The right to conscientious objection in the provision of healthcare is the subject of a lengthy, heated and controversial debate. Recently, a new dimension was added to this debate by the US Supreme Court's decision in Burwell vs. Hobby Lobby et al. which effectively granted rights to freedom of conscience to private, for-profit corporations. In light of this paradigm shift, we examine one of the most contentious points within this debate, the impact of granting conscience exemptions to (...) class='Hi'>healthcare providers on the ability of women to enjoy their rights to reproductive autonomy. We argue that the exemptions demanded by objecting healthcare providers cannot be justified on the liberal, pluralist grounds on which they are based, and impose unjustifiable costs on both individual persons, and society as a whole. In doing so, we draw attention to a worrying trend in healthcare policy in Europe and the United States to undermine women's rights to reproductive autonomy by prioritizing the rights of ideologically motivated service providers to an unjustifiably broad form of freedom of conscience. (shrink)

Human and veterinary medicine have many commonalities. The split into distinct disciplines occurred at different times in different places. In Europe, the establishment of the first veterinary universities towards the end of the 18th century was triggered by ravaging rinderpest epidemics and the increasing importance of livestock for draft, food supply, and war fare. Given this background, would it make sense to combine human, animal, traditional and modern medicine in healthcare provision, especially in less developed countries? Such a (...) “one-medicine” approach could enhance biomedical progress, improve the outreach of medical and veterinary services especially in remote areas, offer greater choices to patients, and make healthcare more culturally appropriate. On the other hand, it would require generalists rather than specialists and rare diseases may go unrecognized. The commonalities of human and veterinary medicine and the financial constraints many governments are presently facing are arguments in favor of a “one-medicine” approach, while status thinking, education systems, administrative structures, and legislations hinder its implementation. There are no instant recommendations for the application of one medicine but governments and development professionals need to generate fine-tuned, location-specific healthcare solutions. Advocacy, changes in education and training, the creation of institutional linkages, and the removal of legal barriers could help overcome obstacles. (shrink)

(No abstract is available for this citation).

Primary care givers commonly interpret shortages of time with patients as placing them between a rock and a hard place in respect of their professional obligations to fairly distribute available healthcare resources (justice) and to offer a quality of attentive care appropriate to patients’ states of personal vulnerability (compassion). The author argues that this a false and highly misleading conceptualisation of the basic structure of the ethical dilemma raised by the rationing of time in clinical settings. Drawing on an (...) analysis of the Aristotelian virtue of nemesis, or “the sense of justice”, it is argued that, far from being a moral orientation distinct from justice, compassion is a justice response insofar as it is conceptualised as a rational, appropriate response to others’ adversity. The author then proceeds to point out that the perspective on justice and compassion as attributes of healthcare professionalism suggests a novel critical viewpoint on the ethics of managed forms of clinical rationing and the “scarcity paradigm” they engender: clinical conditions where primary care givers’ time is intentionally rendered a commodity in chronically short supply run a deficit of justice, because they fail to make adequate accommodations for the provision of the quality of care human beings deserve in situations of illness and injury, and when they are dying. (shrink)

Both healthcare professionals and the healthcare system must defend each patient's health individually while simultaneously seeking to protect the population's health in general. Nowadays, there is an important increase in the cost of healthcare supply, mainly due to the developments of medical science, the public's expectations and the demographic ageing. Since healthcare resources are not unlimited, it is obvious that immoderate consumption of them by certain patients limits the use of the same funds by others. Therefore, (...) we have to seek an optimal distribution of the existing resources in order to manage a constriction of expenses, especially under the circumstances of the modern economic crisis. The criteria of effectiveness and efficiency should be used. Health policies focus on both the public's behaviour and the rules of medical practice. Under the modern challenges the physician's role is particularly important for the protection of the patient's health and the promotion of public health. (shrink)

Private medical aids are essentially non-profit organisations that aim to deliver speedy treatment and should prevent members from unexpected, out of pocket expenses for medical care. However, although the latest statistics show that 16.2% of individuals in South Africa were members of medical aid schemes, making the promise of private healthcare accessible to a small percentage of the population, they are not without their own unique set of challenges. The restrictions that exist within the private sector have a direct (...) bearing on the types of healthcare services patients can access, which in turn impacts on the fundamental right to access healthcare. Using a recent High Court Case decision, this article seeks to explore whether there is justice in the provision of healthcare services, specifically within the private sector in South Africa. (shrink)

Familial disclosure of genetic information is an important, long-standing ethical issue that still gives rise to much debate. In France, recent legislation has created an innovative and unprecedented procedure that allows healthcare professionals (HCPs), under certain conditions, to disclose relevant information to relatives of a person carrying a deleterious genetic mutation. This article will analyse how HCPs in two medical genetics clinics have reacted to these new legal provisions and show how their reticence to inform the patients’ relatives on (...) their behalf leads them to use this option sparingly. (shrink)

Delivering healthcare to undocumented migrants presents a complex challenge for healthcare providers. Integrating advocacy efforts into their daily practices can be ambiguous in practical terms, stemming from the intricate task of addressing the health needs of this population while simultaneously advocating for their health rights within the constraints imposed on them. This study seeks to consolidate findings from literature regarding the advocacy approaches employed by healthcare providers and the correlated ethical challenges. We conducted a scoping review of (...) qualitative literature by systematically searching four databases—PubMed/Medline, Embase, Cinahl, and Cochrane Library. For developing our search strategy, we employed the PICO (Population, Intervention, Comparison, Outcome) scheme. Our analysis followed the qualitative content analysis approach proposed by Graneheim and Lundman. 30 studies were included, revealing a cumulative total of 915 healthcare providers who were interviewed. A total of 30 themes emerged comprising 14 advocacy approaches and 16 ethical challenges. Healthcare providers made a deliberate choice to engage in advocacy, responding to injustices experienced by undocumented migrants. The spectrum of advocacy initiatives varied, encompassing voluntary participation in healthcare provision, empathetic understanding, and healthcare-focused strategies. We also identified numerous correlated ethical challenges, necessitating healthcare providers to strike a balance between their eagerness to assist and their professional competence, respect the autonomy of undocumented migrants, and establish trust with them. These findings not only offer practical guidance for healthcare providers to enhance accessibility to healthcare services for undocumented migrant patients but also foster awareness of the ethical challenges that may arise in their advocacy roles. (shrink)

