The Clinton administration's revised rules regulating but not prohibiting the common practice in managed care of linking physician compensation with cost cutting and control of services demonstrates the complexity of ethical issues in managed care. As originally proposed, the federal guidelines on payment for Medicare and Medicaid services would have precluded any interrelationship between payment to physicians and delivery of services. Such a restriction would have gutted the primary mechanism in managed care plans (...) to curb the unacceptably high cost of healthcare delivery: making physicians directly responsible for cost control by placing them at direct financial risk. At first blush such a linkage seems to involve an obvious and irreconcilable conflict of interest. How can a physician be responsible for the well-being of a patient while at the same time aware that a proportion of his or her income is linked to the provision of cost-conscious care? (shrink)

: The market success of managed health plans in the 1990s is bringing to medicine the easy availability of electronically stored information that is characteristic of the securities and consumer credit industries. Protection for medical confidentiality, however, has not kept pace with this information revolution. Employers, the managed care industry, and legal and ethics commentators frequently look to the concept of informed consent to justify particular uses of health information, but the elastic use of informed consent (...) as a way of responding to managed health plans' disclosure of information to third parties fails to address underlying questions involving substantive value choices. (shrink)

In Japan, most residents with Hansen’s disease live in dedicated sanatoria because of an established quarantine policy, even after being cured of the primary disease. They suffer from secondary diseases and are advancing in age, and advance care planning is increasingly crucial for them to live their lives with dignity in a sanatorium. In this study, we have three aims: to understand how to promote communication about their wishes for medical treatment, care, and recuperation; to identify required assistance; (...) and to explore how to promote ACP in a sanatorium. This study is a qualitative research conducted through semi-structured interviews. The study included 57 ex-Hansen’s disease patients and 66 staff from 10 facilities. Ex-Hansen’s disease patients were expected to consider ACP, but this was in the context of uncertainty about whether a sanatorium would close and whether there would be doctors to manage their needs. They reported being confused when staff rushed to confirm their advance directives, feeling that they were not provided with enough information before being approached. Barriers to promoting ACP were found to be insufficient of team-based care and information sharing, ex-Hansen’s disease patients’ weak interest in their end of life, and their conservative thoughts. We believe that ACP can be achieved by listening to the wishes of recovered patients through regular home care visits by nurses and everyday support by care workers. Furthermore, multidisciplinary coordination is urgently needed for promoting ACP. (shrink)

Our objective was to better understand the values and ethical dilemmas surrounding advance care planning through stories told by registered nurses and licensed social workers, who were employed as care managers within Area Agencies on Aging. We conducted eight focus groups in which care managers were invited to tell their stories and answer open-ended questions focusing on their interactions with consumers receiving home-based long-term care. Using narrative analysis to understand how our participants thought through particular experiences (...) and what they valued, we identified seven themes representative of their work with consumers and families: humility, respect, responsibilities, boundaries, empowerment, courage, and veracity. (shrink)

: In its response to pressures to rationalize health care resource allocation, the American health care system has embraced managed care without concurrent comprehensive health care reform, either in the form of the centralized tax-based systems found in Europe and Canada or that of the Clinton reform plan. What survives is managed care without managed competition, employer mandates, or universal access. Two problems inherent in the incentive structure of managed care (...) plans developed in the absence of comprehensive health care reform work against the public interest. First, sacrifices in terms of medical innovation and quality of care may not be offset by greater equity in the distribution of health care. Second, such managed care plans fail to address the need for long-term accountability. (shrink)

In response to the many changes currently going on in health care, this book offers the combined insight and wisdom of a stellar group of scholars and professionals with extensive experience in the health care field. The book opens with a look at people's actual experience of health care today, from four different perspectives. It then addresses foundational questions, including the nature of medicine, nursing, and justice. Surveyed next are the changing economics of health care as (...) well as the impact of these changes on such areas as mental health care, long-term care, health care for minorities, and legal malpractice. The closing section of the book assesses from a Christian perspective available constructive alternatives, including creative funding strategies with special attention to the needs of poor persons, physician unions, and the use of "alternative medicine" therapies. (shrink)

Due to society's need to control health care costs and to the failure of legislated health care reform, managed care is expanding at a rapid rate and will soon be the predominate form of health care delivery. Plans by Congress to bring Medicare and Medicaid under managed care will further consolidate this trend. Barring some legislative fiat, managed care is here to stay.The term managed care describes a diverse (...) set of organizational forms. Wide variations in approach, financing, physician involvement, and philosophy exist among the different types of managed care organizations. While many articles on the ethics of managed care acknowledge this variety, most analyses focus on the for-profit entities, paying less attention to the ethical distinctions among the different forms of managed care. This paper discusses the key distinctions among MCO types, in particular the difference between for-profit and non-profit plans; the relationship of the physician to the MCO; the incentives used to control costs; the incentives that improve patient care; and the organizational features that nurture the principled practice of medicine. (shrink)

