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Values in critical care medicine

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Title:
Values in critical care medicine a study of public and physician differences in Colorado
Creator:
Foss, Linda Louise
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Language:
English
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x, 199 leaves : illustrations, forms ; 28 cm

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Subjects / Keywords:
Critical care medicine -- Public opinion -- Colorado ( lcsh )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references (leaves 144-160).
General Note:
Submitted in partial fulfillment of the requirements for the degree, Doctor of Philosophy in Public Administration, Graduate School of Public Afairs.
General Note:
School of Public Affairs
Statement of Responsibility:
by Linda Louise Foss.

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|University of Colorado Denver
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Auraria Library
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
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ocm22992463
Classification:
LD1190.P86 1989d .F67 ( lcc )

Full Text
VALUES IN CRITICAL CARE MEDICINE:
A STUDY OF PUBLIC AND PHYSICIAN DIFFERENCES IN COLORADO
by
Linda Louise Foss
B. S. N., Texas Womans University, 1969
M. P. A., University of Colorado, 1983
A thesis submitted to the
Faculty of the Graduate School of Public Affairs of the
University of Colorado in partial fulfillment
of the requirement for the degree of
Doctor of Philosophy in Public Administration
Graduate School of Public Affairs
1989


Copyright by Linda Louise Foss,
All Rights Reserved
1989


Foss, Linda Louise (Ph.D. in Public Administration)
Values in Critical Care Medicine: A Study of Public and
Physician Differences in Colorado
Thesis directed by Associate Professor E. Sam Overman
The use of public opinion data is not new, nor
are discussions and speculations about value issues in
health care. This study examines the opinions of
physicians and public respondents in Colorado on value
issues in critical care medicine to determine if
differences exist. This study uses opinion data from
two separate surveys conducted in Colorado. Eighteen
similar question-statements were used to obtain data on
these value issue. The question-statement were grouped
for the purpose of analysis around the values of
autonomy, beneficence, equity, access and allocation of
resources as well as issues of organ transplants and
imperiled newborns.
The primary assumption of this study is that the
opinions on these values and issues will differ because
of the educational and professional experiences of a
physician impact values. The findings of this study
indicate that differences in public and physician
opinion exist in the areas of autonomy, beneficence,


vi
equity, access and organ transplants. Public and
physicians respondents agreed on the issues surrounding
imperiled newborns and the allocation of critical care
medicine.
The form and content of this abstract are approved,
recommend its publication.
Signed
member in charge of thesis


Dedication
I want to take this opportunity to thank Francis
E. Foss and Josephine F. Foss, my parents for instilling
in me the belief that hard work, honesty and a sense of
humor would sustain you through the successes and
failures of life.
The dedication of Frederick R. Abrams, M.D. ,
Alfred H. Boersch, Ph.D., Gloria Boersch, R.N. Russell
A. Cargo, and Michael S. Victoroff, M.D., made the
Colorado Speaks Out on Health project reality. They are
people who have a vision of a fair, equitable health
care system that respects the autonomy of those
involved. Their support and the Robert Wood Johnson
Foundation funding of Colorado Speaks Out on Health made
this study possible.
Fran, Terry, Mark and Harold, your friendship
encouragement and willingness to listen will never be
forgotten.


This thesis for the PhD of Public Adminstration
degree by-
Linda L. Foss
has been approved for the
Graduate School
of Public Affairs
Fredrick R. Abrams
Date


Foss, Linda Louise (Phd. in Public Administration)
Values in Critical Care Medicine: A Study of Public and
Physician Differences in Colorado
Thesis directed by Associate Professor E. Sam Overman
The use of public opinion data is not new, nor
are discussions and speculations about value issues in
health care. This study examines the opinions of
physicians and public respondents in Colorado on value
issues in critical care medicine to determine if
differences exist. This study uses opinion data from
two separate surveys conducted in Colorado. Eighteen
similar question-statements were used to obtain data on
these value issue. The question-statement were grouped
for the purpose of analysis around the values of
autonomy, beneficence, equity, access and allocation of
resources as well as issues of organ transplants and
imperiled newborns.
The primary assumption of this study is that the
opinions on these values and issues will differ because
of the educational and professional experiences of a
physician impact values. The findings of this study
indicate that differences in public and physician
opinion exist in the areas of autonomy, beneficence,


VI
equity, access and organ transplants. Public and
physicians respondents agreed on the issues surrounding
imperiled newborns and the allocation of critical care
medicine.
The from and content of this abstract are approved. I
recommend its
Signed


CONTENTS
CHAPTER I
INTRODUCTION .....................................1
Overview......................................... 1
Purpose of the Study .............................6
Problem Statement ................................7
Significance of the Study ........................8
Implications of the Study .......................10
General Limitations of the Study ................11
CHAPTER II
REVIEW OF THE LITERATURE ........................14
Overview ........................................14
Ethics and Values ...............................15
Medical Ethics ..................................23
Professionals and Society .......................39
Experts and Public Policy .......................50
Public Opinion and Public Policy.................57
Summary .........................................71


viii
CHAPTER III
RESEARCH METHODOLOGY ............................74
Overview ........................................74
Population and Sample ...........................76
Characteristics of the Sample ...................78
Public .................................... 78
Physicians .................................84
Selection of Question-Statements ................87
Method of Analysis .............................100
CHAPTER IV
Findings .......................................101
Review of Assumptions...........................101
CHAPTER V
CONCLUSIONS ....................................133
BIBLIOGRAPHY ........................................144
APPENDIX
A. Grant for Colorado Speaks Out on Health ...161
B. Center for Health Ethics and Policy ........164
C. List of Organisations ......................165
D. Questionaire for public survey .............168
E. Questionaire for physician survey ..........180
F. Frequency Tables ...........................191


TABLES
Table
3.1 Demographics of Public Sample ...............79
3.2 Demographics of Physician Sample.............85
3.3 Autonomy: Question-Statements................89
3.4 Beneficence: Question-Statements.............91
3.5 Access: Question-Statements..................93
3.6 Equity: Question-Statements..................94
3.7 Allocation of Resources:
Question-Statements................96
3.8 Organ Transplants: Question-Statements.......97
3.9 Handicapped Newborns: Question Statements ... 99
4.1 Overview of Assumptions.....................102
4.2 Autonomy: Analysis of Variance..............104
4.3 Beneficence: Analysis of Variance...........Ill
4.4 Equity: Analysis of Variance................119
4.5 Access: Analysis of Variance................124
4.6 Organ Transplants: Analysis of Variance... 129
F.l Frequencies for Statement One...............193
F.2 Frequencies for Statement Three.............193
F.3 Frequencies for Statement Six...............194


X
194
195
195
196
196
197
197
198
198
199
199
200
200
201
201
F. 4 Frequencies for
F. 5 Frequencies for
F. 6 Frequencies for
F. 7 Frequencies for
F. 8 Frequencies for
F. 9 Frequencies for
F. 10 Frequencies for
F. 11 Frequencies for
F. 12 Frequencies for
F. 13 Frequencies for
F. 14 Frequencies for
F. 15 Frequencies for
F. 16 Frequencies for
F. 17 Frequencies for
F. 18 Frequencies for
Statement Seven.......
Statement Nine........
Statement Ten.........
Statement Eleven......
Statement Twelve......
Statement Thirteen....
Statement Fourteen....
Statement Fifteen.....
Statement Twenty......
Statement Twenty-One..
Statement Twenty-Two..
Statement Twenty-Three
Statement Twenty-Five.
Statement Twenty-Six..
Statement Twenty-Seven


CHAPTER ONE
INTRODUCTION
Overview
Decision-making in critical care medicine has
been traditionally dominated by physicians, who have
also had great influence in the health policy process.
Physicians have been powerful in both areas largely
because they have been viewed as experts and
professionals (Califano, 1986; Starr, 1982; Mechanic,
1974, 1976). Physicians are at the center of the
discussions in many of the issues in critical care
medicine.1 Physicians, who have been accused of playing
God in some instances, have become an easy target for
blame when discussing problems in health care. Other
experts, politicians, nuclear scientists, and military
leaders, make decisions which affect humanity, but are
not held accountable for their action to the extent
1 Critical care medicine is defined in Appendix A.


2
physicians because their decisions are often general and
anonymous while the decisions made by physicians affect
identifiable, individual lives.
The issues, such as whether to tell the truth
to terminally ill patients, whether to treat severely
handicapped infants, or whether to limit access to
critical care technology, are not simply issues of
science but of values2 and can no longer be examined
just in the realm of professionals and experts (Abrams
and Wolff, 1984). The gravity of the issues requires
that the values of ordinary citizens be included along
with those of physicians and the professionals in both
bedside decision and in the policy making process.
In health care, the need to make value
judgments has increased because the use of sophisticated
technology. For example, it is now possible to keep a
person breathing even though his or her brain is
considered clinically dead. It is also feasible to keep
alive infants that are born prematurely and weigh as
little as 500 grams. Medical technology is able to
sustain these lives, but the quality of life is often
2 The definition of value is discussed in Chapter Two.


profoundly threatened because of severe brain damage
that occurs frequently in these miniature infants. On
the other hand, technological advances of medicine have
also enhanced the lives of patients. The ability to
replace faulty heart valves and hip joints and to remove
cataracts are examples of technology that has
significantly improved the quality of life of many
people. The considerations that we face as a society
today are not about the apparent improvements of medical
technology, but the ramifications of technology that do
not necessarily improve quality of life. The new
technology often only prolongs dying not living as it
uses up the financial resources of its victims and
sometimes of society. The burden of choice is often as
great as its potential.
Such value issues in health care are being
discussed today in many different forums. In addition
to many scholarly articles and books by ethicist,
philosophers, political scientist, books by newspaper
reporters, a former Cabinet member, and social workers,
as well as families of patients and the patients
themselves have addressed these issues (Califano, 1986;


