionals that medical professionals have the
communication skills needed to conduct difficult conversations well.
Medical professionals: Lacking in education and training,
but not confidence
At any rate, medical
professionals have not been properly educated or trained in communication
skills. Current medical education and training only minimally touch on issues
regarding the role of emotions, relationships, and continuity of care for
patients and caregivers (Jurkovich et al. 2000; Krahn, Hallum, and Kime 1993;
Sharp, Strauss, and Lorch 1992; Lashley et al. 2000; Simpson et al. 2000; Young
et al. 1998; Cheng et al. 1996; Byrnes et al. 2003; Corrigan and Feig 2004;
American Academy of Pediatrics 2002). This is disturbing since communication
between the medical professional and the patient is the most common
intervention in all of medicine (Levetown 2008; Cassell 2012).
Instead of
education and training, the medical profession relies on mentorship as the method
for young practitioners to develop their communication skills. The experience of
older professionals assists younger colleagues in developing communication skills.
This approach assumes that a practiced medical professional can guide younger
colleagues in learning proficient communication skills in a practical and
appropriate way. Yet, evidence indicates that medical professionals’ self-assessments
of their communications skills are inaccurate because they overestimate their abilities
in conducting difficult conversations with patients and caregivers (Ford,
Fallowfield, and Lewis 1994; Hilden et al. 2001). So instead of guiding young professionals
in the proper ways to have difficult conversations, medicine’s reliance on
mentorship reinforces the likelihood that their communication skills will be,
at best, greatly overestimated and, at worst, inappropriate.
In the following
section, I suggest that the first step toward improving medical professionals’
ability to conduct difficult conversations is to invest in education and
training to develop empathic communication skills.
Empathy and empathic communication
Empathy plays a
key role in communicating with patients and caregivers. Conceptually, empathy is
defined as the ability to understand the feelings of others. It has an
affective and a cognitive component (Simmons 2012). The affective, lower level,
component of empathy is that a person, to some varying extent, feels the other
emotions that another person is experiencing. This aspect is the basic component
of empathy and nearly everyone is familiar with it. By way of illustration, Aaron
Simmons (2012) refers to our moments of “feeling with others” (even if briefly
and with less intensity) when we see someone win a gold medal in the Olympics
or when we enter into the raw emotion of someone who has lost a loved one. The
second, higher level, component of empathy is cognitive: an intellectual
awareness of another person’s internal states (Simmons 2012; Stueber 2006). While
this component draws upon the affective component, at this level, a person is
able to understand another person’s emotions in certain situations or how a
person’s emotion or emotional reaction provides a reason for acting in some
circumstances (Stueber 2006). It is possible to develop the cognitive aspect of
empathy into an intellectual skill. For example, a medical professional
understands that a patient’s strong emotional outburst is the result of having
been given a recent “bad” diagnosis. Having the intellectual skill of empathy allows
an individual to retain a degree of emotional detachment from the person with
whom he or she is empathizing (e.g., a medical professional can empathize with,
and understand, the actions of a patient who has been given a terminal
diagnosis, but without becoming so emotionally involved that he or she is
unable to care for the patient) (Oakley and Cocking 2001; Simmons 2012).
A medical professional’s
empathy allows him or her to engage in empathic
communication with patients and caregivers. Empathic communication, generally speaking, focuses on communicating
with patients and caregivers in a manner that (i) seeks to identify the patient
and caregiver’s emotions or emotional concerns, (ii) responds to and addresses
these emotions or emotional concerns, and (iii) explores the underlying basis of
the emotions or emotional concerns, e.g., unmentioned or unaddressed issues (Back, Arnold, and Tulsky 2009). Empathic
communication with patients and caregivers, in a way that achieves (i), (ii), and (iii),
requires education, training, and practical skills (Bendapudi et al.
2006).
Communication enhancements
Teaching and
training medical professionals in empathic communication is likely to be
beneficial not only for patients and caregivers, but also for the professionals
themselves. One way to facilitate this process
is by the strategic use of pharmaceutical neuroenhancements. Pharmaceutical
neuroenhancements are
biomedical chemicals used to augment a range of cognitive and neurological
capacities in a healthy person. For the purposes of this paper, since the
specific pharmaceuticals in question are used to augment a medical professional’s cognitive and
neurological capacities related to having a difficult conversation, I refer to these pharmaceutical neuroenhancements as communication enhancements.