In the move to critique managed care, the essential principles that first made it a reasonable alternative to fee-for-service medicine can easily be lost. Careful reflection on the history of early grassroots movements that created managed care, and on selected textual narratives of the founders of the managed care organizations at their inception, offers us insight into which of the critical premises and goals of that effort might be reclaimed as we analyze the current (...) managed care environment. (shrink)

The risk of tort liability for health maintenance organizations and other managed care plans has dramatically increased in recent years. This is due in part to the growing percentage of health care rendered through managed care plans. The cost-containment mechanisms commonly used by managed care plans, such as limiting access to services and/or choice of providers, creates a climate ripe for disputes that may end up in court. As dissatisfied patients (...) and providers seek recourse in the courts, tort doctrines are extended and new legal theories emerge as needed. For example, the concepts of direct and vicarious tort liability developed in the hospital context have been extended by courts to encompass HMOs. vicarious liability claims, based on ostensible agency or respondeat superior doctrines, have been brought against HMOs and managed care plans for negligent treatment by physicians selected to provide care to members. (shrink)

Exploring the dynamics of power: A Foucauldian analysis of care planning in learning disabilities services This paper draws upon a study completed in 2000 that focused upon health and welfare provision for people with learning disabilities in one English county. This study drew upon the theoretical insights of Michel Foucault to provide an analysis of the micro politics of care planning. This involved the analysis of text from two sources: the academic literature and interview material gained from a (...) number of professionals working in health and welfare services for people with learning disabilities. Drawing upon this research material, the first part of this paper briefly explores the relationship between policy, professional practice and the people who are the subjects of that practice. The discussion then moves on to consider Foucault's five methodological precautions and the way power produces a localised web of activity that identifies specific targets for management. In this process power draws into the web a range of informal and formal practices that initially lie outside of the web. The discourse produced through the activity surrounding care planning provides the evidence of this flow of power. This discourse then takes on the status of science (truth), which reproduces this activity. (shrink)

We examined the management of completed advance directives including why participants completed a document, what procedures and values they chose, with whom they held end-of-life conversations, and where they stored their document. Participants elected to complete a SurveyMonkey survey that was made available to individuals who wrote an advance directive through Texas-LivingWill.org; 491 individuals elected to fill out the survey, aged 19 to 94 years. The survey asked multiple questions about why participants completed an advance directive, where they would store (...) it, and with whom they had conversations about their end-oflife wishes. A list of procedures and values allowed participants to indicate what they refused or requested in their advance directive. Advance directives are most often completed to allow patients to prepare and control the healthcare they wish to receive when dying. One-half to two-thirds of individuals refuse common end-of-life medical procedures, and the rest request the procedures. We found a correlation between the choice to refuse or request a procedure and the age of the participant. Participants reported that their end-of-life conversations most often occurred with their spouse. Respondents often reported that their advance directive was stored with their physician and power of attorney for healthcare, conversations with those individuals rarely happened. Advance directives document patients’ requests for and refusals of end-of-life care. Physicians and surrogates need to be better educated so that the documents are part of a meaningful conversation with the patient. Because patients’ choices change over their lifespan, these documents need to be revisited regularly and not completed as a onetime event. (shrink)

In the face of escalating Medicaid costs and anticipated reductions in federal Medicaid spending, states are increasingly converting from fee-for-service to managed health care systems. The interrelated issues of enrollment and auto-assignment are fundamental to the overall success or failure of Medicaid managed care programs. The purpose of this article is to suggest how policy makers, consumer advocates, and providers should address these issues. My major premise is that implementation of managed care will proceed (...) more smoothly if states adopt enrollment strategies that promote voluntary selection of health plans by Medicaid consumers, minimize the likelihood of auto-assignment, and mitigate the negative consequences of mandatory assignment of consumers to managed care organizations.States seeking to implement Medicaid managed care must apply for a waiver from the secretary of the Department of Health and Human Services. Two different types of waivers are available to implement Medicaid managed care. (shrink)

Appropriate concerns about cost and unequal access to healthcare have resulted in the creation of powerful managed networks seeking to share the risks of high healthcare costs among plans, providers, and patients. Much to their credit, these managed networks have slowed the rise in healthcare spending by as much as 44% in markets with high HMO penetration. However, whether these savings will materially improve access and quality remains to be seen.