Medical electives have long been part of the undergraduate curriculum, and many students choose to undertake a placement in a developing country. In countries where healthcare provision is hugely underresourced, students have found themselves under pressure to exceed their role. They have been expected to diagnose and treat patients without direct supervision from a qualified doctor. Some have found themselves running clinics and wards; others have found themselves to be the most qualified person available.1,2The British Medical Journal believes (...) students should not take on the role of a qualified doctor, “irrespective of any encouragement which students may receive from members of the host organisations to which they are attached”.3 This includes not diagnosing, prescribing, or treating any patient without strict clinical supervision. They feel that students fail to appreciate the dangers of treatment, particularly where familiar medical problems are complicated by unfamiliar poverty. Their deontological view is saying that students should treat their work …. (shrink)

Our national Minister of Health, Dr Aaron Motsoaledi, described publicly the challenges facing our healthcare system and discussed the national and provincial measures that are being implemented to allow all South Africans to obtain quality healthcare. One would then certainly argue that the issue of quality healthcare has been debated to its ultimate exhaustion, but at what point do we begin to be silent about pertinent issues, especially those affecting the livelihood of a whole nation? This paper (...) addresses many of the issues highlighted above; it attempts to define what quality healthcare is, in the South African context, and its relationship to the branch of bioethics. It cites current views on ethics and rights in healthcare and the role of individuals and healthcare professionals in improving the provision of healthcare in our country. (shrink)

While there is a prolific debate surrounding the issue of conscientious objection of individuals towards performing certain clinical acts, this debate ignores the fact that there are other reasons why clinicians might wish to object providing specific services. This paper briefly discusses the idea that healthcare workers might object to providing specific services because they are against their professional judgement, they want to maintain a specific reputation, or they have pragmatic reasons. Reputation here is not simply understood as being (...) in good standing with a professional body. Rather, reputation is treated in the sense that a craftsman might wish to be known for providing a specific type, quality, and style of service. Professionalism is understood as acting according to the philosophical and scientific principles that are the basis of healthcare (such as acting for the benefit of the patient’s health and following well- evidenced treatment pathways). (shrink)

In Japan, few studies and ethical debates have addressed medical futility, but articles suggesting the practice of such treatment exist. The present study aimed to explore attitudes about this by examining personal practical experiences of those who have been involved in judging treatments as futile. We employed a qualitative descriptive design with content analysis of semi-structured and focus group interviews with 11 Japanese physicians and 9 nurses of a university hospital in Japan. The interviews mined their practical experience to identify (...) why they provided treatment that was regarded futile, factors for determining futility, and attitudes toward foregoing futile treatments. All participants had provided treatments judged as futile for various reasons, such as patient request, inadequate decision-making processes, request from another physician, and the lack of standards with which to judge futility, among others. In addition to medical science factors , participants also considered non-medical science factors to determine if a treatment was futile. Almost all participants agreed that futility should be defined and that such treatments should be foregone, but they did not take a proactive stance towards this due to factors related to the healthcare worker‟s situation or the patient. Although the implications of the present study are somewhat limited, our results indicate that futile treatments are provided at multiple treatment departments. Health-care workers employ a variety of factors to determine futility, including non-medical science factors. As provision of such treatment is not always performed for reasons of patient autonomy, diverse approaches should be employed to cope with situations regarding futile treatments. (shrink)

This paper examines the law relating to healthcare resource allocation in England. The National Health Service Act 1977 does not impose an absolute duty to provide specified healthcare services. The courts will only interfere with a resource allocation decision made by an NHS body if that decision is frankly irrational is engaged). Such irrationality is very difficult to establish. The ECHR has made no significant contribution to domestic English law in the arena of healthcare provision. The (...) decision of the European Court in the Yvonne Watts case establishes that, in relation to the question of entitlement to seek treatment abroad at the expense of the NHS, a clinical judgment about the urgency of treatment trumps an administrative decision about waiting list targets. That decision goes against the grain of domestic law about healthcare allocation, but is not likely to have wide ramifications in domestic law. (shrink)

Healthcare provision, like many other sectors of society, is undergoing major changes due to the increased use of data-driven methods and technologies. This increased reliance on big data in medicine can lead to shifts in the norms that guide healthcare providers and patients. Continuous critical normative reflection is called for to track such potential changes. This article presents the results of an interview-based study with 20 German and Swiss experts from the fields of medicine, life science research, (...) informatics and humanities of digitalisation. The aim of the study was to explore expert opinions regarding current challenges and opportunities related to data-driven medicine and medical research and to provide a methodological framework for empirically grounded, continuous normative reflection. To this end, we developed a heuristic tool to map and structure empirical findings for normative analysis. Using this tool, our interview material points to a polarisation between individualistic and collectivistic orientated argumentations among experts. The study shows that a multilevel analysis is required to deal with complex normative implications of data-driven approaches in medical research and healthcare. (shrink)

Despite significant progress in the legalization and decriminalization of abortion in Australia over the past decade or more recent research and government reports have made it clear that problems with the provision of services remain. This essay examines such issues and sets forth the view that such issues can and should be seen as (bio)ethical concerns. Whilst conscientious objection—the right to opt-out of provision on the basis of clear ethical reservations—is a legally and morally permissible stance that (...) class='Hi'>healthcare professionals can adopt, this does not mean those working in healthcare can simply elect not to be providers absent a clear ethical rationale. Furthermore, simple non-provision would seem to contravene the basic tenants of medical professionalism as well as the oft raised claims of the healthcare professions to put the needs of patients first. Recognizing that much of the progress that has been made over the past three decades can be attributed to the efforts of dedicated healthcare professionals who have dedicated their careers to meeting the profession’s collective responsibilities in this area of women’s health and reproductive healthcare, this paper frames the matter as a collective ethical lapse on the part of healthcare professionals, the healthcare professions and those involved in the management of healthcare institutions. Whilst also acknowledging that a range of complex factors have led to the present situation, that a variety of steps need to be taken to ensure the proper delivery of services that are comprehensive, and that there has been an absence of critical commentary and analysis of this topic by bioethicists, I conclude that there is a need to (re)assess the provision of abortion in Australia at all levels of service delivery and for the healthcare professions and healthcare professionals to take lead in doing so. That this ought to be done is clearly implied by the healthcare profession’s longstanding commitment to prioritizing the needs of patient over their own interests. (shrink)