4
Callahan, 1988; Colen, 1986; Frohock, 1986; Guillemin
and Holmstrom, 1986; Gustaitis and Young, 1986; Lyons,
1986; Stinson and Stinson, 1983).
In an era of limited resources, growth in the
United States health care system is increasingly being
challenged, forcing changes in the financing and the
delivery of health care. In other words, decision-
makers in the health care system are being pressured
into considering something other than unrestricted
growth which in turn, forces value choices. Physicians
and their patients are being forced to consider
treatment options and the cost of those treatments in
ways that did not exist ten years ago. Historically, as
a society we have greeted and employed new advancements
in medicine with little and often insufficient
questioning about medical and social outcomes.
Generally, physicians have been charged with the
responsibility of deploying medical technology. Today,
we can no longer afford this singular perspective.
The patient-client relationship has also
changed with the advancements in technology and science.
In the past physicians and their patients were often


5
cognizant of each others values and beliefs, because
many individuals received medical care from the same
physician throughout their lives. The effects of
specialization required by progress has not encouraged
the continuation of these familiar relationships.
Today, in the time of crisis, the physician and the
patient may often be strangers unaware of each others
values and beliefs. The breakdown of trust as
specialization occurs renders people incomprehensible to
each other
Another factor that contribute to the
difficulty of making decision in critical care medicine
...is a societal inability to accept death as
part of life. Ours is a death-denying culture.
Youthfulness, vitality, and outward beauty are
steadily portrayed as the norm; to be aging,
impotent, and manifestly in a state of decline
that will inevitably end in death is not part
of the popular scenario. The pivotal events of
the life cycle--birth, sickness, suffering
aging and death-- no longer take place in the
home..... This phenomenon perhaps more than
any other, underlies our unease and even
incompetence in choosing who should live and
who should die (Gustaitis and Young, p. 19,
1986).
The loss of experiences around the events of the life
cycle make it difficult for us to discuss disease and


6
death. The issues faced in critical care medicine
forces us to deal with the uncomfortable subject of
death.
In many ways, the critical care unit is a
reflection of ourselves as people who love to tinker and
sometimes in taking things apart and putting them back
together again we lose our sense of the whole (Gustaitis
and Young, 1986). Technology, as a driving force,
obscures the purpose for which it was devised, to make
life and living better. Our preoccupation with goals at
times has blinded us to the means. The coming to terms
with technology is the challenge that faces society,
families, individuals, professionals, and policy-makers.
Purpose of the Study
The purpose of this study is to identify what,
if any difference in values exists between the public
and physicians on issues that occur in critical care
medicine. The results of this study can serve as the
corner stone for expanding discussions on these value
issues.


7
The empirical portion the study is based on
questionnaires that were administered to a sample of
physicians and a sample of the public in Colorado in
1987-1988. A primary hypothesis of this study is that
opinions around values issues in critical care medicine
will differ because of the educational and professional
experiences of physicians leads them to a specific value
orientation that is likely to conflict with the publics
view.
Problem Statement
Since decision-making in critical care medicine
often involves value judgments. Values of professionals
and their patients can be in conflict. This becomes a
problems when the values of the professional force
unwanted treatment on patients that prolongs their life
or compromises their quality of life.
This study attempts to identify differences of
opinion between physicians and the public on values that
are involved in making decisions in critical care
medicine. It also attempts to quantify the degree of


8
feeling or conviction behind the opinions. The study
should clarify the similarities and differences in
physicians opinions and public opinion about issues that
occur frequently in an highly technological and
stressful environment.
Significance of the Study
The results of this study will be significant
to those involved in the health care delivery system.
Professions do not operate without the consent of
society. Society has given professions, not the
individual professional, authority and autonomy in
return for safeguarding the public trust (Page, 1975;
Silva, 1983). Autonomy is expected by health care
professionals in the United States. However respect for
patient autonomy has not been a consistent fact in the
health care environment. The withholding of information
from patients occurred frequently in the past, because
many physicians felt it would be harmful for their
patients to know the truth about their conditions. It
is hoped that this study will demonstrate to


9
professionals that the public wants to know the truth
about their illness and that by not telling the truth to
a patient is not concurrent with the general values of
society. The knowledge of the values of the public
should inform practitioners the general values of the
public and facilitate the discussions with individual
patient about treatments. Public awareness of the
values of professionals should facilitate the
understanding and questioning of physicians about their
professional values.
The survey findings will also be useful to
policy makers. Concerns of the citizens of Colorado
about these ethical issues in critical care medicine
have not been collected before nor have they been
compared with the opinions of physicians. The analysis
of opinion data assists the policy makers and
administrators in gaining an understanding of the
contextual environment which they are working in.
Rochefort and Boyer (1988) state three purposes for
public administrators to examine and evaluate public
opinion data on health care issues. The first purpose
is to assess a range of policy design and implementation


10
of opinions against a backdrop of perceptions and
probable response by the publie-at-large and selected
population subgroups. The second purpose is the "eyes
and ears" function to distinguish those components of
existing programs that work and those that do not. Polls
are an important form of citizen feedback. Thirdly, it
is important to confirm and verify assumptions made
about the policy,environment (Rochefort and Boyer,
1988). It can also assist in the improving
effectiveness and implementation of new initiatives in
health policy.
Another area of significance is that the
opinion data can lead to discussion among the various
individuals involved. This will result in developing
trust and cultivating cooperation among medical
professionals, public, and policy-makers.
Implications of the Study
The implications of the study are notable
insofar as the study has the potential to provide
insight into the value issues that have not been


11
discussed in a public context in the state of Colorado.
A general understanding of how members of the public and
physicians compare on their responses to the issues
addressed in the study can enlighten the process of
discussing the goals and direction for public policy.
Additionally, knowledge of the differences and
concurrences in how the public and physicians feel about
these value issues can be the target for further
discussion that can then affect the change process in
the health care delivery system in the state of
Colorado.
General Limitation of the Study
A number of factors limit the generalising of
this studys findings. The first limitation concerns
the representativeness of the samples. As discussed in
Chapter III random samples were not used. Participation
in both samples, physician and public was done on the
basis of self-selection. Another limitation of the
study is the level of data collected. It is felt that


12
the extremely large sample overcomes these limitations;
and, therefore, the findings are important.
Organization of the Remaining Chanters
Chapter Two reviews selected literature
pertaining to values, ethics, medical ethics,
professional contracts with society, and the use of
expert and public opinion in public policy.
Chapter Three focuses on the methodology
involved in the research. The four sections of this
chapter include the following: an overview of the
research methods and objectives; characteristics of the
sample; and methods of analysis.
Chapters Four and Five, respectively, present
the findings and conclusions of this study. Chapter
Four outlines each of the research assumptions examined
in the study and presents the results of the statistical
techniques used to analyze the data. Chapter Five


13
provides a summary of the results and conclusions drawn
from the study. This chapter ends with discussion of
the implications of findings.


CHAPTER TWO
REVIEW OF THE LITERATURE
Overview
Since this study measures opinions of the
general public and physicians about value issues in
critical care medicine, the literature review explores
the following: the role of values in society, ethics,
medical ethics, professional codes, the use of public
opinion in public policy. The difficult decisions that
occur in critical care medicine dissects across the very
essence of individual and societal values as. well as how
we conceive ourselves as individuals and members of a
humane and caring society. Historically, as a society
we have accorded value and respect to the individual
sometimes at the expense of the common good.
This study attempts to identify the values of
the public and physicians surrounding several issues in
critical care medicine. The basic premise of this study
is that the values of both physicians and the public are
essential to the discourse on these issues.


15
In many instances, the dilemmas addressed in
public policy discussions on health care are caused by
conflicting core values. For example, the belief by
some that health care is a right conflicts with the
other belief that there is market for health care
operates in the realm of supply and demand and not
individual need or right. This survey explores the
opinions of physicians and the public on values that are
of concern in the practice of critical care medicine.
Ethics and Values
The term value has many meanings. In
economics, it refers to exchange value, the ability of a
good or service to purchase other goods. In other
instances, the term value attaches to ideals, motives,
and sentiments. When values are defined in this
context, the judgments around these values tend to be
discussed in terms of worthiness, goodness,
desirability, obligation, and rightness or wrongness of
an act (Scruton, 1982; Rachels, 1980). Values that are
identified in an individual or a nation suggest a


16
pattern of attitudes or behaviors that occur frequently.
These attitudes or behaviors have an history, either
personal or societal, before they become a value (Rohr,
1979). Public opinion is a method of measuring values,
beliefs, and expectations around issues (Hennessey,
1975).
Ethics integrates values within a framework of
morality. Ethics attempts to provide direction for
conduct (Rachels, 1980). Jonsen and Hellegas (1976)
defined human morality as the actual behavior of human
beings around judgments, actions, and attitudes that are
used to construct social norms. Ethics can be
considered as the values set forth by society as
meriting intrinsic obedience (Jonsen and Hellegas, 1976;
Scruton, 1982). Ethical theories provide a framework of
values applied to an endeavor. Bioethical theories
provide a framework for the practice of medicine.
Judgments or actions about what should be done in a
particular case are usually justified by rules, that
are, in turn, supported by moral principles and,
ultimately, are justified by ethical theories (Beauchamp
and Childress, 1982). Judgments are expressions of a


17
decision, verdict, or a conclusion about a particular
action. The difference between rules and principles is
not distinct. Rules usually state actions ought or
ought not to be done because they are right or wrong.
Principles tend to be more general and fundamental.
The interpretation of facts and the impact of
scientific, cultural, and religious beliefs influence
our judgments and the application of ethical theories.
The complexity of this interrelationship among the tiers
of moral justification and factual beliefs is
significant. Facts are often seen through the prisms of
our values and ethical systems.
Values that are important to ethical frameworks
in our society are often neglected in the economic and
political models used in describing society. The
economic model often assumes that people operate only
from self-interest; the value of profit or utility
maximization is believed to be right. The political
model of pluralism recognizes the formation of groups of
people with similar interest. The group becomes the
unit of analysis that promotes interest by using its
resources to maximum advantage (Reich, 1988).