It is often claimed that managed care organizations involve physicians in conflicts of interest by creating financial incentives for physicians to refrain from ordering treatments or making referrals. Such incentives, the argument goes, force the physician to balance the patient's health interests against the MCO's interests and the physician's own financial interest. I assume, for the sake of argument, that such arrangements at least provide reason to believe that physicians in MCOs are involved in conflicts of interest. Two (...) approaches have evolved for dealing with these conflicts. On one approach, MCOs disclose the financial arrangements under which their physicians work so that patients can consent to the managed care plan and thereby to the plan's limitations. The chief proponent of this approach is Mark Hall, whose recent book Making Medical Spending Decisions applies prior consent to a variety of decisions regarding medical financing and allocation. The other approach is simply to forbid conflicts of interest through regulations. (shrink)

How can health plans make fair determinations about when “experimental” (and costly) treatments such as high dose chemotherapy with autologous bone marrow transplantation should be covered despite lack of clear clinical consensus about their benefits? Different models for managing “last chance” therapies evolving in some health plans offer promising examples of how issues of fairness and legitimacy in decisionmaking can be addressed.

The increased competition for a share of the market of insured patients, which arose in the wake of failed comprehensive health care reform, has provoked questions about what, if any, standards will govern new “competitive” health care organizations. Managed care arrangements, which typically shift to providers and patients some or all of the financial risk for patient care, are of special concern because they can create incentives to withhold beneficial care from patients. Of course, (...) fee-for-service medical practice creates incentives to provide unnecessary services, and managed care can avoid that type of harm. Still, as Edmund Pellegrino has noted, “managed care, by its nature, places the good of the patient into conflict with … the good of all the other patients served by the plan; the good of the plan and the organization, themselves…; and the self-interest of the physician. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Managed Health Care: New Ethical Issues for All*Martina Darragh (bio) and Pat Milmoe McCarrick (bio)Changes in the way that health care is perceived, delivered, and financed have occurred rapidly in a relatively short time span. The 50-year period since World War II encompasses enormous growth in medical technology, soaring health care costs, and significant fragmentation of the two-party patient- physician relationship. This relationship first grew (...) to include the third-party payer, the health insurance industry, and now “with great speed and relatively little public awareness, a significant change has occurred in the way some decisions are made about a patient’s medical care” (III, Institute of Medicine 1989).The new means of providing health care bring an increasing number of parties into clinical decision-making processes. With this change, ethical issues that once concerned only health care professionals, the physician or the nurse, have expanded to include the patient and the groups who “manage” care—e.g., health maintenance organizations (HMOs), preferred provider organizations (PPOs), point of service groups (POSs), independent practice associations (IPAs), insurance reviewers, hospital administrators, institutional managers, and, the most recent players, purchasers of group health care who base their decisions on competitive pricing.The term “managed care” refers to a variety of continually adapting and developing arrangements that involve four groups. These groups, which have been labeled by the world of business, not health, are the “consumer” (once the patient), the “provider” (the physician and other health care professionals), the “insurer” (the reimburser for any care), and the “purchaser of care” or the primary buyer of health services (the large employer organization). Capitation is a common way to pay for health services in managed care systems. A certain dollar amount is negotiated for health services for a specified number of patients whether the care is delivered or not; the provider shares with the [End Page 189] insurer any financial risk for the actual cost of care (III, Centers for Disease Control 1995).When the Clinton administration’s health care reform movement failed to gain support in the U.S. Congress, the use of managed care to control rising health care costs accelerated. The literature on managed care and its effect on the patient-physician relationship reflects this shift. During the era of health care reform, “debate centered on how managed care could control costs, on the use of technology and patient satisfaction, [and] on access and barriers to care” (IV, Emanuel and Dubler 1995). When managed care organizations began contracting with physicians to provide health care services subject to the plans’ provisions, these plans became agents in clinical decision making on a wide-spread basis. HMO enrollment grew to 51 million persons by 1994 (III, Centers for Disease Control 1995). This “corporatization” of health care has sparked a plethora of articles about the effects of the marketplace on the physician’s ability to do what is best for the patient, and on the patient’s ability to trust the physician to do so.Many authors make it clear that managed care itself is not the problem, but rather the development of for-profit managed care plans by “corporate conglomerates with billions of dollars in assets that compensate their executives as grandly as basketball players” (V, Kassirer 1995) “in a marketplace that is largely unregulated” (I, Zoloth-Dorfman and Rubin 1995). “Some, mostly older plans that were created when cost containment was an unexpected benefit rather than their central purpose, deliver high-quality care economically. Unfortunately, others cut costs by recruiting the healthiest patients, excluding the sickest, rationing care by making it inconvenient to obtain, and denying care by a variety of mechanisms” (V, Kassirer 1995).These cost-containment features now play an intimate role in clinical practice. When a managed care plan contracts with a physician, the doctor becomes a “double agent” with contractual obligations to the plan to provide a preset amount of services and professional responsibilities to each patient to authorize necessary treatment (V, Angell 1993). This duality can undermine the physician’s fiduciary responsibility to the patient wherein the physician “has power over the affairs of [the patient]...and is required by law to act on that person’s... (shrink)

