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This article reflects on the assumption underlying the argument of Little et al. that "contested understandings" in the clinic are susceptible to reconciliation within a liberal framework described as "pragmatic pluralism". It is argued that no such reconciliation is possible or desirable because it is of the nature of the clinic that it provides a forum for multiple voices, ethical and cultural perspectives, and conceptual frameworks, and this is the source of its fecundity and creativity. Medicine itself cannot be represented by a single discourse, precisely because it is itself an unruly collection of practices that, despite their heterogeneity, are able to engage in productive dialogues with each other. The heteroglossia of the clinic, therefore, is not a problem to be overcome. Rather, it is a rich resource to be mobilized in accordance with its multiple inherent purposes. [ABSTRACT FROM AUTHOR]

Rituals may be understood broadly as stereotyped behaviours carrying symbolic meanings, which play a crucial role in defining relationships, legitimating authority, giving meaning to certain life events and stabilising social structures. Despite intense interest in the subject, and an extensive literature, relatively little attention has been given to the nature, role and function of ritual in contemporary medicine. Medicine is replete with ritualistic behaviours and imperatives, which play a crucial role in all aspects of clinical practice. Rituals play multiple, complex functions in clinical interactions and have an important role in shaping interactions, experiences and outcomes. Longstanding medical rituals have been disrupted in the wake of coronavirus disease 2019 (COVID‐19). Medical rituals may be evident or invisible, often overlap with or operate alongside instrumentalised practices, and play crucial roles in establishing, maintaining and guaranteeing the efficacy of clinical practices. Rituals can also inhibit progress and change, by enforcing arbitrary authority. Physicians should consider when they are undertaking a ritual practice and recognise when the exigencies of contemporary practice are affecting that ritual with or without meaning or intention. Physicians should reflect on whether aspects of their ritual interactions are undertaken on the basis of sentiment, custom or evidence‐based outcomes, and whether rituals should be defended, continued in a modified fashion or even abandoned in favour of new behaviours suitable for and salient with contemporary practice in the interests of patient care. [ABSTRACT FROM AUTHOR]

This review essay examines the emergence of the patient narrative or "pathography" in the late eighteenth and early nineteenth century in relation to the great cultural, epistemological, and ethical transformations that enabled the formation of modern medicine. John Wiltshire's book provides an historical overview of this complex process, as well as laying the basis for a contemporary critique of some of its key assumptions. [ABSTRACT FROM AUTHOR]

The Arab and Islamic world is in cultural, political and ethical flux. Pressures of globalisation contend with ancient ideas and concepts that permeate cultural frameworks. Health professionals are among the many groups battling to accommodate the rapidly changing conditions. In many predominantly Muslim countries intense debates are underway among clinicians about the impact of the forces of change on their practices. To help understand these forces we conducted a study of the experiences of clinicians in the Hashemite Kingdom of Jordan, a Middle Eastern nation state where the overwhelming majority of the population is Muslim. The sample contained 508 doctors and doctors-in-training, of whom 63% were male and 80% were younger than 40 years of age. It included both a quantitative survey, covering a wide range of issues, and qualitative, free-text written responses. Our results demonstrated high levels of disquiet related to the overall organisation and administration of the health care system, the specific content of ethical decisionmaking, and the impact of changing social, cultural and religious factors. Concerns included overcrowding, widespread corruption and hierarchical, non- democratic, management practices, and tensions relating to traditional and modern approaches to ethics, especially in relation to consent, organ donation, confidentiality, privacy, abortion, and the role of women. The roles of religion and religious authorities, the relative importance of the family, and community and tribal obligations were also areas of contention. The study exposes profound divisions and widely differing perspectives among Jordanian doctors and an abiding sense of uncertainty and instability within the profession. Many doctors express ambivalence in relation to both modern trends and traditional precepts. Three main axes of ethical contention were demonstrated, relating to the tensions between: "conservative" and "pragmatic" styles of decision-making; "traditional" approaches and internationalised standards of ethics; and the role of Islam and pressures to disengage ethical decision- making from religious authority. We speculate that these issues and divisions, and the deep sense of disquiet revealed by our data reflect large-scale forces to which Jordanian society is exposed and to a substantial degree may provide a way to understand the ethical predicament of many other countries in the contemporary Arab world. [ABSTRACT FROM AUTHOR]

The article offers information on the concerns regarding the transvaginal implantation of synthetic mesh for the treatment of urinary stress. It discusses the wide-ranging issues relating to the accreditation and regulation of innovative medical treatments, the management of conflicts of interests, strategies for communication at multiple levels, and the protection of vulnerable patients and research participants.