18
Individual preferences and behavior are
slighted in several ways by the economic model. It
treats the role of values as a consumption choice.
Values, beside shaping individual behavior, also play a
societal role, defining how the economic and political
game will be played and what outcomes are acceptable.
Rights to employment, education, health care, and a
minimum standard of living are not determined by
economics; yet these ideas are critical to the shape of
economic outcomes. General beliefs broadly define, what
can, what cannot, and what must be done. Government
often intervenes in society in order to foster a more
desirable and equitable distribution of resources and to
guarantee citizens rights of pursuing important social
goals, such as health and education. This intervention
is the outcome of values held by individuals and groups,
not the economic model (Orren, 1988).
Orren (1988) states, "In politics as well as
economics, values set the boundaries of the acceptable
for the public agenda, the terms of the public debate
and the final shape of public policy (p. 23)." At times
certain redistributive policies are considered


19
illegitimate because they conflict with core values. If
we focus on the debate without attending to the values
that define the range, then we may only be explaining a
fragment of what shapes public policy and our
predictions may be erroneous. This study is one that
compares the public and professional opinions on core
values, autonomy, beneficence, non-maleficence, sanctity
of life and justice that are central to the practice of
medicine because it is felt that these opinions and
values are important to the policy process. Another
approach for defining values is to explore public
opinion literature. Opinions are based on a
multiplicity of components. Opinions help people create
reason out of circumstances. Opinions based on
underlying beliefs, values, and expectations are a
measure of values. Values represent the things people
find most important in life (Bennett, 1980). They are
the preferences people have for certain ends or ways of
doing things (Nimmo, 1978). Values are features that
are seen as necessary to the good life. Values are
often personal goals, such as success, wealth, and
enlightenment (Bennett, 1980). Values are abstract and


20
generalized behavioral ideals to which group members
feel a strong emotional commitment. Values provide a
standard of judging specific acts and goals. Values are
associated with norms. Norms are cultural definitions
of behaviors learned through socialization (Fischer,
1980). Allport (1937) defines personal values as the
dominating force in life, and all activities are
directed towards realizations of those values. Familiar
American social values are a commitment to freedom,
equality, justice, hard work, self-reliance, and
competition (Allport, 1937).
Beliefs are the facts that we often take for
granted about the world. The person who holds a belief
perceives some relationship between two things or
between a thing and a characteristic of it (Bern, 1970).
Beliefs are regarded as real and true. Bern (1970) has
classified beliefs into two categories, primitive and
higher order. Probably the most primitive belief is our
unquestionable faith in the validity of our senses; our
sensory experiences are a source of belief.
Another key to our faith in beliefs is the
tendency to accept without question the credibility of


21
some external authority in fixing our views (Bern, 1978).
Many of our beliefs have been confirmed by someone who
is highly respected. Our Founding Fathers expressed a
belief in the preamble of the constitution, that begins
"We hold these truths to be self evident......" Yet
another example is the statement made by parents to
their child, that the doctor knows best.
The central quality of a primitive belief is
that it endures unquestioned. A higher order belief
occurs when one no longer treats the first premise as
the final conclusion. As we develop we become more
skeptical and tend not to over generalise about our
beliefs. Our belief structure broadens as our
experiences multiply. Generalizing from a limited set
of experiences and treating individuals as members of a
group is a common cognitive act. This process allows us
to package our world into manageable numbers of
categories.
Values can operate independently of beliefs,
but beliefs can serve to connect values with the real
world. Opinions are the result of a complex value and
belief calculation that establishes a sensible fit


22
between the outer world and life experiences. Peoples
opinions are like coded messages about their life
experiences, and underlying systems of beliefs and
values provide the keys to the code. Opinions can be an
individual effort to corroborate personal experience and
understanding. When an individuals opinions merge with
the sentiments of a larger group, the presumption of
support of his or her life experiences is reaffirmed
(Bennett, 1980). The process of reaffirmation continues
when the opinion of the group has some influence on the
resolution of an issue. When this happens, the
individuals values and beliefs have become
institutionalized. Public opinion has then channeled
individual orientation into common expressions that
influence the development of policy (Bennett, 1980;
Hennessey, 1975; Nimmo, 1978).
The range of individual values seems deeply
affected by personal experiences, and it is necessary in
some way to measure values. The monotheistic theory of
Betham (1948) and Mill (1941) required that the measure
of painful and pleasureful states of one person be
compared to anothers state of pain or pleasure in order


23
to decide which one is greater. It is difficult to
measure values of health, happiness, or pleasure. The
health belonging to one person may not be the same for
another (Self, 1979).
The difficulty with values and value judgments
is that they are hard to quantify. Values vary in
direction, intensity, and saliency to the individual
(Nimmo, 1978). A utility scale that measures the
strength of individual and group preferences is a way to
measure values. Another problem in measuring
preferences on value statements is that the researcher
is still unsure of the true values because they are not
acted out by the respondent; we have only an idea of how
they might act (Fischer, 1980).
Medical Ethics
A discussion of medical ethics is important to
the framework of this study. The statements used to
seek public and physician opinions were composed with
one or more medical ethical values in mind. Medical
ethics frames values for the practice of medicine. It


24
is assumed in the survey that the professionalization
process of becoming a physician incorporates these
values in their decision-making and opinions.
Medical ethics is a branch of ethics, not
medicine (Brody, 1981). Medical ethics is the branch of
applied ethics dealing with the application of values in
formulation of judgments in the practice of medicine,
the planning and the delivery of health care, and the
conduct of medical research (Brody, 1981; Jonsen and
Hellegas, 1976; Beauchamp and Childress, 1983). Medical
ethics is discussed on two levels, individual and
societal. The individual level is concerned with the
individual and the practice of medicine. Individual
level discussions usually centers on what is the "best"
treatment for the patient. Societal level discussions
center on justice. The values of autonomy, beneficence,
nonmaleficence, sanctity of life, and justice as they
pertain to the practice of medicine are discussed in the
following paragraphs.


25
Autonomy
Autonomy, or the right to self-determination,
constitutes an important ethical principle or value. As
a form of personal liberty, autonomy is grounded in the
tradition of human rights and serves as the central
element for patient rights. The legal doctrine of
informed consent is rooted in this principle. In recent
years, informed consent has been legally mandated before
initiating any therapeutic or research procedures
(Beauchamp and Childress, 1983; Brody, 1981; Veatch,
1981).
Autonomy is concerned with the general self-
governance of ones own person. Autonomous persons
determine their own course of action in accordance to
their own plans. Actions that are autonomous should not
be constrained by others (Beauchamp and Childress, 1983;
Brody, 1981; Veatch, 1981). Kant (1969) and Mill
(1941), shaped our understanding of autonomy as freedom
of will and freedom of action. Kants view of autonomy
was that people were rational agents of unconditional
worth who must not be treated as incapable of choosing


26
for themselves (Kant, 1969). To be autonomous in Kants
view was to govern oneself, including making ones own
choices.
While Kant was concerned with moral autonomy of
will, Mill was concerned about the autonomy of action
and thought. Mill argued that social and political
control over individual actions is legitimate only if it
is necessary to prevent harm to other individuals.
Mills definition of the value of utility permitted all
citizens to develop their potential according to their
convictions, as long as they do not interfere with
others. Autonomous expression maximizes the benefits of
all concerned (Mill, 1941 and 1978).
The principle of autonomy has a legal
counterpart in the right of self-determination.
Informed consent is a legal requirement that reflects
change in the clients relationship with the
practitioner in the health care setting. Historically,
treatment was suggested by the practitioner and accepted
by the patient. Today, it is the adult clients right
to accept or reject these recommendations. The right of
the patient to make decisions is significant; to ignore


27
or neglect patient preferences may violate ethical,
legal, and professional expectations (Brody, 1981;
Beauchamp and Childress, 1983).
Courts have defined informed consent as the
clients right to know, before agreeing to a treatment,
what the procedure or treatment entails, the hazards,
the possible complications, and the expected results of
the treatment. The patient also has the right to be
made aware of alternative procedures or treatments and
the results expected from non-treatment (Beauchamp and
Childress, 1983; Brody, 1981; Veatch, 1981).
Problems have, at times, risen with informed
consent because professionals have persisted in using
medical terminology with laypersons unfamiliar with it.
From the patients viewpoint, three components that
affect informed consent from the patients viewpoint.
These are (1) decision-making capacity, (2)
voluntariness, and (3) information. Decision-making
capacity is not simplistically determined by legal
competency requirements; it is dependent on how the
patient is functioning in a particular situation.
Voluntariness, the second factor affecting informed


28
consent, is destroyed when consent for treatment is
obtained through coercion or other manipulation of the
patient. Such actions inhibit the patients ability to
make an informed decision. Then the decision is not
based on free choice; and obtaining an involuntary
consent disrespects the clients dignity. Information,
the third factor affecting consent . the amount and
nature of the information that the client needs to make
an informed decision . is a widely debated topic; and
universal agreement has not been reached (Presidents
Commission, 1982).
Another difficulty with informed consent is
determining whether the patient is competent to chose.
Physicians sometimes confuse the notions of competence
and capacity to chose by simplifying or applying it in
the wrong circumstances. Often a patient who refuses
treatment is believed by many health care professionals
to be incompetent. Competence should be judged
separately from treatment decisions. The refusal of a
patient to undergo treatment does not equate to
incompetence. The term competence is value-laden, and
the judgement of a clients competence is often flawed


29
because of this confusion. Beauchamp and Childress
(1982) state that an individual is competent if, and
only if, that person can make decisions based on
rational reasons. There is a fine line between
competence and incompetence (Beauchamp and Childress,
1982).
Another issue related to the value of autonomy
is the treatment of infants and children that requires
the consent of the parents. Should parents have the
right to refuse treatment for their children? It is
accepted that parents have the right to make fundamental
decisions regarding the upbringing of their children.
The United States Supreme Court has said:
"It is cardinal with us that the custody, care
and nurture of the child reside first with the
parents, whose primary functions and freedom
include preparation for obligations that the
state can neither supply or hinder (Prince v.
Massachusetts. 1944)."
If the parents fail to care for the child, however, the
state will protect the child from the actions or
inactions of the parent (Brant, 1981). Clark (1981)
explained that courts have often taken the following
attitude towards children. While the child belongs to
his parents, he also belongs to his state. The fact