One of the most prevalent rationales for public healthcare policies is a human right to healthcare. Governments are the typical duty-bearers, but they differ vastly in their capacity to help those vulnerable to serious health problems and those with severe disabilities. A right to healthcare is out of the reach of many developing economies that struggle to provide the most basic services to their citizens. If human rights to provision of such goods exist, then governments would (...) be violating rights without doing anything wrong. I argue that such variable ability to provide healthcare depends not only on financial resources, but on institutional capacity, and that the latter represents a more fundamental challenge to the existence of a human right to healthcare than previously recognized. This challenge does not imply that government has no obligations to protect and improve the health of their citizens, but that it is best to think of such obligations as generated by conventional rights, namely rights arising from local legal and social conventions, which require governments to pursue health-related moral goals such as reducing suffering, closing opportunity gaps for the disadvantaged, and preventing the spread of contagious diseases. We need not think of such moral goals in terms of human rights. (shrink)

One fundamental healthcare issue brought to the fore by the current COVID-19 pandemic concerns the scope and nature of the right to healthcare. Given our increasing need for the usually limited healthcare resources, to what extent can we demand provision of these resources as a matter of right? One philosophical way of handling this issue is to clarify the nature of this right. Using the challenges of COVID-19 in the Philippines as the context of analysis, we (...) argue for the view that regards the right to healthcare as fundamentally moral in kind, which should thereby guide its legal and contractual appropriations. In particular, we respond to objections against this view stemming from issues concerning the universality and satisfiability of the right’s correlative duty. We deal with such issues by invoking the relative degree of incumbency of moral rights and the capability-relativity of positive duties. We further contend that as these factors define the scope of the moral right to healthcare, they thus constrain what we can demand as a matter of right to meet our healthcare needs in this time of the pandemic. (shrink)

Healthcare delivery and access, both in the United States and globally, were negatively affected during the entirety of the COVID-19 pandemic. This was particularly true during the first year when countries grappled with high rates of illness and implemented non-pharmaceutical interventions such as stay-at-home orders. Among children with special healthcare needs, research from the United Kingdom (U.K.) has shown that the pandemic response uniquely impacted various aspects of their care, including decreased access to care, delays in diagnosis, and (...) poorer chronic disease control. In response to these findings, and to begin to comprehend whether the concerning findings from the nationalized system of healthcare in the U.K. extend to the highly dissimilar United States (U.S.) healthcare context, we reviewed the literature on alterations in access to and delivery of care during the early stages of the COVID-19 pandemic for children with special healthcare needs in the U.S. We then utilize these findings to consider the ethical and policy considerations of alterations in healthcare provision during pandemics and crisis events in the U.K. and U.S. and make recommendations regarding how the needs of CSHCN should be considered during future responses. (shrink)

Conscientious objection was barely mentioned in debates about the ethics of healthcare provision before the 1970s.1 The conscientious objections that attracted public and academic attention were those of conscripts who objected to participation in military forces, and of parents who objected to the vaccination of their children. All of this was changed by the 1973 US Supreme Court decision Roe v. Wade, which established a constitutional right to abortion in the USA. Shortly after this decision, the American Medical (...) Association's (AMA) House of Delegates, the peak policy-making body within the AMA, adopted a resolution that sought to protect hospital employees from having to contribute to the provision of abortion if they felt that doing so was immoral. The resolution was adopted in response to a specific controversial court decision, but the language employed in it was broad in scope. House of Delegates Health Policy 5.995 contained a conscience clause stating that ‘Neither physician, hospital, …. (shrink)

This paper proposes a refocusing of consent for clinical genetic testing, moving away from an emphasis on autonomy and information provision, towards an emphasis on the virtues of healthcare professionals seeking consent, and the relationships they construct with their patients. We draw on focus groups with UK healthcare professionals working in the field of clinical genetics, as well as in-depth interviews with patients who have sought genetic testing in the UK’s National Health Service. We explore two aspects (...) of consent: first, how healthcare professionals consider the act of ‘consenting’ patients; and second how these professional accounts, along with the accounts of patients, deepen our understanding of the consent process. Our findings suggest that while healthcare professionals working in genetic medicine put much effort into ensuring patients’ understanding about their impending genetic test, they acknowledge, and we show, that patients can still leave genetic consultations relatively uninformed. Moreover, we show how placing emphasis on the informational aspect of genetic testing is not always reflective of, or valuable to, patients’ decision-making. Rather, decision-making is socially contextualised – also based on factors outside of information provision. A more collaborative on-going consent process, grounded in virtue ethics and values of honesty, openness and trustworthiness, is proposed. (shrink)

Background: Ethical issues are increasingly being reported by care-providers; however, little is known about the nature of these issues within the nursing home. Ethical issues are unavoidable in healthcare and can result in opportunities for improving work and care conditions; however, they are also associated with detrimental outcomes including staff burnout and moral distress. Objectives: The purpose of this review was to identify prior research which focuses on ethical issues in the nursing home and to explore staffs’ experiences of (...) ethical issues. Methods: Using a systematic approach based on Aveyard (2014), a literature review was conducted which focused on ethical and moral issues, nurses and nursing assistants, and the nursing home. Findings: The most salient themes identified in the review included clashing ethical principles, issues related to communication, lack of resources and quality of care provision. The review also identified solutions for overcoming the ethical issues that were identified and revealed the definitional challenges that permeate this area of work. Conclusions: The review highlighted a need for improved ethics education for care-providers. (shrink)