The communication enhancement I focus on is oxytocin. Evidence shows that administering oxytocin increases
attachment bonding between mammals; for humans, it enhances a person’s
abilities to recognize certain social cues and information (Young and Wang
2004). Evidence indicates that some of the social cues and information that oxytocin
enhances are a person’s capacities for recognizing familiar faces and accuracy
in recognizing a person’s masked emotional expressions (Schulze et al. 2011;
Rimmele et al. 2009). In respect to communication, one study which focused on
couples in argumentative discussions found that, when oxytocin was taken through
a nasal inhaler, it reduced stress and increased positive communication (Ditzen
et al. 2009). So for the sake of argument, I will assume that the use of oxytocin
as a communication enhancement modestly augments a medical professional’s capabilities
for recognizing the social cues and information of patients and caregivers. Specifically,
communication enhancement will work to identify social cues and information in
a patient’s or caregivers’ masked emotional expressions and decrease stress
during communications with patients.
It is reasonable
to think that a medical professional who is better able to spot social cues,
information, and masked emotional expressions is likely to be in a better
position to identify, respond to, and explore the underlying basis of patients’
and caregivers’ emotions and emotional concerns. When discussing a terminal
prognosis, advance care planning, or changing goals of treatment, patients and
caregivers are undergoing emotional distress. It is imperative for professionals
to be able to accurately identify and
understand the emotions and emotional reactions of patients and caregivers during
these circumstances. Moreover, it is reasonable to think that a medical professional
whose own stress level does not escalate during these discussions is more
likely to be open and responsive when communicating with patients and caregivers.
Consider, for
example, that evidence shows pediatric patients’ and adult caregivers’ factors of
interest, caring, warmth, and responsiveness are all predictive of effective
communication between patient, caregiver, and medical professional (Simonian
et. al 1993; Wofford et al. 2004; Heller and Solomon 2005). During difficult
conversations, what caregivers want from a medical professional is not hope for
a long-shot treatment, but rather recognition of their child’s unique value as
a person, and not merely a sick patient (Krahn, Hallum, and Kime 1993). What
these pediatric patients want is not to be shielded from a terminal prognosis
or changing goals of care, but to be given choices, even if the choice is not
determinative of the final course of treatment or the eventual goals of care
(Levetown 2008; McCabe 1996). A professional who is better able to identify
these emotions or emotional concerns, while not letting the stress of the
situation overwhelm them, is more likely to express interest, caring, warmth,
and responsiveness when communicating with these patients and their caregivers.
Therefore, using a communication enhancement is one reasonable option for improving communications with patients and caregivers during
difficult conversations.
Limitations
Admittedly, the use by professionals of a communication enhancement for difficult conversations has many limitations. The first is that without any education and
training in proper communication skills, the use of a communication enhancement
is worthless. Just as a pill that makes a person smarter or more morally virtuous
does not exist, there is no chemical or pharmaceutical that can make someone a
better communicator (Smith and Farah 2011). Empathic communication skills require
education, training, preparation, and practice (Epner and Bailey 2011).
Thus, the use of a communication enhancement requires that medical
professionals already have some education and training in empathic
communication skills.
The second limitation is that the use of a communication
enhancement is only a conducive condition –not a necessary or
sufficient condition – for developing open and responsive lines of communication. From augmenting a professional’s capabilities for recognizing
masked emotional expressions and reducing his or her stress levels, it does not
follow he or she will actually (i) be more empathic or (ii) have better communication
skills. Augmenting a professional’s capabilities for recognizing social cues and information
is not an enhancement of the cognitive or neurological capacities that underwrite
empathy. To put this another way, it is possible for a professional to be able
to identify a patient’s emotional concerns, by recognizing social cues and
information, and yet still not be able to understand or make accurate
predictions about how this emotion is a reason for a patient’s reaction in a
given situation.4 Moreover, even if the use of communication
enhancement were to augment a person’s capacity for empathy, empathy is only a
necessary condition, not a sufficient condition, for empathic communication. Having
empathy is not the same thing as being able to communicate it proficiently and
appropriately. These two limitations illustrate that the use of communication enhancements by medical
professionals is not a panacea for improving their skill when having difficult
conversations with patients and caregivers.