30
that the child belongs to the state imposes upon the
state many duties. One of the duties is to protect his
right to live and grow up with a sound mind in a sound
body (Clark, 1981). Courts have overruled parents
decisions about refusing medical treatment when it was
felt to be in the best interest of the child. Other
court decisions have reaffirmed the parents decisions
not to treat their children where it was known that no
treatment would prolong the children lives (Benesch, et
al, 1986).
BENEFICENCE
The core value of beneficence is embodied in
many professional codes, dating back to the inception of
the Hippocratic Oath. Beneficence directs doctors and
others to do good (Beauchamp and Childress, 1982;
Macklin, 1987). Historically, the failure to benefit
others when in a position to do so, violates social or
professional duties.
Beneficence is generally considered to be more
far reaching than nonmaleficence (above all else, do no


31
harm) because it requires positive steps to help others.
The term beneficence includes among its meanings mercy,
kindness, and charity. Beneficence as a core value in
the practice of medicine asserts a duty to help others.
The duty is to confer benefits and to prevent and remove
harms. This is important, but it is equally important
to balance benefits against the harms of an action
(Beauchamp and Childress, 1982; Brody, 1981; Jonsen,
Siegler and Winslade, 1982).
Beneficence in critical care medicine is
frequently difficult to discern. Often in the neonatal
intensive care unit, which cares for the very young, the
use of respirators causes bleeding in the brain that can
result in severe brain damage and lung damage that can
last a life time. The application of this technology
thus challenges the physicians and parents to weigh the
benefits of treatment against the possible harms. Often
the use of technology to prolong life results in effects
that limit the quality of a persons life. The question
then becomes one of life at all cost or life with
quality.


32
As previously mentioned nonmaleficence is
closely associated with beneficence and demands that the
health professional "above all do no harm". The idea of
nonmaleficence is somewhat ambiguous. "Does harm
refers to disability or death. The definition of harm
can be very broad (Beauchamp and Childress, 1982).
Usually the interpretation of this value includes the
following: Dont kill .. Dont cause pain .. Dont
disable .. Dont deprive.of freedom or opportunity ..
(and) Dont deprive of pleasure" (Gert, 1973).
The value of nonmaleficence encompasses not
only actual harms, but also risks of harm. Another
approach to nonmaleficence by Jonsen, Siegler, and
Winslade (1982) requires that medicine develop motives
and intentions to serve the well-being of their
patients. The iatrogenic effects of the use of
technology are often known and need to be weighed by
physicians and their patients, or the parents, when
making decisions.
Physicians, nurses, and administrators
sometimes have a conception of benefits, harms, and
their balance, which differs from the patients. There


33
is, therefore, a question of whose conception of
beneficence or nonmaleficence should prevail. If a
patients decision is considered poor by the
professional, he or she is inclined to take one of two
approaches. Some are inclined to respect the autonomy
of the patient by not interfering with the decision.
Others are inclined to protect the patient against the
harmful consequences of his or her choices. The problem
of whether to intervene in the decisions is the problem
of paternalism.
Paternalism is as old as medicine itself.
Paternalism is analogous with declaring the role of the
professional as that of the father. Paternalism
presupposes two features of the paternal role, that the
father is benevolent and that he makes all decisions
relating to his childrens welfare. Paternalism
therefore requires that beneficence take precedence over
the value of autonomy. The justification for
paternalistic behavior often came from non-malfeasance.
For instance, a physician does not want to do harm by


34
alarming the patient with a diagnosis for fear, the
patient might become depressed, upset, or refuse
treatment (Beauchamp and Childress, 1982; Brody, 1982).
The advancement of technology presents us with
the dilemma of prolonging life that may not been viewed
by some as a life worth living. Thus, the values of
those who view life as sacred are in direct conflict
with those who ascribe to the notion of quality of life
being an important consideration. Quality of life
discussions have resulted because natural death and the
moment of death can be controlled by medical
interventions and technology (Jonsen, Siegler, and
Winslade, 1982; Beauchamp and Childress, 1982).
The discussion of whether treatment is optional
or obligatory involves the values concerned with the
sanctity of life versus the quality of life. The
quality of life discussion is value-laden. This
approach shifts the question from whether treatments are
beneficial to the question of whether patients lives
are beneficial to them. Who makes the value judgement,
the person who lives the life, or an observer?


35
The perception of quality of life changes over
time. Quality of life is difficult to define. Jonsen,
Siegler, and Winslade (1982) offer the following
perspectives on a definition of quality of life.
Quality of life may refer to the subjective satisfaction
expressed or experienced by an individual in his
physical, mental, and social situation even though they
may be deficient. Quality of life may refer to the
achievements by certain persons of attributes and skills
that are highly valued in our culture. Quality of life
may refer to the subjective evaluation by an onlooker of
anothers subjective experiences of life. It is evident
that interpretation of these definitions is value-laden
and difficult to make in a clinical setting.
The conflict between the quality of life and
sanctity of life is at the center of the issue of
treating, or withholding treatment, from severely
impaired infants or very-low-birth-weight-infants. The
fact that some babies, lives will be abysmal, no matter
what is done medically, is of concern to physicians and
parents alike. Should these considerations be an aspect
in the decision-making?


36
Advocates of the quality of life criteria do
not view biological existence as an absolute value.
Bresnahan (1982) believes that when considering whether
to treat a handicapped child, one ought to give insight
into the future suffering that the child will endure.
He continues with the thought that the suffering is not
just pain; it is also the loss of ability to do certain
things. The parents suffering out of empathy for the
child should also be considered.
Advocates of the sanctity of life voice concern
that some parents might wash their hands of a child
simply because it is defective or an inconvenience to
their lives. Their approach asserts that there is an
obligation to provide care and sustenance. Paul Ramsey
(1978), a professor of religion, states that it is never
right to turn against human life.
Richard McCormick (1978), a Jesuit and
professor of ethics, offers another perspective to the
quality versus sanctity of life discussion. He sees no
contradiction between sanctity and quality of life. He
states that quality of life assessments ought to be made
within the reverence for life as an extension of ones


37
respect for the sanctity of life. There will be times
when the continuance of physical life can easily be an
assault on the person and his or her dignity (McCormick,
1978).
Justice
At the societal level, medical ethics is
concerned with broad social policies. The emphasis of
justice in the discussion of medical ethics has
increased because of scarce resources. Common to all
theories of justice is Aristotles theory that states
equals ought to be treated as equals and unequals may be
treated unequally. The problem with this approach to
justice is its lack of substance. Who is equal and
unequal? How does one specify the relevant aspects by
which people are to be treated equally?
The major health policy issues surrounding
justice are the debates around access, equity, and .
allocation of resources. Problems in allocation arise
on two levels, macroallocation and microallocation. At
the societal level of justice, decisions must be made


38
around how much of societys resources should be used
for various goods, as well as how to distribute them.
One approach to distributing health care is to
treat people equally, but this ignores the fact that
some people have different needs. If this approach is
invoked, the sick may go without needed care, or the
well would have unneeded care forced on them. A
modification would be to provide an equal maximum amount
of care to everyone, but this approach is difficult to
implement (Veatch, 1981).
A utilitarian approach for the distribution of
health care, acknowledges a right to health care at the
expense of society. This viewpoint advocates the
distribution of resources so it produces the greatest
good for the greatest number. This approach does not
address whose health is being promoted, but focuses on
the public-at-large. A national health policy based on
utilitarian theory must be concerned with the aggregate
health of society. If some individuals must suffer for
the good of society, so be it (Veatch, 1981).
Yet, another approach to the question of how
much health care should a society provide can be derived


39
from John Rawls, A Theory of Justice (1971). Rawls
theories are based on two concepts. The first is that
every person is to have equal rights to an extensive
total system of equal liberties. The second is that
social and economic inequalities should be arranged so
they are both to the greatest benefit of the least
advantaged and open to all under conditions of fair
equality of opportunity. Applying this theoretical
perspective to health care is complex and difficult.
A third approach to justice is to distribute
health care resources on the equalitarian method. This
approach distributes health care resources on the basis
that everyone has a claim to health care needed to
provide an opportunity for a level of health equal to
others as far as possible.
Professionals and Society
One assumption of this survey is that the
profession of medicine does not exist in a social or
ethical vacuum. A second assumption is that the values
central to the practice of medicine also need to reflect


40
societal values. A third assumption is that the
educational and professional process of becoming a
physician impacts the values, opinions, and beliefs of
the individual.
Talcott Parsons (1954) discusses professions
and social structures in his essay on social theory. He
notes that the professions occupy a position of
importance in our society and that many of the most
important features of our society are dependent on the
smooth functioning of professions. He continues that
assumptions made about people involved in market
activities are not attributed to professionals.
Professionals are often viewed as being altruistic.
Another aspect of professions pointed out by
Parsons (1954) is how they exercise authority in our
society. Doctors issue "orders" even though we know
that the only "penalty" for not obeying them could be
possible injury to the patients health. "Professional
authority has a peculiar sociological structure. It is
not based on a generally superior status nor on a
superior wisdom nor on high moral character. It is
based on the superior "technical competence" of the


41
professional. The professional is held to be an
"authority" only in his or her own field (Parsons, p.
38, 1954).
Talcott Parsons (p. 372, 1954) defined a
profession as a "cluster of occupational roles, that is
roles that the incumbents perform certain functions
valued in society in general and by these activities
earns a living at a full time job." Parsons continues
that the typical professional is trained in a tradition
that is usually done in a formally organized process, so
that only those with the proper training are considered
qualified to practice the profession. Futhermore only
members of the profession are treated as qualified to
interpret the "traditional authority."
Page (1975) expands the concept by viewing a
profession as a part of society that receives its
mandate from society. The mandate of medicine is to
serve the public good in the area of health care, not to
promote the profession of medicine. Hobbes (1972),
Locke (1952), and Rousseau (1913) based theories of
politics and ethics on a social contract that creates a
binding obligation among men. These philosophers made