Geographical variations are documented for a wide range of health care services. As many such variations cannot be explained by demographical or epidemiological differences, they are problematic with respect to distributive justice, quality of care, and health policy. Despite much attention, geographical variations prevail. One reason for this can be that the ethical issues of geographical variations are rarely addressed explicitly. Accordingly, the objective of this article is to analyse the ethical aspects of geographical variations in the provision of (...) health services. Applying a principlist approach the article identifies and addresses four specific ethical issues: injustice, harm, lack of beneficence, and paternalism. Then it investigates the normative leap from the description of geographical variations to the prescription of right care. Lastly, the article argues that professional approaches such as developing guidelines, checklists, appropriateness criteria, and standards of care are important measures when addressing geographical variations, but that such efforts should be accompanied and supported by ethical analysis. Hence, geographical variations are not only a healthcare provision, management, or a policy making problem, but an ethical one. Addressing the ethical issues with geographical variations is key for handling this crucial problem in the provision of health services. (shrink)

All over Europe, the provision of healthcare services is widely considered a primary duty of the government. Universal access to medical care can be considered a basic ingredient of the so-called “European social model.” But if universal access to medical care is seldom questioned, European governments—faced with expanding costs caused by an increasing demand driven by an aging population and technology-driven improvements—are contemplating the possibility of “rationing”1 treatments, or the possibility of allowing a greater role for private suppliers. (...) If a “multi-tier” healthcare system has long been anathema to the European leadership, guaranteeing a uniform access to state-of-the-art care seems to be well beyond the means of states suffering from persisting debt crisis. Was the failure of state-controlled “adequate” healthcare totally unpredictable? Far-sighted criticisms had been offered by two eminent thinkers in the classical liberal tradition, Herbert Spencer and Friedrich A. von Hayek . Neither author is usually recognized as a forerunner of contemporary critics of the welfare state, and both investigated the issue of the state financing and providing health services well before or right after the establishment of national health services. With the benefit of hindsight, reading Spencer and Hayek helps us to understand how the crisis of state-supplied healthcare is not rooted in the mere progress of clinical technology, but is rather the logical consequence of the theoretical basis of the model itself. Whereas modern theorists of the welfare state tend to offer theories that are impervious to a critical appraisal of their unintended consequences—insofar as they are framed in a language of “rights”—both Hayek and Spencer understood that human systems are complex, and that unwanted effects of public policy should be taken into account. Although Spencer emphasized the moral hazards accruing from the paternalism involved in governmental provision of health services, Hayek explained how modern healthcare systems differ from real, private insurance designed to offer proper coverage against risks. These authors appreciated that the politicization of healthcare was bound to result in both standardization of care and disregard for the responsibility that comes with personal freedom. These two “diagnoses before the illness” can help us in defining the challenges and the potential solutions that healthcare systems face today. Understanding the fatal conceits inherent in the very architecture of national health services can be the first step toward healing our healthcare systems. (shrink)

Contemporary realities of global population movement increasingly bring to the fore the challenge of quality and equitable health provision across language barriers. While this linguistic challenge is not unique to immigration contexts and is likewise shared by health systems responding to the needs of aboriginal peoples and other historical linguistic minorities, the expanding multilingual landscape of receiving societies renders this challenge even more critical, owing to limited or even non‐existing familiarity of modern and often monolingual health systems with the (...) particular needs of new linguistic minorities. The centrality of language to health beliefs, attitudes, practices, cultural scripts, and conceptual frameworks emphasizes its pivotal role in the healthcare process, and consequently in the adverse effects of treatment that is language‐insensitive and unaware. Such an attitude on the part of medical authorities risks considerable epistemic injustice in the form of a (mis)judgement of patients’ intelligence, credibility, and rationality based on the language that they speak and the manner in which they speak it, consequently impacting the quality and equity of care provided. This danger, I argue, may be effectively countered by fostering among the participants in the healthcare process a sense of epistemic humility through greater metalinguistic awareness. Outlining a range of operative steps that can be used to facilitate this. I argue that the reality of language barriers in the healthcare process, while not entirely eliminable, may nevertheless be successfully addressed, in order to mitigate the challenge of quality and equitable healthcare provision in multilingual societies. (shrink)

This article sets out the moral failure of single-tier basic healthcare. Single-tier basic healthcare has been advocated on the grounds that the provision of healthcare should be divorced from ability to pay and unequal access to basic healthcare is morally intolerable. However, single-tier basic healthcare encounters a host of catastrophic moral failings. Given the fact of human pluralism it is impossible to objectively define “basic” healthcare. Attempts to provide single-tier healthcare therefore become (...) political processes in which interest groups compete for control of scarce resources with the most privileged possessing an inherent advantage. The focus on outputs in arguments for single-tier provision neglects the question of justice between individuals when some people provide resources for others without reciprocal benefits. The principle that only healthcare that can be provided to everyone should be provided at all leads to a leveling-down problem in which advocates of single-tier provision must prefer a situation where some individuals are made worse-off without any individual being made better-off compared to plausible multi-tier alternatives. Contemporary single-tier systems require the exclusion of noncitizens, meaning that their universalism is a myth. In the light of these pathologies, it is judged that multi-tier healthcare is morally required. (shrink)

This article explores the very limited cases historically in the twentieth century when human rights was used in American policy debate as a defending principle for the provision of government-guaranteed universal healthcare. It discusses these cases and examines various reasons as to why this is so, noting the major emphasis in American political culture on negative rather than positive liberty. It examines the shift in political culture from the Roosevelt, Truman, and Johnson eras that embraced social and economic (...) rights and defined them as such to the post-Reagan era when conservative ideologies were ascendant. These ideologies reject the legitimacy of social and economic rights and remain dominant in the United States. It comparatively situates the American refusal to consider universal healthcare a human right with European affirmations of such a right and to those found in various treaties of international law. Finally, it analyzes how Barack Obama’s Patient Protection and Affordable Care Act—while not adopting the rhetoric of human rights does, functionally, enable as a matter of public policy an entitlement to healthcare. (shrink)