Objection
From these two
limitations, a plausible objection follows: if a medical professional’s use
of communication enhancements is worthless without proper education and training in empathic
communication and is only conducive – not necessary or sufficient – for developing
open and responsive lines of communication with patients and caregivers, then
what is really gained?
This objection,
however, is misguided if it presupposes that a healthcare professional’s use of
a pharmaceutical for reasons of neuroenhancement is, in and of itself, a
problem. A pharmaceutical neuroenhancement is but one option out of a range
that the profession of medicine has available for facilitating medical
professionals’ improvement in conducting difficult conversations. It is
reasonable and consistent with the argument in this paper that instead of a
pharmaceutical neuroenhancement the profession of medicine chooses other,
non-pharmaceutical, options for improving medical professionals’ communication
skills.
Instead of using
communication enhancements, more emphasis might be put on early and continuing education
and training in developing communication skills. Another option is that medical
institutions could implement policies and procedures requiring that difficult
conversations with patients and caregivers always be conducted with a trained
social worker or counselor present. Or possibly, medical professionals could be
required, by the profession or their institution, to discuss matters pertaining
to terminal prognosis, advance care planning, or changing goals of care in
their initial meetings with patient and caregivers. These are all legitimate
options. However, it is also reasonable to hold that the use of pharmaceutical
neuroenhancements could be one option available to improve medical
professionals’ communication skills relevant to difficult conversations.
Now, one reply to
this response is to argue that even if one grants that pharmaceutical
neuroenhancements are but one out of many options, it is still not clear what
is gained by allowing communication enhancements as
an option in this discussion. Evidence of the efficacy of oxytocin as a pharmaceutical neuroenhancement is not
currently conclusive, and its use is not yet a feasible option. So, arguing for the use of a communication enhancement is merely an academic
exercise, not a practical matter.
To respond, I agree
that current evidence of the efficacy of oxytocin is
not definitive and that its
use is not currently a feasible option. Yet, these are not conclusive reasons to
close down discussion of communication enhancements as a future possibility. The
use of chemicals to augment or enhance our cognitive or neurological capacities
is not a particularly modern issue. The latest applications of incredibly accurate
pharmaceuticals to affect a range of human cognitive or neurological capacities
– which, in turn, can alter, restore, or enhance a person’s capacities,
capabilities, attitudes, or dispositions – warrant careful examination and
argument (Stein 2008). First, we can begin
to survey the use of currently available pharmaceuticals that are already employed
for enhancement by medical professionals (e.g., methylphenidate,
dextroamphetamine, or amphetamine as cognitive-enhancing drugs). In a recent
study, out of 1,115 medical students 18 percent used cognitive-enhancing drugs
(Emanuel et al. 2013). This study, along
with others focused on undergraduate students, indicates that the use of
cognitive-enhancing drugs for reasons of enhancement is often higher than many
would assume.5 Second, careful examination and argument relating to
the ethics of pharmaceutical neuroenhancement should assist to grapple with
novel uses for these drugs. Compare the current debate about the permissibility
of “love enhancement”: the use of pharmaceuticals to strengthen or augment the
chemical process in a person’s brain in an effort to preserve a loving marriage
as a couple ages or to protect their children from the harms of divorce. This
appears to be a viable use of neuroenhancing drugs (Savulescu and Sandberg
2008; Earp, Sandberg, and Savulescu 2013). There is also current discussion relating
to the use of pharmaceuticals for chemical breakups; here, a person might
attempt to lessen or diminish their feelings of love to facilitate their escape
from an abusive relationship (Earp et al. 2013).
Discussion of the
ethics of pharmaceutical neuroenhancements has also moved from the level of
individuals to that of institutional rules and policies. Lucke and Partridge
(2013) have argued that, in terms of public health, the use of pharmaceutical
neuroenhancement is the least effective and safe option for improving cognitive
capabilities. The importance of all this inquiry and debate is that it helps to
generate empirical data for a better understanding of neuroenhancing drugs and,
importantly, encourages a dialogue about them. This dialogue is important
because it will guide the agenda regarding policies and rules on the
appropriate use of pharmaceutical neuroenhancements by medical professionals
and others. It follows that the use of communication enhancements by medical
professionals is one element in a larger discussion of the ethics of
pharmaceutical enhancement.