42
the assumption that all men are by nature equal; but,
without some form of agreement, individual self-interest
would lead to dispute, conflict, and hostility. Or as
Hobbes stated, without a social contract, men find
themselves in a "war of all against all."
Contract theory assumes that all men have
natural rights to self preservation as a people
(Rousseau, 1913). To secure these rights, it is
rational to form contractual obligations and to form
governments. Authority of the government is based on
the consent of the governed. Maintaining individual
rights and freedoms is the goal of society in contract
theory. This social-contract view of society is readily
accepted in the United States (Page, 1975; Silva, 1982).
Historically, the profession of medicine has a
professional code to instill in the public, confidence
in physicians. Codes in this instance are defined as a
system of principles or rules for moral conduct
(Beauchamp and Childress, 1983). The traditional
orientation of these codes has dealt with the following
issues: the physician-patient relationship; patient
confidentiality and privacy; informed consent; and


43
truth-telling. Abuses that occurred in biomedical
research created the need for codes that protected human
subjects. The first major code, the Nuremburg Code, was
developed as the result of the objections to research
practices conducted by Nasi doctors in World War II.
Since the formulation of the Nuremburg Code, U.S.
federal regulations and other international
proclamations have been adopted to guide research
practices (Hiller, 1981).
It is important to understand that codes do not
create virtue. Codes specify normative standards for
situations likely to arise in the practice of medicine
(Beauchamp and Childress, 1982). Their pragmatic
directions establish certain regularities of procedures
that elicit public confidence. Jonsen and Hellegas (p.
22, 1976) suggest that
...codes as they now exist, might be called the
archeological ruins of a doctrine of medical
virtue. The present medical codes are a
collection of pragmatic directions that mark
the outer limits of the physician-patient
covenant.
There is a distinction between general moral
codes, which govern a whole society and apply to
everyone alike, and the moral codes which govern groups,


44
such as doctors, nurses, advertising agencies,
engineers, and lawyers. A general moral code consists
of fundamental moral principles and rules. In contrast,
a special professional code emphasises moral rules that
specify obligations and duties for a particular group.
The function of professional codes is to promote public
trust and confidence and encourage professional
activities that accomplish socially valued ends, such as
care of the sick (Silva, 1982; Page, 1975; Hiller,
1981).
As previously mentioned, professionals have
been entrusted to define ethical and professional codes.
When these codes differ from those of theigeneral
public, the social contract and the public trust have
been abridged. There are weaknesses to. the codes
because they do not address autonomy and justice in
present day terms expected by the clients of medicine.
Currently, the professional code for physicians focuses
on the obligation of the professional rather than the
rights of those receiving services. These codes tend to
be paternalistic by affirming the professionals
judgement about harms and benefits for the patient,


45
rather than stressing the rights of patients autonomy
(Jonsen and Hellegas, 1976). The professional code of
medicine does not adequately address the rights of
patients to determine their own care. This gap between
the professional codes of conduct and the demands of the
public has created an environment that demands
participation from the public not just the professionals
involved.
Public participation to restore trust in
medicine is essential for both political and pragmatic
reasons. Medicine, like other professions, historically
has not accorded ethical self-regulation a high-level of
priority. The issues and value judgments that
physicians face are intrinsically collective and public.
Distribution of health care, for example, involves more
than one person. There is a need to establish a
coherent framework instead of ad hoc reactions to
ethical problems (Abrams and Wolff, 1984). Private
decisions have an inescapable public dimension. Whether
a patient is declared dead for lack of brain function,
or another refuses treatment, these decisions confer a
precedent that is important for later cases. Ad hoc


46
2decisions in a world without substantive or procedural
uniformity will guarantee error and conflict. There is a
need to articulate the moral ground we share and to try
to enlarge it (Abrams and Wolff, 1984). This gives the
public a stake in how these medical-ethical decisions
are made.
The growing skepticism over technological
intervention, not only in medicine but other fields, has
increased the demand for greater citisen participation.
John Nesbitt (1982) in Megatrends identified that as a
society, we were moving from a representative to a
participatory democracy. Barber (1984), Besold (1978),
and Toffler (1980) write of the need for an anticipatory
democracy that is able to deal with the advancement and
problems of society before they occur rather than being
crisis oriented. There has been growth in government-
sponsored citisen involvement since the 1960s.
Grassroots citisen activism has also taken place. The
rise of the consumer and the environmental movement in
the early 1970s have lead to a growth of citisen
participation in dealing with technological advancement.


47
The degree to which technological development and
citizen participation can interact and coexist is an
open arena.
At the state level, a grassroots movement of
seeking citizen input to the issues surrounding high
technology medicine started in Oregon (Crawshaw, 1985).
Oregon Health Decisions was a citizen-based project
intended to develop a statewide awareness of severe
bioethical dilemmas. This project became the prototype
for other states (New Jersey, Vermont, Colorado,
California, Hawaii, Idaho, Illinois, Iowa, Maine, and
Washington). These individual projects have been
successful in securing funding from the Prudential and
Robert Wood Johnson foundations. Jennings (1986) states
that the projects cut across many of the boundaries and
divisions that mark our diverse, pluralistic society.
The basic objective on the whole of the community-
bioethic movement has been to make that pluralism a
source of enlightenment rather than confusion. The
bioethic projects have not been single-issue projects or
lobbying groups in the traditional sense (Jennings,
1986).


48
The death of Baby Doe in Bloomington, Indiana,
also galvanised social reformers and increased public
awareness. The immediate pressure on the Reagan
Administration from groups representing the handicapped,
right-to-life, and citizens for the retarded resulted in
a notice from the Department of Health and Human
Services to health care institutions receiving federal
funding. Institutions were given notice that they would
lose federal funding if they denied treatment to
handicapped babies. The notice dated May 18, 1984, was
debated by pediatricians, physicians in general,
hospital administrators, nurses, and other special
interest groups.
The Baby Doe regulations required that signs
with a hotline phone number to report suspected cases of
non-treatment be posted in all nurseries. After a call
was received, "Baby Doe Squads" were sent to investigate
the claims. Opposition was immediate and widespread.
The theme was that the invasion by the state into
medical decision-making and family life was
unprecedented. Ultimately, the original regulations
were modified as a result of judicial challenges by


49
professional organisations. A recommendation out of
this controversy was that infant review committees, or
ethics committees, be a part of the decision-making
process. The federal governments intervention was
aimed directly at physician control over decision-
making. This control was questioned and opened for
others to observe. Medical-ethical questions had taken
another step into the public domain.
A common claim often made by professionals and
policy makers was that the public lacked information or
the capability of providing input into medical decision-
making. The awareness and information that the public
now has access to is significantly different from
several years ago. In the last three years, there has
been several books written about the issues surrounding
premature infants and their treatments in. the neonatal
intensive care units. Others have written about the
aging population. One book, written by a popular movie
critic, presents the case of Baby Doe in Bloomington,
Illinois (Lyon, 1985). The parents of Baby Andrew
Stinson wrote a book outlining the long dying process he
underwent in a neonatal intensive care unit (Stinson and


50
Stinson, 1983). Fred Frohock (1986), professor of
public affairs, visited a neonatal intensive care unit
for six months and then wrote of the daily activities
and problems in a neonatal intensive care unit. B.D.
Colen (1986) has written a book that addresses neonatal
issues but also deals with issues surrounding other
areas of medical technologies. Daniel Callahan (1988)
writes a book on setting limits on health care cost.
Three themes that are consistent in the writings are
whether the application of new technology is necessary
in every case, who should make the decisions surrounding
these issues, and what can we afford.
Expert Opinion and Public Policy
One of the purposes of this study is to
determine if the values of physicians are different from
the general public on issues in critical care medicine.
The role of the "expert" in setting public policy has
been powerful. At times experts have been more powerful
in policy-making than the public that is affected by the
policy. The issues that face society today are not just


51
in the realm of experts alone. The following section
explores the role of experts in developing public
policy. The role of the physician in health policy
parallels that of experts in other fields. Experts,
whether physicians or others, have been given a
tremendous amount of power by the public and by
legislative bodies over time. Experts have been looked
to for answers and solutions that were often thought
beyond the capabilities of ordinary men and women.
The emergence of technological change is so
accelerated that it has been described as ten Industrial
Revolutions and Protestant Revolutions combined,
occurring within a single generation (DeSario and
Langston, 1987). New technological capabilities and
applications bear implications for every aspect of
society. As a society we need to realize that
technological capability does not have to equate with
technological desirability (DeSario and Langston, 1987).
Over the years the federal government has
acquired a central role in developing, applying,
regulating, and financing technology (Murray, 1984).
During the 1950s and 1960s, inventions were monitored by


52
Congress; but as the scope and implications of
technology increased, the ability of Congress to
evaluate and monitor was greatly decreased (Mesthene,
1977). This leap in technology overloaded Congress and
led to the formation of a large specialized professional
bureaucracy. Experts were conferred a special status.
The familiarity of the expert with theories, models,
procedures, and formulas led to the assumption that they
could calculate a correct answer both technologically
and ethically. Technocrats were often seen as imbued
with social objectivity and neutrality (DeSario and
Langston, 1987; Kweit and Kweit, 1981). Physicians
assumed this role in the health care system.
Physicians had the power to dominate the
formation of policy and design of health policy for
several reasons. First, the general public has held
doctors in high esteem. The social consensus, that the
medical profession with its code of ethics and members
who were all public spirited and unselfish, gave doctors
political power to influence health policy and its
design (Taylor, 1960). Secondly, expertise and special
knowledge permitted doctors to make decisions about the


53
technical details of medical practice with little
outside interference (Mechanic, 1976). Persons who lack
medical knowledge usually cannot effectively question or
challenge the physicians decisions about health care
services. Thirdly, physicians decisions about health
care are often shielded from public scrutiny.
Professional associations have used the confidentiality
measures of their professional code to insulate their
decisions;, and they have been able to block legislation
that would lessen the degree of insulation. This
insulation from the public has allowed the professional
interest to dominate the health policy process
(Mechanic, 1976 and 1974). These facts lead to the
conclusion that few consumers were involved in health
policy formation.
Historically, the medical profession has
stopped any interference by government or others in the
practice of medicine. Organized medicine has always
opposed intervention by the government on the basis that
it would destroy the physician-patient relationship,
also known as the "medical friendship" that was special
and unique to the practice of medicine. Organized


54
medicines inability to defeat the passage of Medicare
in 1965 was the first major change in the relationship
of government and medicine. Organized medicine remains
a powerful lobby, but it is less able to control the
regulation of health care as it once did. The formation
in 1978 of the bipartisan Presidents Commission for the
Study of Ethical Problems in Medicine and Behavioral
Research was another significant change in the
relationship of government and medicine. The commission
formation occurred because of the questions arising from
the advancements of medicine and technology. These were
no longer just medical questions but questions that
required the attention of society (Abrams and Wolff,
1984). The fact that technologies could do new things
raised the question of whether they ought to be done.
These issues were raised in a public, not a medical,
context. The questions being asked were ethical, not
medical in nature (Cohen, 1986; Frohock, 1986; Califano,
1986; Fuchs, 1973). The solutions needed to reflect the
values of society and people in general not just the
values of physicians or other health care professionals
(Abrams and Wolff, 1984).