Medical decision making when a patient cannot participate is complicated by the question of whose voice should be heard. The most common answer to this question is that "autonomy" is paramount, and therefore it is the voice of the unwell person that should be given priority. Advance care planning processes and practices seek to capture this sentiment and to allow treatment preferences to be documented and decision makers to be nominated. Despite good intentions, advance care planning is often deficient because it is unable to facilitate a relational approach to decision making in cases when the patient's competence is reduced. In this article we present findings from a study of the ways in which older people and their significant others understand decision making in such circumstances. Critical to the participants' understanding was the emergent concept of "relational knowing," a concept that is poorly articulated in the advance care planning literature. Our findings suggest that the dominant understanding of decision making in conditions of impaired competence is incomplete and obscures much of what matters to people. We conclude that, having recognized a broader set of ethical concerns, it is necessary to develop a relational and narrative based approach that applies in appropriate settings. [ABSTRACT FROM AUTHOR]

The article discusses the arising possibilities of adverse outcomes regarding the mandated work practices, the ethical purpose and responsibilities of health care professionals. Topics mention include the excessive working hours lead to underperformance, increased risks and actual harms and judicious management of human resources which enhances health outcomes and minimizing the economic cost.

The article focuses on a debate on universal electronic health record system called the ‘My Health Record', discussing its creation of records automatically for the individual citizens of Australia. It reports that the main motive behind the creation of My Health Record for the improvement of coordination of care, preventing duplication of services and investigations and helping avoid drug errors. The health record system benefits various sectors.

Research into the effects of medical interventions is one of the oldest traditions of any medicine, as is the study of its ethical dimension. In this paper, we briefly describe and recount the history of both quantitative and qualitative methods in clinical research. We discuss key theoretical, methodological and practical features of both methodological perspectives and consider some of the central ideas of medical ethics. We sketch a theory of the relationship between the quantitative and qualitative as essentially complementary and interdependent. The theory is illustrated by reference to the placebo effect and a research 'case study' from within the Chinese medicine community. We conclude that despite the challenges, combined research methodologies in Chinese medicine offer both scientific and ethical benefits. [ABSTRACT FROM AUTHOR]

The article discusses the article "Clarifying Conflict of Interest," by Howard Brody. In the article the authors offer their opinions on several statements and assertions that are contained in Brody's article and on a need which exists for to have a systematic analysis and ethical dialogue in an effort to prevent ethical issues related to conflicts of interest that are raised as a result of relationships that are formed between physicians and for-profit organizations.

A letter to the editor is presented which concerns the Australian Medical Council's (AMC) draft code of professional conduct.

Introductory note by Paul Komesaroff The following reflection was written by the wife of a patient who died in the intensive care unit of a large public hospital after a stay of nearly 5 months. The author has chosen to remain anonymous to protect her privacy. The article is presented because we believe it offers deep insights into the experiences of relatives and other carers of patients with serious illnesses. Caring for carers or relatives is usually considered to lie outside the boundaries of the doctor–patient relationship. Although meticulous attention is often given to providing information and consulting about medical decisions, clinicians rarely consider that they have a responsibility to those closest to the patient, even though it is these people who will carry the burden of the experiences of the illnesses of their loved ones, perhaps for many decades. Clinical communication is concerned not only with the transmission of information. It is not a purely formal process of conveying facts or data. It is also about engaging another person in a dialogue about fears, uncertainties and hopes and, where appropriate, negotiating with him or her about priorities, goals and values. In many cases the perceptions of the health-care team are very different from those of patients and their relatives; accordingly, there may be no way of avoiding the need for such dialogue and negotiation. This article draws attention to the importance of ‘recognition’ as an ethical act: recognition of the roles carers and relatives play in the lives of their loved ones, and of the pain and loss they themselves are suffering. When a physician cares for a patient it is not just an isolated individual who is being treated but the full, complex network of social relations in which he or she is embedded. Recognition also entails acknowledgment of error or of bad outcomes. In the world of someone undergoing bereavement, such acknowledgment might acquire great intensity. Small gestures can make a big impact. Where appropriate – for example, in the case of an adverse outcome – a formal apology, independent of any admissions of legal liability, may play a powerful therapeutic role. This article emphasises the fundamental healing potential of the apology. The voices of patients and relatives must be acknowledged and interpreted in their proper contexts. It is not suggested here that these expressions are of greater validity or authenticity than the perspective of the medical team. Nor should they be regarded as demonstrating the existence of a pathology within the psyches of patients and relatives that can only be understood through the instrumental discourses of medicine 1 . Rather, as this case demonstrates, patient narratives constitute a supplement to the medical ones, but also offer a commentary on them and provide insights from which clinical practice can be enriched and refined. [ABSTRACT FROM AUTHOR]