In the healthcare sector, race, ethnicity and religion have become an increasingly important factor in terms of patient care due to an increasingly diverse population. Health agencies at a national and local level produce a number of guides to raise awareness of cultural issues among healthcare professionals and hospitals may implement additional non-medical services, such as the provision of specific types of food and dress to patients or the hiring of chaplains, to accommodate the needs of patients (...) with religious requirements. However, in an attempt to address the spiritual, cultural and religious needs of patients healthcare providers often assume that ethnic minority groups are homogenous blocks of people with similar needs and fail to recognize that a diverse range of views and practices exist within specific groups themselves. This paper describes the example of the Sikh community and the provision of palliative care in hospitals and hospices. Although, the majority of patients classifying themselves as Sikhs have a shared language and history, they can also be divided on a number of lines such as caste affiliation, degree of assimilation in the west, educational level and whether baptized or not, all of which influence their beliefs and practices and hence impact on their needs from a health provider. Given that it is unfeasible for health providers to have knowledge of the multitude of views within specific religious and ethnic communities and accounting for the tight fiscal constraints of healthcare budgets, this paper concludes by raising the question whether healthcare providers should step away from catering for religious and cultural needs that do not directly affect treatment outcomes, and instead put the onus on individual communities to provide resources to meet spiritual, cultural and religious needs of patients. (shrink)

Serving as a healthcare worker in a conflict zone is an experience that is characterized by peculiar and unimaginable challenges. This commentary is an exposition on twelve collated stories of healthcare providers currently serving or who have previously served in war. The stories bring to bear the heaviness of emotions such as fear and guilt that the authors grappled with, while concurrently showing that they embody virtues such as altruism, self-sacrifice, courage, and solidarity. In these stories, we see (...) highlighted recurrent ethical themes including the tension between the duty to others and the duty to self, prioritization and allocation of scarce health resources, ethics of research in war, ethics of virtue and the lasting effects of war. This commentary thus explores and heightens our awareness of the interplay between personal morals and the translation of these into ethics of healthcare provision in war. In so doing, the commentary urges us to reflect on ways by which we can engage the discourse pertaining to war and healthcare ethics. (shrink)

This paper examines the implications of the General Agreement on Trade in Services (GATS), the World Trade Organization’s agreement governing trade in health-related services, for health policy and healthcare reform in the United States. The paper describes the nature and scope of US obligations under the GATS, the ways in which the trade agreement intersects with domestic health policy, and the institutional factors that mediate trade-offs between health and trade policy. The analysis suggests that the GATS provisions on market (...) access, national treatment and domestic regulation, which are designed to eliminate ‘regulatory barriers’ to global trade in health services, limit the range of options that state and federal regulators and legislative bodies can employ to regulate the health sector and implement healthcare reforms. As such, the paper identifies the broader social and ethical implications of free trade policy. (shrink)

In the United States 46 million people are uninsured and it is from within this population that many ‘normal, healthy’ research participants are selected. Research institutions and sponsors are not required to compensate or provide free treatment to participants when they incur research-related harm, and most studies do not stipulate the provision of free medical care to treat research-related adverse events. The consequence for uninsured participants is that they must assume these medical costs unless they successfully sue the study (...) sponsor or research institution. This article discusses the matter of healthy volunteers becoming ‘the sick’ as a result of research participation, and proposes guidance for the informed consent process in order to optimize awareness about injury potential and injury compensation. Guidance regarding health screening for these volunteers is also presented. (shrink)

In recent years, policy debates in the United States have focused heavily on rising healthcare costs and what measures can be taken to ensure greater provision of healthcare to individuals of limited means. Much of the rhetoric on this subject has taken on an explicitly moral character, and one common sentiment is that healthcare is or should be viewed as a basic human right. However, the notion of a right to healthcare has not been well (...) articulated, and critics have failed to distinguish between legal and moral rights. Additionally, there are numerous problems inherent to viewing healthcare as a basic human right-many of which are in direct conflict with distinctly American conceptualizations of rights. The present paper reviews the debate over “rights”-both legal and natural-to healthcare, and argues that problems associated with natural rights arguments render them severely compromised. Instead, market systems commonly accepted in American society may be better suited to reducing healthcare costs and increasing access to services in the United States. (shrink)

In December 2017, Law 219/2017, ‘Provisions for informed consent and advance directives’, was approved in Italy. The law is the culmination of a year-long process and the subject of heated debate throughout Italian society. Contentious issues are addressed in the law. What emerges clearly are concepts such as quality of life, autonomy, and the right to accept or refuse any medical treatment – concepts that should be part of an optimal relationship between the patient and healthcare professionals. The law (...) maximizes the value of the patient’s time to decide. Every patient is allowed to make choices for the present as well as for the future, conceived as a continuation of the present, and to decide what comes next, based on what he/she already knows. The law identifies three distinct but converging paths towards the affirmation of a care relationship based on reciprocal trust and respect: the possibility to consent to or refuse treatment, the shared care planning, and advance directives. The fundamental point to emerge from the new Italian law is that consensus is an essential connotation of the treatment relationship. Consensus is not limited to the acceptance/rejection of medical treatment but is ongoing. It is projected into the future through shared care planning and advance directives which act as tools for self-determination and the manifestation of the beliefs and preferences of persons unable to express their will. These principles are in line with the idea of appropriate care as evaluated from two different perspectives, one of scientific adequacy and the other commensurate with the individual’s resources, fragility, values, and beliefs. Surely, however, the new law is not the end of the matter on issues such as conscientious objection, which is deeply rooted within the Italian cultural and political debate. In this regard, healthcare institutions and policymakers will be called upon to develop and implement organizational policies aimed at the management of foreseeable conscientious objection in this field. (shrink)

Conscientious refusal involves decisions by healthcare workers, on grounds of their conscience, to refuse to provide legal, professionally permissible and safe health interventions to patients. Conscientious provision involves decisions by healthcare workers, also on grounds of conscience, to provide safe and beneficial healthcare to patients that is prohibited by law or policy. Some bioethicists believe that the moral issues governing both are identical, and that if one permits conscientious refusals, one should also permit conscientious provisions. This (...) article argues that this assumption of symmetry is incorrect. To demonstrate this, it does the following: first, it establishes why it matters that we understand the difference between them; second, it describes three recent cases of conscientious provision in Canadian healthcare to help characterize its nature and scope; third, it situates these cases in a socio-economically nuanced analysis of the role of the conscientious provider under conditions or privilege and oppression; finally, it applies insights from the cases and the intersectional analysis to common criticisms of conscientious refusal to reinforce the fundamental asymmetries between conscientious refusal and conscientious provision. (shrink)