Another reason
that warrants consideration of the use of communication enhancements by medical
professionals is ethical necessity. It is an ethical necessity for medical
professionals to have difficult conversations and this provides a substantial
consideration as to why the profession of medicine should always seek and
evaluate means or methods for improving professionals’ communication skills.
Done poorly, discussions concerning a terminal prognosis, advance care
planning, or changing goals of treatment negatively impact patients and
caregivers. Since many medical professionals have not received proper education
or training in communication, it is quite plausible, all-things-considered,
that they are likely to have such an negative impact.
We should
seriously consider the possibility that communication enhancements could quickly
facilitate improvements in medical professionals’ communication skills. The
ethical necessity of conducting difficult conversations with patients and
caregivers provides a reason for serious evaluation of the use of pharmaceutical
neuroenhancements as an option for improving medical professionals’
communication skills.
In this article, I argued that the use of a communication enhancement is one reasonable
option for medical professionals because using it may be
conducive to the development of open and
responsive communication with patients and caregivers during difficult
conversations. Still, whether one accepts this argument or not, it draws
attention to the importance not only of the role of communication in the
patient-physician relationship, but also the need for medical education,
training, and practice aimed at developing communication skills. At the very
least, the argument indicates a need for further development of, or a greater
emphasis on, communication skills within the profession of medicine, whether
achieved by pharmaceutical
or other means.6 7
Notes
1. Elsewhere, however, I have explored the
question of whether medical professionals have a responsibility to use
neuroenhancements in order to provide patients with the best possible care (Enck
2013).
2. This does not mean that death is always,
intrinsically, a bad thing. Depending on a person’s situation, his or her death
may be good, e.g., passing away while surrounded by loved ones, or bad, e.g., a
14-year-old struck by a drunk driver. However, some may contend that all death
is bad. I find this position to be empirically and ethically unreasonable;
because of length constraints, however, I cannot address it in detail.
3. I use the
terms “obligations” and “responsibilities” in the following way. Although
obligations and responsibilities, broadly speaking, are both about certain
things a person is ethically bound to do (or not do) an obligation is
understood at higher level of abstraction, it is more general and indeterminate;
whereas a responsibility is understood in a specific context, role, or
institution and has more determinate content.
4. Incorrectly attributing a reason for
why an agent acted, i.e. attribution error, is the basis for the philosophical
position situationalism, which holds that
character traits are not stable and cross-situationally consistent (Doris 1998,
2002; Harman 2000).
5. Consider that while only 20 percent of
undergraduate students used cognitive-enhancing drugs, 90 percent of those students
indicated that they did so for enhancement purposes (White et al. 2006).
6. This article was made possible because
of a clinical ethics fellowship from the University of Texas MD Anderson Cancer
Center in Houston. During this fellowship I had the privilege of learning from
the finest medical professionals in the world. At MD Anderson Cancer Center,
Daniel Epner MD deserves praise for demonstrating to me, as well as tirelessly
attempting to teach others, that patient-centered communication is a skill which
must be learned. Suresh K. Reddy MD, in the most difficult of situations, showed
me why it is an ethical necessity for medical professionals to have these
difficult conversations. Working with Martha Aschenbrenner and Luke Coulson I quickly
learned that they do more good for patients and their families in a single day
than I could ever hope to do in a career. At Children’s Memorial Hermann
Hospital the Chronic and Palliative Service for pediatrics and neonates (CAPS)
team of Kristie Cullum RN, Patrick Jones MD, and Shih-Ning Liaw MD taught me
that the noble-hearted always seek to alleviate suffering even in the most
challenging situations.
7. This paper benefitted from the
editorial work of Christina E. Guajardo, Brittany Campbell, and Elizabeth Enck.
Russell Blackford’s excellent comments and edits provided clarity to this
article.
References
American Academy
of Pediatrics, Committee on Hospital Care. 2003. Family-centered care and the
pediatrician’s role. Pediatrics 112(3
pt 1): 691–697.
American Academy
of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health.
2001. The new morbidity revisited: A renewed commitment to the psychosocial
aspects of pediatric care. Pediatrics
108(5): 1227–1230.