55
Another aspect is that, as a society, we became
disillusioned with the experts failure to solve
problems (DeSario and Langston, 1987). The
disillusionment began when the social problems of the
ghetto were still present after the major social
interventions of the Great Society (Murray, 1984).
Medicines inability to deliver the cure for cancer, as
it had promised to Americans, is identified as the start
of the disillusionment with medicine (Starr, 1982). The
experts had started a very slow decline in the power the
public was willing to allow them in the decision-making
process (DeSario and Langston, 1987). The consumer
movement of the late 1960s and 1970s put the
professionals and bureaucrats on notice (Starr, 1982;
DeSario and Langston, 1981). Public interest groups
forced hospitals to implement a bill of rights for
patients. Simultaneously unrest with government
processes occurred. People looked to consumer groups
that were able to mediate with the large structures of
government and business (Levin and Idler, 1981).
Experts, considered effective when making
technical decisions, were not as effective with value


56
decisions (DeSario and Langston, 1987). Science might
provide information useful to making a value decision,
but rarely is it the sole determinate (Mesthene, 1977).
Value decisions, or a mix of technical and value
decisions, involve the normative dimensions of "what
should be." The ethical problems discussed in intensive
care units today are a mixture of value and technology.
The question of whether and how we deploy these
technical wonders are value issues which scientists or
physicians have no particular providence over (DeSario
and Langston, 1987).
In a few short years, we have gone from
physicians telling the patient what is best for them, to
seeking informed consent for anything done to the
patient. The decisions that at one time concerned only
the patient and the physician can now be decisions that
allocate societal resources. The paradox of human
i
values of dignity, compassion, and service versus the
dedication towards the advancement of technology faces
the physician daily (Abrams and Wolff, 1984; Beauchamp
and Childress, 1982).


57
Public Opinion and Public Policy
A discussion of the role of public opinion in
public policy is important to this study. Determining
public opinion is a method of obtaining a reading on the
values, beliefs and expectations surrounding issues.
Public opinion was of little concern to the holders of
power or policy-makers before the ideological revolution
of the Eighteenth Century. The effects of the
equalitarian and majoritarian ideas of Locke, Rousseau,
and Jefferson expanded the political power base. The
authors of The Federalist Papers argue that all
government rests on opinion." David Hume (1972} states
that it is on opinion that government is founded.
Leiserson (1953) notes that public opinion has come to
refer to a secular idol, and is a "god-term" to which
citizens, scientists, and politicians alike pay
allegiance, partly as an act of faith, partly as matter
of observation, and partly as a condition of sanity.
Key (1964) reflects that to speak with precision about
public opinion is a task not unlike coming to grips with
the Holy Ghost! Machiavelli in Discourses declared a


58
wise man will not ignore public opinion in regards to
particular matters, such as the distribution of offices
and preferment."
Rousseau (1913) was one of the first modern
political thinkers to make an analysis of public
opinion. He felt that opinion had its origin in social
relationships. Many have written about public opinion,
but most have felt no need to define it. Though most
agree that the role of public opinion is important to
democratic government, their comments become less clear
when the role is discussed. By the end of the
Nineteenth Century, the importance of public opinion was
openly acknowledged by statesmen and politicians.
Woodrow Wilson (1887) in "The Study of Administration"
stated "wherever public opinion exists it must rule."
Weissberg (1976) states Americans accept that government
actions ought to bear some relationship to the
preferences of the public, today.
Popular influence in politics can be traced
back to early civilisations. In the United States, the
"voice of the people" is often celebrated as a perennial
source of political wisdom. The United States may lead


59
the world in ritualistic deference to public opinion
(Key, 1964; Bennett, 1980). Public opinion in any true
democratic sense must respect that the people and their
governmental leaders are distinct. The leaders do draw
their powers from a basic level of consent to social
structure and institutions (Wilson, 1983).
The idea of "public opinion" suggests a
collection of people who hold opinions on some issues.
Public opinion is a diverse and ever-changing form of
social expression. Opinion has roots in different
spheres of society it can take on different attributes
under diverse circumstances. The configuration of "the
public" changes constantly from one political situation
to another because the objects of opinion are many and
vary in magnitude (Bennett, 1980; Weissberg, 1976; Key,
1964; Hennessey, 1975).
Another view of public opinion is as an
unorganized process that goes through stages of
initiation and debate to reach recognizable collective
decisions on issues (Hennessey, 1975). Yet, another
approach taken by Key (1964) is to imagine that public
opinion emerges from a public consisting of individuals


60
and groups linked together by mass communication which
centers the attention on an issue, discusses and
deliberates, and in some mysterious way proceeds to a
decision. The public becomes a social group, different
from a mob yet not the same as a mass. Public opinion
then becomes a form of group thinking, and the process
bears an analogous relationship to the individuals
complete act of thought (Key, 1964).
Lowells (1954) approach restricted the term
public opinion. The view of the public on public
questions did not constitute public opinion. For a
"real" public opinion to exist, it had to be a community
opinion. Public opinion did not need to be a unanimous
opinion, but it should create an "obligation moral or
political for the minority" to submit to under certain
conditions. Lowell (1954) stressed that a consensus was
the basis for public opinion. Hennessey (1975) states
"public opinion is the complex of preferences expressed
by a significant number of persons on an issue of
general importance."
Hennessey (1975) accompanies his definition by
detailing five facts that are integral to the


61
understanding of public opinion. First, the presence of
an issue involving contemporary conflict can create
public opinion. A recognized group of people concerned
about the issues is a second fact. This is "the public"
of the public opinion. There are many publics, affected
by issues. Each issue creates its own public. Publics
tend to be transient, occasional, and issue-centered.
The third fact is the preferences of the public. The
public will divide itself in two or more different
points of view. Not all the points of view will be
contradictory or mutually exclusive (Hennessey, 1975).
The expression of opinion, a fourth fact, is
affected by the motivational strengths of the attitudes
involved and the rules of the social group. The
expression of opinion is also affected by available
media communications. The number of persons involved or
the size of the public is the fifth fact according to
Hennesseys definition. The size of the public does not
require that a majority of persons affected by the
issues hold an opinion on that issue, but, rather, the
success of those members to create or change preferences
of those not in the public (Hennessey, 1975).


62
The diversity in public opinion needs to be
evaluated by its saliency, stability, fluidity and
durability. Saliency is an aspect that changes over
time. Saliency means that people feel involved with
these issues, connected with them, and relevant to them.
The stability of opinions can vary. Generally, people
remain loyal to their groups, including political
parties, more than to issues or policies that they
cannot relate to those groups. The fluidity of the
attitude is another important aspect. Certain attitudes
can change dramatically. The durability of an opinion
is dependent largely on the saliency of the issue.
People vary in the fervency of their beliefs. Some will
be mildly in favor, other mildly opposed; still others
are fanatically for or against. Others will have no
interest in the matter at all. The variation of
intensity is important for political considerations and
public policy. Public opinion may merely exist as a
potential. The latent opinion often sets the boundaries
that attentive publics and political leaders must
operate. Latent opinion can be an opportunity or a
danger for political leaders. The distribution of the


63
opinion is a final quality of public opinion. The
extent to which opinions on certain issues are widely or
evenly distributed through the different sectors of the
public has major implications for public policy (Burns,
Peltason and Cronin, 1975).
The relationship between public opinion and
public policy is neither simple nor direct. There are
several approaches to describing the opinion-policy
linkage that answer the following questions. Are the
choices of policy-makers shaped or determined by public
opinion? Does public opinion serve as a decision
criteria? Public policy, like public opinion, means
different things to different people. The measurement
of public opinion is not the controlling feature in the
determination of public policy. Most policy decisions
by legislatures and by other authorities are made under
circumstances in which a very small number of the
general public have any awareness of the issues. The
legislator deciding how to vote is not generally
affected by public opinion. The legislator might try to
anticipate reaction of the public, but he or she has
great latitude because of this unawareness. The linkage


64
between public opinion and policy is weak (Bennett,
1980; Cnuddle and McCrone, 1966; Hiller and Stokes,
1963).
One approach to opinion-policy linkage is to
discuss the following two operational problems of
democratic practice: the majority-minority problem and
the direct-representative problem. Bennett, (1988)
points out that in a democratic process, whenever a
decision must be made, it becomes a dichotomy.
Therefore, in a democracy, those who decide policy must
produce a majority opinion.
The direct-representative problem imposes a
decision-making body between the electorate and public
policy. A majority-minority opinion is produced in the
legislature. The complex of views that make up public
opinions is difficult to represent in a legislative
body. In this model, it is possible that the
legislative majority opinion may not be the same as the
public majority of opinion. Effective opinion in an
representative democracy may be a minority coalition of
people and group opinions. Effective opinion turns on
the degree of participation, intensity of effort, and