The United Nations Educational, Scientific and Cultural Organization's Declaration on Bioethics and Human Rights asserts that governments are morally obliged to promote health and to provide access to quality healthcare, essential medicines and adequate nutrition and water to all members of society. According to UNESCO, this obligation is grounded in a moral commitment to promoting fundamental human rights and emerges from the principle of social responsibility. Yet in an era of ethical pluralism and contentions over the universality of human (...) rights conventions, the extent to which the UNESCO Declaration can motivate behaviors and policies rests, at least in part, upon accepting the moral arguments it makes. In this essay I reflect on a state's moral obligation to provide healthcare from the perspective of Islamic moral theology and law. I examine how Islamic ethico-legal conceptual analogues for human rights and communal responsibility, ḥuqūq al-’ibād and farḍ al-kifāyah and other related constructs might be used to advance a moral argument for healthcare provision by the state. Moving from theory to application, I next illustrate how notions of human rights and social responsibility were used by Muslim stakeholders to buttress moral arguments to support American healthcare reform. In this way, the paper advance discourses on a universal bioethics and common morality by bringing into view the concordances and discordances between Islamic ethico-legal constructs and moral arguments advanced by transnational health policy advocates. It also provides insight into applied Islamic bioethics by demonstrating how Islamic ethico-legal values might inform the discursive outputs of Muslim organizations. (shrink)

Background Research shows that undocumented migrants have difficulties in accessing healthcare. Act 2013:407 came into force in 2013 and entitled undocumented migrants to healthcare that cannot be deferred. To date, studies about undocumented migrants’ access to care in Sweden and the impact of Act 2013:407 are sparse. Hence, the aim of this study was to describe professionals’ experiences of access to healthcare for undocumented migrants in Sweden and the impact of Act 2013:407. Methods A qualitative design with (...) semi-structured interviews was employed. Nine interviews were carried out in 2015 with nurses at two NGO healthcare centres for undocumented migrants – and an additional seven interviews in 2022 with staff at an NGO healthcare centre for undocumented migrants and personnel at a regional health and medical care administration. Interpretive description was used for the analyses. Ethical considerations Permission to carry out the study was obtained from managers at the participating NGOs and the regional health and medical care administration. Participants received verbal and written information about the study, and informed consent was obtained from all participants. Findings Six categories emerged from the analysis: Changes since the Act was introduced, General problems with healthcare access, Care for undocumented migrants – politics and social economy, Lack of knowledge, ‘Healthcare that cannot be deferred’ and Being an undocumented migrant. Conclusion Undocumented migrants’ social needs are as great as their needs for healthcare. Healthcare staff are burdened with healthcare cost considerations which affect their judgement of care provision and prioritization. Healthcare staff attitudes towards undocumented migrants affect their access to healthcare. Undocumented migrants in need of healthcare are especially vulnerable due to their legal status, being ill and the fear of being reported and deported. To assure undocumented migrants’ access to healthcare and maintain healthcare ethics, the only possible solution is to provide healthcare based on needs. (shrink)

Standardization has emerged as the dominant principle guiding the organization and provision of healthcare, with standards resultantly shaping how nurses conceptualize and deliver patient care. Standardization has been critiqued as homogenizing diverse patient experiences and diminishing nurses’ skills and critical thinking; however, there has been limited examination of the philosophical implications of standardization for nursing knowledge and practice. In this manuscript, I draw on Foucault's philosophy of order and categorization to inform an analysis of the consequences of (...) class='Hi'>healthcare standardization for the profession of nursing. I utilize three exemplars to illustrate the impact of the primacy of standardized thinking and practices on nurses, patients and families: pain assessments using the 0‐10 pain scale; patient triage emergency departments through the Canadian Triage and Acuity Scale; and determination of cause of death within the context of the current opioid crisis. Through each exemplar, I demonstrate that standardization reductively constrains nursing knowledge and the health and healthcare experiences of patients and populations. I argue that the centrality of standardization must be re‐envisioned to embrace the complexity of health and more effectively and meaningfully frame nursing knowledge and practice within healthcare systems. (shrink)

The COVID-19 pandemic has exacerbated inequalities, including among the healthcare workforce. Based on recent literature and drawing on our experiences of working in operating theatres and critical care in the UK’s National Health Service during the pandemic, we review the role of personal protective equipment and consider the ethical implications of its design, availability and provision at a time of unprecedented demand. Several important inequalities have emerged, driven by factors such as individuals purchasing their own personal protective equipment, (...) inconsistencies between guidelines issued by different agencies and organisations, and the standardised design and procurement of equipment required to protect a diverse healthcare workforce. These, we suggest, have resulted largely because of a lack of appropriate pandemic planning and coordination, as well as insufficient appreciation of the significance of equipment design for the healthcare setting. As with many aspects of the pandemic, personal protective equipment has created and revealed inequalities driven by economics, gender, ethnicity and professional influence, creating a division between the ‘haves’ and ‘have-nots’ of personal protective equipment. As the healthcare workforce continues to cope with ongoing waves of COVID-19, and with the prospect of more pandemics in the future, it is vital that these inequalities are urgently addressed, both through academic analysis and practical action. All data relevant to the study are included in the article. (shrink)

The social production of an enterprise clinic: nurses, clinical pathway guidelines and contemporary healthcare practicesIn this paper I critically engage with the forming of contemporary nursing practice with/in an ‘enterprise clinic’ in order to discuss the practical potential of developing a mode of reflective practice that is a critical ontology of self. Critical engagement in the paper is secured through a ‘troubling’ of the relationship between the contemporary practices of both the self and governance, without the reduction of one (...) to the other. The paper draws on my doctoral study in which I combined the techniques of ethnography and discourse analysis in order to critically examine registered nurses’ employment of clinical pathway guidelines through an analysis of the political technologies through which that engagement was constituted. This critical purchase was applied because of the influence of the contemporary ‘problematisation’ of healthcare provision in western society on the formation and deployment of the professional identities of nurses. (shrink)