American Academy
of Pediatrics, Section on Cardiology and Cardiovascular Surgery. 2002.
Guidelines for pediatric cardiovascular centers. Pediatrics 109(3): 544–549.
Bendapudi, N., L.
Berry, K. A. Frey, J. Parish, and W. Rayburn. 2006. Patients’ perspectives on
ideal physician behaviors. Mayo Clinic
Proceedings 81(3): 338–344.
Bor R., R. Miller,
E. Goldman, and I. Scher. 1993. The meaning of bad news in HIV disease: Counseling
about dreaded issues revisited. Counselling
Psychology Quarterly 6(1): 69–80.
Byrnes A., N. Berk,
M. Cooper, and M. Marazita. 2003. Parental evaluation of informing interviews
for cleft lip and/or palate. Pediatrics
112(2): 308–313.
Cassell, E. 2012.
The nature of healing: The modern practice of medicine. Oxford: Oxford
University Press.
Cheng T., J. Savageau,
J. DeWitt, C. Bigelow, and E. Charney. 1996. Expectations, goals and perceived
effectiveness of child health supervision: a study of mothers in a pediatric
practice. Clinical Pediatrics 35(3): 129–137.
Corrigan J. and S.
Feig. 2004. American Academy of Pediatrics. Guidelines for pediatric cancer
centers. Pediatrics 113(6): 1833–1835.
Ditzen,
B., M. Schaer, B. Gabriel, G. Bodenmann, U. Ehlert, and M. Heinrichs. 2009. Intranasal
oxytocin increases positive communication and reduces cortisol levels during
couple conflict. Biological Psychiatry
65(9): 728–731.
Doris, J. 1998.
Persons, situations, and virtue ethics. Nous
32(4): 504–530.
Doris, J. Lack of character: Personality and moral behavior.
Cambridge University Press, 2002.
Earp, B.D., A.
Sandberg, and J. Savulescu. 2013. Natural selection, childrearing, and the ethics
of marriage (and divorce): Building a case for the neuroenhancement of human relationships.
Philosophy and Technology 25(4): 562–587.
Earp, B.D., O.A.
Wudarczyk, A. Sandberg, and J. Savulescu. 2013. If I could just stop loving
you: Anti-love biotechnology and the ethics of a chemical breakup. American Journal of Bioethics 13(11):
3-17.
Emanuel, R.M., S.L.
Frellsen, K.J. Kashima, S.M. Sanguino, F.S. Sierles, and C.J Lazarus. 2013.
Cognitive enhancement drug use among future physicians: Findings from a multi-institutional
census of medical students. Journal of General
Internal Medicine 28(8): 1028-1034.
Enck, G.G. 2013. Pharmaceutical
enhancement and medical professionals. Medicine,
Health Care and Philosophy. First published online August 7, 2013. DOI
10.1007/s11019-013-9507-z.
Epner, D. and W.
Baile. 2011. Wooden’s pyramid: Building a hierarchy of skills for successful
communication. Medical Teacher 33(1):
39–43.
Fallowfield L.
1993. Giving sad and bad news. Lancet
341(8843): 476–478.
Ford S., L.
Fallowfield, and S. Lewis. 1994. Can oncologists detect distress in their out-patients
and how satisfied are they with their performance during bad news
consultations? British Journal of Cancer
70(4): 767–770.
Gert, B., C.
Culver, and K. Clouser. 1997. Bioethics:
A return to fundamentals. Oxford: University Press.
Harman, G. 2000. Moral
philosophy meets social psychology: Virtue ethics and the fundamental attribution
error. In Explaining value and other essays
in moral philosophy, 165–178. Oxford: Oxford University Press.
Heller K, and M. Solomon.
2005. Continuity of care and caring: What matters most to parents of children
with life-threatening conditions. Journal
of Pediatric Nursing 20(5): 335–346.
Hilden J.M., E.J Emanuel,
D.L. Fairclough, MP Link, KM Foley, BC Clarridge, L.E. Schnipper, and R.J.
Mayer. 2001. Attitudes and practices among pediatric oncologists regarding
end-of-life care: Results of the 1998 American Society of Clinical Oncology survey.
Journal of Clinical Oncology 19(1): 205–212.
Jurkovich G., B.