The total value set of a working individual consists of three components: personal, professional and organizational values. In the light of the changing health care environment, the individual nurse manager’s values may no longer be applicable for coping with the needs of the work environment. For many nurses who developed their values in keeping with the humanistic tradition, the ‘new’ organizational values may create confusion, frustration and conflict. The purpose of this study was to determine if the organizational domain (...) in the value sets of Israeli middle nursing managers in acute care hospitals reflect the process of shifting values needed in today’s management roles. Analysis of the results revealed that head nurses did not yet fully internalize the ‘new’ organizational values. Implications of the results for planning undergraduate and graduate programmes are detailed. (shrink)

As increasing proportions of our global population age, transgender people are experiencing higher rates of dementia, and many are afraid to enter long-term care. Structural interventions such as advance directives may help mitigate fears around entering long-term care by managing specific anxieties that transgender people may have about dementia, loss of decision-making capacity, and discrimination in long-term care settings.

: The answer to the question of what health care services should be covered by a managed care plan is straightforward; the plan should cover whatever the consumer is willing to pay for. From the plan's perspective, the consumer is the payer, that is, the employer who negotiates the plan; not the individual patient whose personal preferences and interests may be quite different. Since managed care organizations contract with payers to arrange for health care (...) services within a defined set of benefits, there is a broader question as well: Within the benefits chosen by the payer, what actually is covered? Criteria for determining "medical necessity," which managed care plans frequently use as the basis for coverage, are discussed. (shrink)

There have always been medical standards of care in the American health-care sector. However, never before have they been so deeply incorporated in the delivery of health care as they are today. With the increased delivery of care through integrated delivery systems, as well as the development of the computerized patient record, medical standards of care are now used in innovative ways by providers and health plans in delivering health care to individual patients. (...) There is great potential for even more innovative uses of medical standards of care in the future.This article first presents a taxonomy of the medical standards of care that are involved in health-care delivery today Next, the article traces the historical evolution of medical standards of care since the early 1980s. Included in this discussion are the origins of the standard-setting movement as well as the developments that led to the way standards of care are currently used by large institutional providers and managed care plans to improve the quality of their health-care services. The article concludes with a brief analysis of the key legal issues that affect how standards of care can be used to improve the health care of patients. (shrink)

Background The nursing profession requires ethical and legal regulations to guide nurses’ performance. Ethical climate plays a part in shaping nurses’ ethical practice. Therefore, ethico-legal aspects and ethical climate contribute to improving nurses’ ethical practice and competencies with reducing medical errors in hospital settings. Objective This study examined the effect of ethico-legal aspects and ethical climate on managing safe patient care and medical errors among nurses. Materials and methods A cross-sectional correlational study was carried out on 548 nurses. Data (...) were collected through self-administered questionnaires about nurses’ knowledge in both ethical and legal aspects, ethical practice, competencies, ethical climate and experience with medical error. Results The main sources of nurses’ knowledge of ethical and legal aspects were undergraduate lectures, job experience and colleagues. Nurses’ knowledge in both ethical and legal aspects, nurses’ ethical practice and competencies were insufficient. Nurses fairly perceived their ethical climate. Also, nurses experienced medical errors about 22.6% in their units. Nurses’ knowledge of ethical and legal aspects, as well as the ethical climate were positive predictors of inadequate nurses’ ethical practice and competencies. Additionally, nurses’ knowledge in both ethical and legal aspects, ethical climate and practice had a negative influence on the occurrence of medical errors. Conclusion Enhancing nurses’ knowledge in both ethical and legal aspects as well as ethical climate could significantly influence improving nurses’ ethical practice, competencies and reducing medical errors in the study units. Therefore, planning for enhancing the nurses’ ethico-legal learning and ethical climate seems to be mandatory. (shrink)

In “Avoiding a Death Panel Redux,” Nicole Piemonte and Laura Hermer make the argument that the advance care planning consultation provision during the health care reform debate collapsed both because the language in the provision was deliberately misread and because some features of the language could in fact be misleading. We agree on both counts. We add that the cost‐effectiveness provisions of the bill make us face difficult decisions we as a nation would rather avoid, but can and (...) must face squarely and together. It is time for an honest national conversation about at least two issues concerning medical care near the end of life. First, talking about or planning a good death with your doctor or nurse will not make death happen sooner. The data show that better planning for a well‐managed terminal illness leads to longer life as well as better symptom control and less distress. Second, we need to quickly and directly confront the cost of end of life care in the United State, recognize the political consequences, and work with the broad middle to advance the common good. (shrink)