65
efficiency- of organisation among people and groups who
constitute the involved public on any particular issue
(Hennessey, 1975; Dahl, 1958).
Weissbergs (1976) approach to opinion-policy
linkage views the possible relationships of public
opinion to public policy formation. The most obvious is
that all government actions would strictly adhere to
every public demand. Governing would occur by public
opinion in the most literal sense. Public officials
would have an independent activity. This model is
simple in form, but it would be difficult to find any
public willing to consider every issue and possible
policy direction (Weissberg, 1976).
A second point about linkage occurs in a
representative democracy. A more reasonable linkage is
allowing public preferences to provide broad guidelines
for government action, with officials operating within
those limits. The advantage of this linkage is that it
recognizes that the public is unable to provide clear
instructions and allows freedom of action to the
leaders. The difficulty with this approach is that the
public mandate can be so broadly constructed that it may


66
be impossible to violate (Weissberg, 1976). Schuman
(1986) states that legislators and public health
officials often want to know how people feel on this
issue; they tend to see survey research as a quasi-
referendum on the proposed solutions.
The third linkage between public opinion and
policy is in terms of leadership approval. The publics
approval on policy issues determines the support for the
leadership. This process works as long as the public
feels that the leadership is taking the correct action.
Approval results not from action but from the confidence
in the leaders representing the publics interest
(Weissberg, 1976). Elections provide a direct means of
registering public opinion. In referendums or
initiatives policies can be directly set. Most
elections select leaders and affirm public policy in
this method (Bennett, 1980).
A fourth link between public opinion and public
policy is after-the-fact approval. Before the decision,
the publics opinion would be irrelevant; and leaders
could do what they deem best. Once action was taken,
then public approval would be necessary; if approval was


67
not received then a new policy was implemented. The
problem with this model is that it can be manipulated.
To achieve opinion-policy congruence, all that needs to
occur is convincing a majority that the government
always did the right thing (Weissberg, 1976).
Bennett (1980) links opinion-policy in a
different way. He explores the linkage through
institutions. Institutions are the repositories of
national history, values, and political understandings.
The institutions process issues as they become
associated with themes or political methods that
institutions are empowered by law to protect. An
example is the court system, that, at times, takes
public concern into account in the indirect sense that
its decisions speak for "the people" on matters of broad
social concerns (Bennett, 1980). The institutions can
introduce political values, such as fairness, justice,
or due process, as happens in the judicial system.
Bennett (1980) explores the rituals as a part
of the opinion-policy link. Rituals are broad patterns
of behavior. They serve to link policies and other
outputs to endui'ing cultural themes, fairness, freedom,


68
justice, and equality. These themes are then presented
to the public. The publics response becomes
reaffirmation of the cultural rules. An example of this
occurs in the election process where candidates and
citizens behave in a way to express common concern about
the future.
Even if the public is not the moving force
behind policy, it is involved in at least the
legitimization of the process. The high degree of
support for institutions and consensus on policy are
characteristic of the American political system.
Even though at times, the linkage of public
opinion to public policy is difficult to identify, many
still feel that data are useful to policy-makers.
Public opinion data are useful. Truman (1945) outlined
the use of public opinion data for public
administrators.
Trumans (p. 62, 1945) thesis is "opinions are
facts." Whether widely held throughout the
body politic or insistently advanced by a
militant minority, they are realities of the
political process. Administrators and students
of administration ignore them at their peril.
Public opinion offered the following four
contributions to the field of administration:
the testing of hypothesis or providing data
upon which hypothesis and plans can be


69
developed; testing plans for a project;
evaluating the success of a continuing project;
and simplifying aspects of an operating
process.
Almost forty years later, Wilson (1983)
reviewed the use of citizen surveys in the management of
local governments. He concluded that leaders listen to
citizen preference in the policy process. Davidson
(1972) viewed public opinion survey research as a
component of the social communication network or system.
In this sense, public opinion research helps to inform
decision-makers, about current topics and behaviors in
all sectors of society. It is a feedback mechanism for
decision-makers, and it improves upward flow of
communication.
Rochefort and Boyer (1988) address directly the
issue of health care polls usage in public
administration. They identify two purposes of public
opinion polls: assessment and data gathering. The
assessment of the range of design, options, perceptions,
and probable response to changes is valuable to
administrators. The feedback from the data gathering
helps with the monitoring of design and the evaluation
of continuing program success. The polls clarify the


70
socio-political dimensions of administration and policy
making and the opportunities and constraints that these
provide (Rochefort and Boyer, 1988).
Aberbach and Rockman (1978) surveyed American
Federal Executives about their beliefs regarding the
role of the public. The researchers noted that
confusion exists on how to increase citizen
participation.
One reason for the confusion was the conflict
with other beliefs and commitments: the
commitment to administrative efficiency; the
belief that expertise is required to solve
complex problems and must be given autonomy
from public pressures if they are to perform
effectively in a pluralistic system, program
should be influenced by organized interest with
a 'responsible interest in the policy areas,
consideration of an amorphous 'public interest
' and inclusion of representatives of an ill-
defined 'community will lead to irresponsible
inputs and even uncontrollable conflicts
(Aberbach and Rockman, p.521, 1978).
The administrators surveyed had reservations
and opposition that supported the above theory of
Aberbach and Rockman. The reservation and opposition
centered in four major areas: citizens who became active
in citizen participation programs are often
unrepresentative of the publics they claim to be;


71
citizens who ai-e active will not be responsible
participants because they are not held accountable for
program failure; increase in citizen involvement will
hopelessly complicate an already complex and inefficient
policy process; and citizens lack the expertise to make
an useful contribution (Aberbach and Rockman, 1978).
Most of the executives surveyed did support some type of
involvement, if the above problems could be overcome.
Summary
The values of individuals, professions, and
society are important. Technological advancements and
the evolution of the role of experts and the public
provide an opportunity for evaluation of what our values
around health care issues are. The values of physicians
and public values are important aspects of the health
policy discussion.
Values are an important component of how
societies, people, and professionals define themselves
and relate to others. This study identifies opinions of
two groups on value issues in critical-care medicine.


72
The differences in opinions on value issues are
important to the policy process.
The discussion around the issues in critical
care medicine provides an opportunity to identify the
values of the public and physicians. The values
identified in this survey through the measurement of
opinion on medical ethical theories is important to the
public policy discussion. This survey does not propose
that one set of values are more important than the
other; but, rather public policy makers need to be aware
of both value approaches when defining the parameters of
public policy. This study compares and contrasts the
interested public and physicians. If opinions set the
parameters for public policy, the input of areas of
agreement and disagreement are important to the policy
process.
The following assumptions were made in doing
this study:
1. There are differences between public opinion
and physician opinion surrounding issues of maintaining
patient autonomy.


73
2. Thex'e are differences between public-
opinion and physician opinion surrounding the issues of
handicapped newborn treatment.
3. There are differences between public opinion
and physician opinion on values of beneficence.
4. There are differences between public opinion
and physician opinion on the matter of equitable
distribution of critical care medicine.
5. There are differences between public
opinion and physician opinion on issues of access to
critical care medicine.
6. There are differences between public
opinion and physician opinion on financing issues.
7. There are differences between public
opinion and physician opinion surrounding organ
transplants.
These assumptions are based on the premise that
a physician has different opinions and values than of
non-physicians.


CHAPTER THREE
RESEARCH METHODOLOGY
Overview
This study sought to identify the differences
and similarities between the opinions of the public and
physicians in Colorado on values central to medicines
ethical framework. The data on the public were
collected as a part of the Colorado Speaks Out On Health
Project (CSOOH)i funded in part by a Robert Wood Johnson
Foundation Grant. The purpose of CSOOH was to assess
the level of public awareness, the areas of concern and
the range of public opinion on ethical issues in
critical care medicine in Colorado, to educate and
inform Colorado Citizens in bioethics and critical care
medicine; to gather and publish this information in an
open, unbiased format useful to public and private
agencies; and to establish a network that might
strengthen communication between public, the experts,
and the policy-makers (Abrams et all, 1988).
i Appendix A contains the grant proposal for CSOOH.


75
The physician survey was conducted by the
Center for Ethics and Health Policy at the University of
Colorado at Denver, Graduate School of Public Affairs.2
The Center for Ethics and Health Policy conducted the
survey because it was felt that policy-makers and
citizens needed to know doctors opinions about life-
sustaining treatment. The Center hoped to initiate
rigorous public/private sector dialogue in Colorado
about these opinions and issues (Abrams and Gee, 1988).
This chapter presents the methods used in
gathering and analyzing the data from these two surveys.
First, sample design and a description of the
respondents in each sample is discussed. Second, a
discussion of the selection and classification of
question-statements is included. The method of analysis
concludes the chapter.
2 Appendix B contains a description of the Center
for Ethics and Health Policy.


76
Population and Sample
The sample for this research consisted of 5,855
public respondents and 2,218 physicians from the State
of Colorado. The public respondents are from the CSOOH
project which had a total of 7,431 respondents. The
5,855 respondents were selected to be a part of this
study because they could be identified on the
questionnaire as individuals whose occupation were not
in health-related fields.
A non-random design was utilized in the CSOOH
project because of the project design. First, the
primary goal was to inform and to educate Colorado
citizens on critical care medical issues and the ethical
questions that surrounded each issues. Second, it was
determined at the outset that the program would be
administered primarily through civic organisations, thus
pre-selecting citizens already involved in community
activities. Utilizing existing groups rather than
calling public meetings was felt to be more efficient.
Traditionally, two methods are usually used for
attaining citizen input, public meetings and surveys.
Public meetings are usually plagued by low attendance


77
and, at times, when controversial issues are discussed a
few dissidents who do not represent anyone other than
themselves can dominate the process.
As previously mentioned, the primary method of
date collection was through meetings. The meetings were
structured to first have each group view a videotape
addressing three primary areas of medical-ethical
concern: the right to die; organ donation; and the care
of the critically ill or severely handicapped newborn.
The participants were then asked to fill out the
questionnaire. Once this was complete a discussion
usually occurred if time permitted. A second method of
administration was attempted by placing questionnaires,
along with self-addressed, stamped envelopes in public

places, such as shopping centers, and the Colorado State
Fair. The data from these questionnaires was not
included in this study.
Facilitators for the meetings were trained by
members of the executive committee in meetings held
throughout the state. More than four hundred business,
religious, civic, charitable, professional and education


78
groups were visited in a two year period (Abrams et al,
1988). The coordination of the meetings and
facilitators was handled by the staff for CSOOH.
The physician survey was mailed out to all
7,095 physicians licensed in Colorado in 1988. The
sample of 2,218 physicians represents those who
responded which was 31.2% of the licensed physicians.
Characteristics of the Sample
Public
Table 3.1 presents the demographics of the
public portion of the sample used in this study as
discussed above, a total of 5,855 persons completed the
survey instrument. Some of the questionnaires were only
partially completed; therefore, in some cases totals
will not always add to a 5,855. Two thousand and
ninety-two respondents were men and 3,689 were women.
The range in age was from 11 years of age to 96 years of
age. The mean age was 45 years. Seven hundred and 3
3 Appendix C contains a sample listing of groups.