Both developing and developed countries face an increasing mismatch between what patients expect to receive from healthcare and what the public healthcare systems can afford to provide. Where there has been a growing recognition of the entitlement to receive healthcare, the frustrated expectations with regards to the level of provision has led to lawsuits challenging the denial of funding for health treatments by public health systems. This book analyses the impact of courts and litigation on the (...) way health systems set priorities and make rationing decisions. In particular, it focuses on how the judicial protection of the right to healthcare can impact the institutionalization, functioning and centrality of Health Technology Assessment (HTA) for decisions about the funding of treatment. Based on the case study of three jurisdictions - Brazil, Colombia, and England - it shows that courts can be a key driver for the institutionalization of HTA. These case studies show the paradoxes of judicial control, which can promote accountability and impair it, demand administrative competence and undermine bureaucratic capacities. The case studies offer a nuanced and evidence-informed understanding of these paradoxes in the context of health care by showing how the judicial control of priority-setting decisions in health care can be used to require and control an explicit scheme for health technology assessment, but can also limit and circumvent it. (shrink)

Disability is one of the key public health issues in India and the burden will increase given the trend of an aging population. People with disabilities experience greater vulnerability as they may develop secondary health issues. They face various barriers while accessing health services. This is a major ethical concern. In this article, we frame the barriers to healthcare provision to persons with disabilities and propose an ethical framework to address these barriers. This ethical framework is derived from (...) the basic ethical principles of justice, fairness, trust, solidarity, stewardship, proportionality, and responsiveness. The framework proposes strategies to address these barriers to healthcare service delivery for persons with disabilities in India. (shrink)

The Swedish solution to the legal handling of professional conscientious refusal in healthcare is described. No legal right to conscientious refusal for any profession or class of professional tasks exists in Sweden, regardless of the religious or moral background of the objection. The background of this can be found in strong convictions about the importance of public service provision and related civic duties, and ideals about rule of law, equality and non-discrimination. Employee's requests to change work tasks are (...) handled on a case-by-case basis within the frames of labour law, ensuring full voluntariness, and also employer's privilege regarding the organisation and direction of work, and duties of public institutions to provide services. Two complicating aspects of this solution related to the inclusion of ‘alternative medical’ service providers in a national health service, and professional insistence on conscientious refusal rights to accept legalised assisted dying are discussed. The latter is found to undermine the pragmatic reasons behind recent attempts by prolife groups to challenge the Swedish solution related to legal abortion in courts. (shrink)

:This article analyzes the criteria for the distribution of healthcare services through different justice theories such as utilitarianism and liberalism, pointing out the problems that arise when providing services to a culturally diverse population. The international epidemiological setting is a favorable one for discussing personal responsibility and luck egalitarianism; however, some provisions have to be made so that healthcare institutions do not treat ethnic, cultural, religious, and linguistic minorities unfairly. The article concludes by proposing that accommodations and culturally (...) sensible attention should be provided when possible, without affecting the equal opportunity of others to access these services. (shrink)

IntroductionThe COVID-19 pandemic has led to unprecedented strain to healthcare systems worldwide and posed unique challenges to the healthcare professionals and the general public.ObjectivesThe aim of this study is to evaluate the impact of COVID-19 on the mental health, behavioral, and physical wellbeing of HCPs in the early and mid-term periods of the pandemic in comparison to non-HCPs. Thus, facilitating and guiding optimum planning and delivery of support to HCPs.Methods and AnalysisAn observational cross-sectional survey and cohort study aiming (...) to enroll over 1050 participants. Study questionnaires will be completed at baseline and after 6-weeks and 4-months. Recruitment initiated July 2020. The study was designed in London, United Kingdom, but open to participants worldwide. Baseline: Questionnaires comprising of validated self-administered screening tools for depression, anxiety, sleep-related issues, wellbeing, and burnout. The questionnaires also explore changes in behavior and physical wellbeing of the participants. In addition, associations of these mental health and behavioral factors with work-related factors and support will be explored. Six-weeks and 4-months follow-up: Follow-up questionnaires will assess change in symptoms of anxiety and depression, sleep disorders, use of alcohol and other substances, behavioral or interpersonal relationship changes. Physical wellbeing will be assessed through the presence of suspected or confirmed COVID-19 infection and absence from work. We will also evaluate the impact of variable provision of personal protection equipment, extended working hours, and concern for the wellbeing of family members, anxiety levels, and evidence of burnout.Statistical ConsiderationsThe study has 80% power to detect a 10% difference of combined depression and/or anxiety symptoms between the groups using two-sided type 1 error at 0.05 at baseline. Assuming that only 50% of these HCPs agree to be a part of a cohort survey, we will have 80% power to detect around 12% difference in the two groups in reported physical symptoms, or prevalence of depression and/or anxiety at the end of the study.EthicsThe study was approved by the Cambridge East, Research Ethics Committee.Trial Registration NumberClinicalTrials.gov, NCT04433260. (shrink)

Infertility presents both medical and public health challenges, with in vitro fertilization (IVF) emerging as a prominent solution, particularly when other alternatives are exhausted. However, IVF treatment raises significant ethical questions that have been under explored in the Ghanaian context. This study aimed to explore ethical constraints and dilemmas in the provision of in vitro fertilization (IVF) treatment in Ghana. A descriptive phenomenological qualitative design was employed. Purposive sampling techniques were used to recruit 12 participants including ART experts from (...) three in vitro fertilization (IVF) centres, ethicists and a legal practitioner. In-depth face-to-face interviews guided by an open-ended interview guide were conducted. Thematic analysis of the interviews was performed to identify major themes. Providing IVF treatment in Ghana raises several ethical issues, including inequitable access due to high costs and limited availability, which favour wealthier individuals and leave marginalized populations with fewer options. There are significant ethical considerations in balancing the potential benefits of successful IVF treatment outcomes against the health risks and emotional tolls on patients. Decisions about the fate of surplus embryos present moral dilemmas, including whether to preserve, donate, or discard them. Differing personal beliefs about the moral status of the embryo further complicate the ethical landscape. Ensuring informed consent is challenging due to the complex medical, ethical, and emotional implications of IVF treatment, potentially leading to compromised consent. Additionally, there are ongoing risks of breaches in confidentiality, given the sensitive nature of reproductive health data and the importance of protecting patient privacy. This study revealed that several ethical dilemmas confront both healthcare providers and couples in the process of IVF. There is an urgent need for the development of clear and uniform regulations to govern the practice of IVF treatment in Ghana, with further attention given to mitigating financial barriers and enhancing support systems for couples considering IVF treatment. (shrink)