ABSTRACT This study is an ethical reflection on the formulation and application of public policies regarding reproductive health in Brazil. The Integral Assistance Program for Women's Health (PAISM) can be considered advanced for a country in development. Universal access for family planning is foreseen in the Brazilian legislation, but the services do not offer contraceptive methods for the population in a regular and consistent manner. Abortion is restricted by law to two cases: risk to the woman's life and rape. This (...) reality favors the practice of unsafe abortion, which is the third largest cause of maternal death in Brazil. Legal abortion is regulated by the State and the procedure is performed in public health centers. However, there is resistance on the part of professionals to attend these women. Prenatal care is a priority strategy for promoting the quality of life of these women and of future generations. Nonetheless, it is still difficult for these women to access the prenatal care services and to have the required number of consultations. Moreover, managers and health professionals need to be made aware of the importance of implementing the actions indicated by the public policies in the area of sexual and reproductive health, favoring respect for autonomy in a context of personal freedom. (shrink)

As health care costs continue to escalate, cost control measures will likely become unavoidable and painful. One approach is to engage external forces to allocate resources - for example, through managed care or outright rationing. Another approach is to engage consumers to make their own allocation decisions, through "self-rationing," wherein they are given greater awareness, control, and hence responsibility for their health care spending. Steadily gaining popularity in this context is the concept of "consumer directed health (...) care" (CDHC), which is envisioned to both control cost and enhance choice, by combining financial incentives with information to help consumers make more informed health care decisions and to appreciate the economic trade-offs of those decisions. While CDHC is gaining attention in the popular press, business publications, and academic journals, it is not without controversy about its relative merits and demerits. CDHC raises questions regarding the ethical limits of consumer responsibility for their choices. While the emphasis on consumer choice implies that autonomy is the ruling ethical principle in CDHC, it must be tempered by justice and beneficence. Justice must temper autonomy to protect disadvantaged populations from further widening disparities in health care access and outcomes that could arise from health care reform efforts. Beneficence must temper autonomy to protect consumers from unintended consequences of uninformed decisions. Thoughtful paternalism suggests that CDHC plans offer choices that are comprehensible to lay consumers, limited in their range of options, and carefully structured with default rules that minimize potential error costs. (shrink)

This article is an exploration of the ways in which maternal subjectivity is negotiated and defined in the context of the act or process of giving birth. As such, it is offered as a contribution to and discussion of recent feminist evaluation of childbirth management systems. Written from the partial perspective of my own experiences of pregnant and maternal embodiment, the article considers whether the ethic of the birth plan is a satisfactory representation of consumer needs and participation in contemporary (...) maternity care. By way of a selective personal account of various models of consumer-orientated and woman-centred childbirth management services that exist in Australia and New Zealand, I draw on ideas from feminist theories of corporeality and the dialogical tradition of social thought in order to rethink the ethical encounter between the labouring woman or consumer and her care provider or practitioner. (shrink)

Taking steps to build a more dementia‐friendly society is essential for addressing the needs of people experiencing dementia. Initiatives that improve the quality of life for those living with dementia are needed to lessen controllable factors that can negatively influence how people envision a future trajectory of dementia for themselves. Programs that provide better funding and better coordination for care support would lessen caregiver burden and make it more possible to imagine more people being able to live what they (...) might consider a “good life” with dementia. Specific proposals, such as payment for dementia care managers and new systems to support high‐quality, symptom‐based palliative care beyond the hospice benefit of only six months, would improve and reframe how many people in the United States experience a dementia illness. Such changes should be incorporated into discussions about improving and respecting preferences in the later stages of dementia. (shrink)

This book tackles the concerns of stressed teachers. Whether from nurturance suffering or from the piles of paperwork yet to be tackled, the author helps the reader sort through the causes of stress, the emotional, physical and social reactions to stress and how one can begin to plan a stress management plan.

As Early Years care and education comes under closer outside scrutiny the number of practitioners moving into managerial roles is constantly increasing, this book focuses on how to make policy work in practice: clarifying the manager’s responsibilities and his or her duty to lead exploring the use of policy and procedures, why we have procedure, how to create procedures and how to put it into practice offering advice on effective planning, how to monitor progress and activity, and tips on (...) feedback and reflection providing links to Ofsted. This is a must-have for students, assessors, nursery nurses with an interest in career development into management and anyone working within a early-years environment in a managerial role. (shrink)