79
TABLE 3.1
Demographics of Public Respondents3
VARIABLES FREQUENCY PERCENTAGE
AGE
under 18 740 13.0%
18-30 721 12.7%
31-64 3045 53.7%
65 and over 1166 20.6%
SEX
Male 2092 36.1%
Female 3698 63.9%
Marital Status
Married 3076 53.4%
Single, never married 1561 27.1%
Single, divorced 541 9.4%
Single, widowed 580 10.0%
Number in Household
0 843 16.9%
1 1159 23.2%
2 1246 24.9%
3 655 13.1%
4 700 14.0%
5 275 5.5%
6 73 1.5%
7 24 . 5%
over 7 25 .9%
Religion Affiliation
Protestant 2973 52.3%
Catholic 1481 26.1%
Jewish 165 2.9%
Moslem 9 . 2%
Latter Day Saints 102 1.8%
Other 952 16.8%
3 The percentages have been rounded off to the
nearest tenth.


80
TABLE 3.1 cont.
Educational Level
High School/Vocational 1726 30.7%
College, 2 years 997 17.8%
College, 4 years 1598 28.5%
Masters Degree 800 14.3%
Doctorate/Professional Degree 493 8.8%
Income
Under $5,500 473 8.1%
$5,501- $11,000 474 8.8%
$ll,001-$25,000 1089 20.2%
$25,001-$50,000 1883 34.9%
$50,001-$75,000 911 16.9%
$75,001 and over 598 11.1%
Ethnic
Black 147 2.6%
White 5014 87.0%
Native American 121 2.1%
Hispanic 288 5.0%
Asian 59 1.0%
Other 131 2.3%
Occupational
Professional 2116 37.7%
Technical 163 2.9%
Manager/Administrator 518 9.2%
Sales 221 3.9%
Clerical 228 4.1%
Craftsman/Foreman 41 . 7%
Laborer (exc. farm) 47 .8%
Farm Work 23 .4%
Service Work 144 2.6%
Transport Equip Worker 7 .1%
Operator (exc. transport) 13 .2%
Not employed outside home 540 9.6%
Student 953 17.0%
Other 602 10


81
forty of the respondents were under the age of 18.
Seven hundred and twenty-one were 18 to 30 years of age;
3.045 were in the 31 to 64 age group. The remaining
1,066 were 65 and over.
Fifty-three and four tenths percent of the
respondents were married; 27.1 percent were single.
Nine and four tenths percent were divorced and 10
percent were widowed.
When asked religious affiliation, 52.3 percent
of the respondents indicated that they were Protestant;
and 26.1 percent were Catholic. Two and nine tenths
percent were Jewish. Two tenths of a percent were
Moslem; and one and eight tenths percent were Latter Day
Saints. Sixteen and eight tenths percent indicated
other.
The educational breakdown of the sample
follows. Thirty and seven tenths percent indicted that
they had a high school or vocational diploma; 17.8
percent had two years of college; 28.5 percent selected
the category "four years of college''. Fourteen and
three tenths percent selected masters, and 8.8 percent
indicated a doctorate or professional degree.


82
Combined household income was collected in
ranges. Eight and one tenth percent of the respondents
selected the category of under $5,500. Eight and eight
tenths percent indicated their level of household income
was between $5,501 and $11,000. Twenty and two tenths
percent were in the range of $11,001 and $25,000. The
next range of $25,001 and $50,000 was selected by 34.9
percent of the respondents. Sixteen and nine tenths
percent of the respondents earned between $50,001 and
$75,000. Eleven and one tenth percent of the
respondents earned over $75,000.
The ethnic background of the public sample
follows. Two and six tenths percent of the respondents
were black. Eighty-seven percent were white. Two and
one tenth percent of the respondents were Native
Americans. Five percent were Hispanics, and one percent
was Asian. Two percent selected other.
The occupational breakdown for the sample
included 37.7 percent of the respondents selecting the
category of professional. Two and nine tenths percent
selected the technical category. Nine and two tenths
percent indicated they were managers or administrators.


83
Three and nine tenths percent were in sales. Four and
one tenth percent selected the clerical category.
Craftsman, laborer, farm work, service work, transport
equipment worker--all were under three percent. Nine
and six tenths percent indicated that they did not work
outside the home. Seventeen percent were students. Ten
and seven tenths percent selected other.
When demographics of the public sample are
compared with the demographics from Colorado collected
during the 1980 census, the public sample has a higher
proportion of women respondents than the population.
The breakdown of the public sample found 87 percent of
the respondents indicating they were white and the
remaining 13 percent indicating they were a minority.
The breakdown for Colorado was 83.3 percent white and
16.7 percent minority in 1980. Older citizens are
represented more heavily in the public sample than
younger citizens. The remaining demographic variables
were not collected in equivalent catagories, which makes
comparison difficult.


84
Physician Respondents
As discussed earlier, 2,218 physicians
responded to a mailed survey instrument which was sent
to all 7,095 physicians registered in the State of
Colorado in 1988. The response rate was 31.3 percent.
The age range was 25 years of age to 87 years of age.
The mean age was 43.5 years.
Seventeen and two tenths percent of the
physician respondents were under the age of 35. Thirty-
four and seven tenths percent were in the age bracket of
35 to 44 years. Twenty-one and nine tenths percent fell
into the age bracket of 45 to 54 years. Fifteen and
three tenths percent were in the age bracket of 55 to 64
years. The rest, 7.7 percent were 65 and over.
Fifty-four and three tenths percent of the
respondents indicated that they were Protestant, and
17.7 percent indicated that they were Catholic.
Thirteen and four tenths percent indicated they were
Jewish. The representation of Moslem and Latter Day
Saints was less than 1 percent, and 13.6 percent
indicated other affiliation.


85
TABLE 3.2
Demographics of Physician Respondents*
VARIABLES FREQUENCY PERCENTAGE
AGE
under 35 381 17.2%
35 to 44 770 34.7%
45 to 54 486 21.9%
55 to 64 340 15.3%
65 and over 171 7.7%
RELIGION AFFILIATION
Protestant 1089 54.3%
Catholic 354 17.7%
Jewish 269 13.4%
Moslem 2 . 1%
Latter Day Saints 18 .9%
Other 213 13.6%
CLINICAL SPECIALTY
Family Practice 482 21.7%
Internal Medicine 364 16.9%
Psychiatry 188 8.8%
Pediatrics 183 8.3%
General Surgery 174 8.1%
Obstetrics/Gyn 139 6.4%
Anesthesiology 76 3.4%
Emergency Medicine 74 3.3%
Radiology 60 2.8%
Orthopedics 54 2.4%
Pathology 50 2.3%
Opthamology 49 2.3%
Neurology 39 1.8%
Pulmonary 31 1.4%
Cardiology 30 1.4%
No specialties 26 1.2%
Otolaryngology 24 1.1%
Oncology 23 1.1%
* The percentages have been rounded off to the
nearest tenth.


86
TABLE 3.2 Cont.
Urology 22 1.0%
Dermatology 21 1.0%
Occupational Medicine 20 .9%
Preventive Medicine 14 .6%
Gerontology 9 .4%
Endocrinology 6 . 3%
Neonatology 6 .3%
Hematology 4 .2%
Infectious Disease 3 .1%
Osteopathic Medicine 2 .1%
YEAR OF GRADUATION
1930-39 64 2.9%
1940-49 195 8.8%
1950-59 359 16.2%
1960-69 506 22.0%
1970-79 694 31.3%
1980-87 428 19.3%
The specialty of family practice was selected
by 21.7 percent of the respondents. Internal medicine
as a specialty was indicated by 16.9 percent of the
respondents. Psychiatry, pediatrics, general surgery,
and obstetrics and gynecology specialties were
represented by between 6 percent and 8 percent of the
sample. The other specialties consisted of less than 4
percent in the sample. Table 3.2 presents these
descriptive data from the physician sample. The age of
physicians in this sample closely represents the age


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breakdowns found in similar surveys by the Colorado
Health Department. The specialty designates were not
equivalent to other surveys.
Selection of Question Statements
The 18 forced-choice question-statements
included in both survey instruments are the focus of
this study. The statements were designed to seek
opinion on values in medical ethics which occur in the
critical care medical setting. The questions can be
categorised by values that are addressed in the
statement and by the clinical area to which the
statement addressed. As discussed in Chapter Two, the
areas that the questions explored in relationship to
medical values were autonomy, beneficence, and justice.
The clinical areas addressed were issues pertaining to
handicapped newborns and organ transplant issues.
The scale used to measure opinions was a five-
point Likert scale. The five points were labeled
strongly agree, agree, no feelings one way or another,
disagree, and strongly disagree. The question-


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statements were pretested along with the demographic
questions with over 400 people, including medical
professionals and members of the general public, to
refine and clarify the statements.
Autonomy
The question-statements pertaining to autonomy
were designed to determine the opinions of the public on
the desire to know the truth about their condition and
the desire to make their own decisions about their
treatment.
The physician question-statement wording was
adjusted to seek their opinions on the clients
autonomy, not the physicians autonomy. The statements
used to evaluate opinions on autonomy follow.