Pierce, L. Pananen, and F.P. Rivara. 2000. Giving bad news: The family
perspective. Journal of Trauma and Acute
Care Surgery 48(5): 865–887.
Kaplan S.H., S. Greenfield,
and J. Ware. 1989. Assessing the effects of physician-parent interactions on
the outcomes of chronic disease. Medical
Care 27(3): S110–S127.
Krahn G., A.
Hallum, and C. Kime. 1993. Are there good ways to give “bad news”? Pediatrics 91(3): 578–582
Lashley M., W.
Talley, L. Lands, and E. Keyserlingk. 2000. Informed proxy consent: Communication
between pediatric surgeons and surrogates about surgery. Pediatrics 105(3 pt 1): 591–597
Levetown, M.
2008. Communicating with children and families: From everyday interactions to skill
in conveying distressing information. Pediatrics
121(5): e1441-e1460.
Lucke, J., and Partridge,
B. (2013). Towards a smart population: A public health framework for cognitive
enhancement. Neuroethics 6(2): 419–427.
Lynch E., and N. Staloch.
1998. Parental perceptions of physicians’ communication in the informing
process. Mental Retardation 26(2): 77–81.
McCabe M., 1996.
Involving children and adolescents in medical decision-making: Developmental
and clinical considerations. Journal of
Pediatric Psychology 21(4): 505–516.
Oakley, J., and
Cocking, D. (2001). Virtue ethics and professional roles. Cambridge:
Cambridge University Press.
Quine L., and J.
Pahl. 1987. First diagnosis of severe handicap: A study of parental reactions. Developmental Medicine and Child Neurology
29(2): 232–242.
Rimmele, U., K.
Hediger, M. Heinrichs, and P. Klaver. 2009. Oxytocin makes a face in memory familiar. Journal of Neuroscience 29(1): 38–41.
Savulescu, J. and
A. Sandberg. 2008 Neuroenhancement of love and marriage: The chemicals between
us. Neuroethics 1(1): 31–44.
Schulze, L., A.
Lischke, J. Greif, S. Herpertz, M. Heinrichs, and G. Domes. 2011. Oxytocin
increases recognition of masked emotional faces. Psychoneuroendocrinology 36(9): 1378–1382.
Sharp M.C., R.P..
Strauss, and S.C Lorch. 1992. Communicating medical bad news: Parents’
experiences and preferences. Journal of
Pediatrics 121(4): 539–546.
Simmons,
A. 2013. In defense of the moral significance of empathy. Ethical Theory and Moral Practice. Published online March 13. DOI 10.1007/s10677-013-9417-4.
Simonian S., K.
Tarnowski, A. Park, and P. Bekeny. 1993 Child-, parent-, and
physician-perceived satisfaction with pediatric outpatient visits. Journal of Developmental and Behavioral
Pediatrics 14(1): 8–12.
Simpson M., R.
Buckman, M. Stewart P. Maguire, M. Lipkin, D. Novack, and J. Till. 1991.
Doctor-patient communication: The Toronto consensus statement. British Medical Journal. 303(6814): 1385–1387.
Smith, E., and M.
Farah. 2011. Are prescription stimulants “Smart Pills”? The epidemiology and cognitive
neuroscience of prescription stimulant use by normal healthy individuals. Psychological Bulletin 137(5): 717–741.
Stein, D. 2008. Philosophy
of psychopharmacology. New York: Cambridge University Press.
Stueber K. 2006 Rediscovering empathy: Agency, folk
psychology, and the human sciences. Cambridge, MA: MIT Press.
White, B., K. Becker-Blease and K. Grace-Bishop. 2006. Stimulant
medication use, misuse, and abuse in an undergraduate and graduate student
sample. Journal of American College of
Health 54(5): 261–268.
Wofford M., J.
Wofford, J. Bothra. S. Kendrick, A. Smith, and P. Lichsten. 2004. Patient
complaints about physician behaviors: A qualitative study. Academic Medicine 79(2): 134–138.
Young K., K.
Davis, C. Schoen, and S. Parker. 1998. Listening to parents: A national survey
of parents with young children. Archives
of Pediatrics and Adolescent Medicine 152(3): 255–262.
Young, L., and Z.
Wang. 2004. The neurology of pair bonding. Nature
Neuroscience 7(10):1048–1054.