The declaration of the COVID-19 pandemic by the World Health Organization on March 11, 2020, led to unprecedented events. All regions of the world participated in implementing preventive health measures such as physical distancing, travel restrictions, self-isolation, quarantines, and facility closures. The pandemic started global disruption of socio-economic systems, covering the postponement or cancellation of public events, supply shortages, schools and universities’ closure, evacuation of foreign citizens, a rise in unemployment and inflation, misinformation, the anti-vaccine movement, and incidents of discrimination (...) toward people affected by or suspected of having coronavirus disease. Attempts have been made to protect the oldest age group at risk, but in many cases, this has led to over-restriction and age discrimination. The rationale for working on the Research Topic "Socio-economic systems in the post-pandemic world: Design thinking, strategic planning, management, and public policy" was the need to start reflecting on resilience and lessons learned from this public health event that revealed the global unpreparedness in critical areas. Also, the pandemic triggered both top-down and bottom-up responses that needed more in-depth analyzes. This Research Topic covers interdisciplinary contributions addressing new thinking, challenges, and transformations required for post-pandemic global, national, regional, and local realities. The presented Research Topic combines studies focused on recognizing the actions and interventions leading to the recovery of socio-economic systems during the tail end and after the pandemic. The studies delivered recommendations regarding, among others, the care of vulnerable, planning socio-economic restart, and imagining the "new normal.". (shrink)

Background: Since “dignity” is one of the fundamental rights of every patient, consideration for patients’ dignity is essential. Unfortunately, in many cases, especially in cancer patients, dignity is not fully respected. Dignity is an abstract concept, and there are only a few comprehensive studies on the dignity of cancer patients in Iran. Research objective: This study aimed to evaluate the perception of Iranian cancer patients on human dignity. Research design: A qualitative research approach was used as the study design. The (...) data were collected through individual semi-structured interviews and analyzed using the qualitative content analysis method. Participants and research context: This study was conducted on cancer patients in internal medicine wards in Iran. The data were gathered through semi-structured interviews from May 2017 to February 2018. Ethical considerations: The study protocol was approved by the Research Ethics Committee of medical universities located in Southwest of Iran. The ethical principles were carefully followed throughout the study. Findings: Based on the results of the interviews, 3 main themes and 11 categories were determined. The main themes were identified as the “personal space and privacy,” “respect for human values,” and “moral support.” Discussion: The results of the present study showed the necessity of care for cancer patients in a respectful manner. The key elements in such care were the preservation of their personal space and privacy, respect for their values, and the provision of adequate moral support. These measures will have a positive effect on the perception of such patients on human dignity. Conclusion: Considering the special care required by cancer patients, the Iranian healthcare and hygiene managers should design and implement a care plan that includes the ethical principles related to human dignity. (shrink)

On 11 March 2020, the World Health Organization declared a pandemic of the COVID-19 coronavirus disease that was first recognized in China in late 2019. Among the primary effects caused by the pandemic, there was the dissemination of health preventive measures such as physical distancing, travel restrictions, self-isolation, quarantines, and facility closures. This includes the global disruption of socio-economic systems including the postponement or cancellation of various public events (e.g., sporting, cultural, or religious), supply shortages and fears of the same, (...) schools and universities closure, evacuation of foreign citizens, a rise of unemployment, changes in the international aid schemes, misinformation, and incidents of discrimination toward people affected by or suspected of having the COVID-19 disease. The pandemic has brought to the fore unpreparedness in critical areas that require attention, amid prospects and challenges. Moreover, considerable reorganization efforts are required with implications for assets, resources, norms, and value systems. COVID-19 is challenging the concept of globalization and stimulating responses at the levels of local and regional socio-economic systems that lead to the mobilization of assets that have been unrecognized earlier on, such as various forms of economic capital, social capital, cultural capital, human capital, and creative capital. For example, through digital channels, local groups are forming to create schemes of support for physical and mental wellbeing. These emerging exchanges lead to various social and technological innovations by building on skills and assets that are less important in the free-market economy, such as empathy, skills for crafts, making and fixing; locally grown microgreens; and micromanufacturing. Isolation and local living are also making it much harder to ignore the civic responsibilities towards communities, meant as individuals, vulnerable groups, and local businesses. Whilst the pandemic is limiting physical participation, this challenging time is uncovering alternative ways of mutual support, which may create long-term benefits for socio-economic systems, including environmental and biodiversity protection, reduction of the air pollution, and climate action. The pandemic’s threat to public health will hopefully be overcome with implications for disruption for an extended period that we are unable to forecast at this stage. It is key to focus on studies recognizing the activities and interventions leading to the recovery of socio-economic systems after the pandemic. Reflecting and planning on how societies and economies will go back to “business as usual” requires new forms of communication and cooperation, imaginative design thinking, new styles of management, as well as new tools and forms of participation in various public policies. Many questions related to the care of the vulnerable, economic restart, and the risk of future pandemics, to mention but a few, are already occupying the academic, scientific, experts, and activist communities, who have started to imagine the “new normal.”. (shrink)