Background: Palliative care is acknowledged as an appropriate approach to support older people in nursing homes. Ethical issues arise from many aspects of palliative care provision in nursing homes; however, they have not been investigated in this context. Aim: To explore the ethical issues associated with palliative care in nursing homes in the United Kingdom. Design: Exploratory, sequential, mixed-methods design. Methods: Semi-structured interviews with 13 registered nurses and 10 healthcare assistants (HCAs) working in 13 nursing homes in the (...) United Kingdom were used to explore ethical issues in palliative care. The ‘Ethical Issues in Palliative Care for Nursing Homes’ instrument was used to measure the frequency and level of distress arising from ethical issues through a cross-sectional survey with 69 registered nurses and 129 healthcare assistants. Data collection occurred between December 2014 and November 2015. Ethical considerations: Ethical approval was granted by Queen’s University’s School of Nursing and Midwifery Research Ethics Committee and governance sought from each nursing home’s manager. Findings: The interviews revealed three themes: ethical issues in practice; relational issues; and organisational issues. No significant differences between registered nurses and healthcare assistants were evident, confirming the patterns emerging from the interviews. Relational issues, primarily issues with residents and families, occurred most frequently and caused greater distress. Conclusion: The shared environment is key in the experience of ethical issues; therefore, multidisciplinary education is needed for ethical decision making in palliative care. Addressing staff knowledge and service organisation may reduce ethical issues locally and provide a benchmark for global change. (shrink)

People with disabilities are subject to multiple forms of health-related and wider social disparities; carefully focused research is required to inform more inclusive, safe and effective healthcare practice and policy. Through lived experience, disabled people are well positioned to identify and persistently pursue problems and opportunities within existing health provisions that may be overlooked by a largely non-disabled research community. Thus, the academy can play an important role in shining a light on the perspectives and insights from within the (...) disability community, and combined with policy decisions, these perspectives and insights have a better opportunity to become integrated into the fabric of public life, within healthcare and beyond. However, despite the potential benefits that could be yielded by greater inclusivity, in this paper we describe barriers within the UK academy confronting disabled people who wish to embark on health research. We do this by drawing on published findings, and via the lived experience of the first author, who has struggled for over 3 years to find an accessible PhD programme as a person with energy limiting conditions who is largely confined to the home in the UK. First, we situate the discussion in the wider perspective of epistemic injustice in health research. Second, we consider evidence of epistemic injustice among disabled researchers, focusing primarily on what philosophers Kidd and Carel (2017, p 184) describe as ‘strategies of exclusion’. Third, we offer recommendations for overcoming these barriers to improve the pipeline of researchers with disabilities in the academy. (shrink)

Previously proposed strategies for tackling hermeneutical injustices take for granted the interests people have in certain things about them being intelligible to them and/or to others, and seek to enable them to satisfy these interests. Strategies of this sort I call interests-as-given strategies. I propose that some hermeneutical injustices can instead be tackled by doing away with certain of these interests, and so with the possibility of their unfair non-satisfaction. Strategies of this sort I call interests-in-question strategies. As a case (...) study in when such an interests-in-question strategy ought to be pursued, I look at how to tackle hermeneutical injustices arising in the context of gender-affirming healthcare as provided to adults by the National Health Service in the UK. I argue that considerations of trust, privacy, and respect all support pursuing such a strategy. One way to do so, I suggest, would be by replacing the existing gatekeeping model with an informed consent model for the provision of gender-affirming healthcare. Considerations of hermeneutical justice can hence be added to the already-impressive case for undertaking this shift. (shrink)

Canada’s population is aging, and seniors constitute the fastest growing demographic in the nation. The chronic health conditions, limited social support, functional decline, and cognitive impairment experienced by seniors may necessitate admission to a personal care home (PCH) setting up until the time of their death. The ethical problems that arise in the care of dying patients are numerous and complicated. The care of dying seniors in PCHs, however, is largely provided by frontline workers such as healthcare aides (HCAs), (...) who usually have little training in palliative care or ethics. Research examining the identification and resolution of ethical problems in care of the dying has been conducted from the perspectives of nurses and physicians in various clinical settings, but the voice of HCAs in PCHs is virtually absent from clinical ethics. Given that the inability to satisfactorily resolve ethical issues in clinical practice is associated with feelings of guilt, powerlessness, avoiding contact with patients, failing to provide good physical care, and increased staff turnover, an empirical examination of HCAs’ experiences of ethically challenging situations is warranted.We conducted a phenomenological study to access the lived experience of HCAs (N=12) working in proprietary and nonproprietary care homes as they encountered situations they deemed ethically challenging in providing end-of-life care to dying seniors. The findings reported here explicate: (1) the types of situations that are ethically problematic for HCAs; (2) the meanings they assign to these situations, and (3) the impact such situations have on the provision of end-of-life care. (shrink)

COVID‐19 caused an imbalance between medical resources and the number of patients in Türkiye like in many countries. There was not pandemic‐triage system, and this situation led to decision making based on experience, intuition, and judgment of allocation of scarce resources. The research explains the guiding criteria that healthcare professionals used to prioritize the distribution of scarce medical resources during the COVID‐19 pandemic. The criteria preferred by 928 healthcare professionals were evaluated when preventive measures for COVID‐19 were reduced (...) and so the number of cases increased rapidly. The results indicate that Turkish healthcare professionals largely support the utilitarian approach, which focuses on medical benefit in pandemic. The main problem was that some criteria not approved in COVID‐19 triage guidelines were considered important by healthcare professionals. These criteria, which cause discrimination by preventing the provision of fair and equal medical care to patients, are a prominent issue in the study. (shrink)