Background: Ethical challenges are common in clinical nursing practice, and an infectious environment could put nurses under ethical challenges more easily, which may cause nurses to submit to negative emotions and psychological pressure, damaging their mental health. Purpose: To examine the ethical challenges encountered by nurses caring for patients with the novel coronavirus pneumonia (COVID-19) and to provide nurses with suggestions and support regarding promotion of their mental health. Research design and method: A qualitative study was carried out using a (...) qualitative content analysis. The participants were 18 nurses who agreed to attend an interview and describe their own experiences of providing care to COVID-19 patients in China. They were purposively sampled, and structured, in-depth interviews were performed. Data were iteratively collected and analyzed from February to March 2020. Ethical considerations: The proposal was approved by the Research Ethics Committee of the Second Hospital of Shandong University, China. Findings: The findings revealed three main themes and 10 categories. The themes were the following: (1) ethical challenges (people with COVID-19, inequality, professional ethics, and job competency); (2) coping styles (active control and planning, seeking support as well as catharsis, and staying focused); and (3) impacts on career (specialized nursing skills, scientific research ability, and management skills). Conclusion: Nurses faced ethical challenges on multiple fronts in caring for COVID-19 patients. The results may help nurses with more safety, ethics, and humanistic care in nursing practice. (shrink)

Managers tasked with organizational change often face irreconcilable demands on how to enact justice—situations we call _justice conundrums_. Drawing on interviews held with managers before and after a planned large-scale change, we identify specific conundrums and illustrate how managers grapple with these through three prototypical paths. Among our participants, the paths increasingly diverged over time, culminating in distinct career decisions. Based on our findings, we develop an integrative process model that illustrates how managers grapple with justice conundrums. Our contributions are (...) threefold. First, we elucidate three types of justice conundrums that managers may encounter when enacting justice in the context of planned organizational change (the justice intention-action gap, competing justice expectations, and the justice of care vs. managerial-strategic justice) and show how managers handle them differently. Second, drawing on the motivated cognition and moral disengagement literature, we illustrate how cognitive mechanisms coalesce to allow managers to soothe their moral (self-) concerns when grappling with these conundrums. Third, we show how motivated justice intentions ensuing from specific justice motives, moral emotions, and circles of moral regard predict the types of justice conundrums managers face and the paths they take to grapple with them. (shrink)

Today, health systems around the world are under pressure to create greater value for patients and society [81, p. 1, 119]; increasing access, improving client orientation and responsiveness, reducing medical errors and safety, restraining utilization via managed care, and implementing priority allocation of resources for high-burden health problems are examples of strategies towards this end. The quality paradigm by virtue of its strategic consumer focus and its methods for achieving operational excellence has proved an effective approach for creating (...) higher value in many sectors. If applied in a deliberate and holistic manner, the quality paradigm can bring about a more cost-effective organization of the health systems. In this article, we apply quality concepts to healthcare in a conceptual format; we characterize the health system’s customers and outputs with their quality dimensions. The product of this effort is a blueprint for a customer-driven health system which identifies six types of customers, nine types of outputs and the associated operations. As a preliminary step, a new analysis and definition of health and disease is provided. Rethinking the structure of health system in this manner and the related conceptual model can guide medical research, health sciences education, and health services policy, and help the practitioner to integrate all modern trends in healthcare delivery. (shrink)

Health-care provider liability has again taken center stage in American political debate, but with an ironic twist. In the seventies, physicians wanted tort reform, but they measured such reform solely by a reduction in both the risk of being sued and the size of any judgment a plaintiff could win. Malpractice reforms in many states in the seventies therefore capped damages, reduced contingency awards to lawyers, and restricted other tort rules to limit plaintiff success. Today physicians are conflicted. They (...) want an increase in liability exposure — not for themselves, but for managed care plans. We have therefore ended up with a series of overlapping debates, with the same debaters taking contradictory positions. Should managed care organizations—until now protected by ERISA preemption from liability—be liable? Physicians say yes. But should physicians be protected from the threat of suit, which they argue acts as an in terrorem device that drives disclosure of medical errors into hiding? (shrink)

AimsThis study aimed to investigate barriers in the observation of professional ethics during clinical care from a nursing viewpoint. Also, it examined the association between these barriers and nurse demographic variables.MethodsA descriptive-analytic design was carried out on 207 nurses working in selected hospitals within an urban area of Iran in 2019. Data were collected using a standard questionnaire containing 33 questions that measured barriers to observation of professional ethics. The questionnaire measures three domains of management, environment and individual (...) class='Hi'>care.ResultsIn the management dimension, the most important barrier preventing observation of professional ethics was the shortage of personnel. For the environmental dimension, biological changes due to working on the nightshift, and for the individual care dimension, a lack of time were the most important barriers preventing observation of clinical ethics. Findings additionally highlighted a significantly inverse association between barriers to observing professional ethics and the male gender, participating in the ethics workshop and high work-level experiences.ConclusionsIt is suggested that nursing managers in hospitals correct and remove obstacles with careful planning and emphasis on principles and standards of care including environmental and managerial factors and training professional ethics to nurses. (shrink)

Theory of health care ethics -- Principles of health care ethics -- The moral status of gametes and embryos : storage and surrogacy -- The ethical challenges of the new reproductive technology -- Ethics and aging in America -- -- Healthcare ethics committees : roles, memberships, structure, and difficulties -- Ethics in the management of health information systems -- Technological advances in health care : blessing or ethics nightmare? -- Ethics and safe patient handling and mobility -- (...) Spirituality and healthcare organizations -- A new era of health care : the ethics of healthcare reform -- Health inequalities and health inequities -- The ethics of epidemics -- Ethics of disasters : planning and response -- Domestic violence : changing theory, changing practice -- Looking toward the future. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Working on the Clinton Administration's Health Care Reform Task ForceNancy Neveloff Dubler (bio)This narrative is based on my understanding of the elements of the Health Security Act that may have ethical implications. I have reconstructed these elements from my experience on the Health Care Reform Task Force and they are part of the health care plan that the President presented to Congress. (At the time this (...) article went to press, the actual legislation, which should answer my remaining specific questions more clearly, had not yet been released.) I perceive the most important features of the plan to be:• The legislation will create a "right" to health care for all citizens—access to care will be universal;• The plan will involve some form of managed competition in which groups of providers (called Approved or Accredited Health Plans (AHPs)) will offer comparable benefit packages at slightly (or widely) different costs;• The AHPs will negotiate with the Health Alliance (HA) to determine the price that they will charge their consumer-patients;• There will be open enrollment with no barriers to coverage, such as exclusions for pre-existing conditions;• Community rating will be in effect in different localities and enrolled persons in any AHP will pay the same premium;• The coverage for any enrolled person will be portable;• The overall structure will be a cooperative federal/state enterprise in which the states will have quite extensive abilities to fashion variations of the basic plan to meet their particular needs;• Primary care will be encouraged and incentives for physicians to train in primary care specialties provided;• Non-physician providers will be central to the functioning of the health care plans;• Efforts will be made to develop a "person power" pool so that people with an abstract "right" to health care will have real access to providers, in their localities, who can fulfill the promise that the right creates; [End Page 421]• The goal of cost containment will be central to the organization and regulation of the system;• Administrative simplicity and quality protections will be central.Co-chairing the Bioethics Working Group (BWG) of the White House Task Force on Health Care Reform was a unique experience. Approximately 40 Task Force working groups were established by Hillary Rodham Clinton, the President, and the senior Task Force staff. Various members of the President's office and other knowledgeable members of the Executive Branch selected the participants. In our group, appointments were made largely on the recommendations of the co-chairs. The BWG, among the last of the groups formed, carried the official name "The Working Group on the Ethical Foundations of the New System" and was jointly led by me and Marion Gray Secundy, a Professor of Bioethics at Howard University. The fact that the leadership of the Task Force saw fit to establish such a group, thereby confirming that bioethics is a player in the arena of health care policy, was in itself significant and was made no less so by the lack of clarity regarding the group's aims and goals.The working groups of the Task Force were organized into clusters, determined by the relatedness of the somewhat distinct, but always overlapping, content of their investigations. Separate clusters and working groups, for example, looked at mental health, long term care, and the benefit package and coverage for low-income and non-working families. On this last issue there was also a working group that explored health policy initiatives for underserved populations. This multiple focus on related issues proved to be an excellent method for ensuring that the complexity of these topics was sufficiently explored. There was a published schedule for when these groups met together, and members of other groups who had similar or overlapping concerns were invited to attend and to participate.Every week or so, all of the working groups reported to the Task Force leadership, under the direction of Ira Magaziner, in a process called a "tollgate." Prior to the tollgate, the working groups were required to submit formal written analyses of the problems they had most recently been considering. Copies of these documents were placed in a special room so that those who were interested could review... (shrink)

Background -- Overview of legal sources -- Summary of recent prosecutions and investigations -- Applications of law and professional and trade association standards to physician relationships with industry -- Legal and ethical aspects of specific physician's industry financial relationships -- Approaching and adopting effective compliance plans.

Objective: To identify the frequency and nature of care conflict dilemmas that United States long-term care providers encounter, response strategies, and use of ethics resources to assist with dispute resolution. Design: An online cross-sectional survey was distributed to the Society for Post-Acute and Long-Term Care Medicine (AMDA). Results: Two-thirds of participants, primarily medical directors, have rejected surrogate instructions and 71% have managed family conflict. Conflict over treatment decisions and issues interpreting advance directives were frequently reported. Half (...) of facilities lack a formal dispute mediation policy. Only five respondents have called an ethics consult for assistance. Conclusion: Ethically tense care conflicts commonly arise in long-term and post-acute care facilities. Few facility procedures incorporate ethics resources into actual practice. Recommendations are made to create actionable policy, increase access to ethics services, and support staff skill development in order to improve the end-of-life care experiences for patients, families, and care facility staff. (shrink)