The growing prevalence of health care ethics consultation (HCEC) services in the U.S. has been accompanied by an increase in calls for accountability and quality assurance, and for the debates surrounding why and how HCEC is evaluated. The objective of this study was to evaluate the effectiveness of HCEC as indicated by several novel outcome measurements in East Asian medical encounters.

Political theorists generally defend the moral importance of health care by appealing to its purported importance in promoting good health and saving lives. Recent research on the social determinants of health demonstrates, however, that health care actually does relatively little to promote good health or save lives in comparison with other social and environmental factors. This article assesses the implications of the social determinants of health literature for existing theories of health (...) care justice, and outlines a new approach that can justify publicly subsidized comprehensive health care despite its limited contribution to good health. Even if health care plays a relatively limited role in promoting good health, it remains morally important because of the care it provides to individuals. As such, it can be justified in terms of care ethics. When health care is justified primarily in terms of care rather than health, however, the goals of a just health-care system shift. The measure of a just health-care system is no longer strictly its ability to generate good health outcomes but also its ability to provide individuals with accessible, good quality daily care. This different focus has important consequences for the way we think about the institutions of a just health-care system as well as for the delivery and allocation of medical goods and services. (shrink)

Ethics consultation has become an integral part of the fabric of U.S. health care delivery. This article summarizes the second edition of the Core Competencies for Health Care Ethics Consultation report of the American Society for Bioethics and Humanities. The core knowledge and skills competencies identified in the first edition of Core Competencies have been adopted by various ethics consultation services and education programs, providing evidence of their endorsement as health care (...) ethics consultation (HCEC) standards. This revised report was prompted by thinking in the field that has evolved since the original report. Patients, family members, and health care providers who encounter ethical questions or concerns that ethics consultants could help address deserve access to efficient, effective, and accountable HCEC services. All individuals providing such services should be held to the standards of competence and quality described in the revised report. (shrink)

BackgroundAs hospitals have grown more complex, the ethical concerns they confront have grown correspondingly complicated. Many hospitals have consequently developed health care ethics programs (HCEPs) that include far more than ethics consultation services alone. Yet systematic research on these programs is lacking.MethodsBased on a national, cross-sectional survey of a stratified sample of 600 US hospitals, we report on the prevalence, scope, activities, staffing, workload, financial compensation, and greatest challenges facing HCEPs.ResultsAmong 372 hospitals whose informants responded to (...) an online survey, 97% of hospitals have HCEPs. Their scope includes clinical ethics functions in virtually all hospitals, but includes other functions in far fewer hospitals: ethical leadership (35.7%), regulatory compliance (29.0%), business ethics (26.2%), and research ethics (12.6%). HCEPs are responsible for providing ongoing ethics education to various target audiences including all staff (77.0%), nurses (59.9%), staff physicians (49.0%), hospital leadership (44.2%), medical residents (20.3%) and the community/general public (18.4%). HCEPs staff are most commonly involved in policy work through review of existing policies but are less often involved in development of new policies. HCEPs have an ethics representative in executive leadership in 80.5% of hospitals, have representation on other hospital committees in 40.7%, are actively engaged in community outreach in 22.6%, and lead large-scale ethics quality improvement initiatives in 17.7%. In general, major teaching hospitals and urban hospitals have the most highly integrated ethics programs with the broadest scope and greatest number of activities. Larger hospitals, academically affiliated hospitals, and urban hospitals have significantly more individuals performing HCEP work and significantly more individuals receiving financial compensation specifically for that work. Overall, the most common greatest challenge facing HCEPs is resource shortages, whereas underutilization is the most common greatest challenge for hospitals with fewer than 100 beds. Respondents’ strategies for managing challenges include staff training and additional funds.ConclusionsWhile this study must be cautiously interpreted due to its limitations, the findings may be useful for understanding the characteristics of HCEPs in US hospitals and the factors associated with these characteristics. This information may contribute to exploring ways to strengthen HCEPs. (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)

This essay argues that medical innovation proceeds most efficiently and effectively within a free market economy. Medical innovation is an expression of the technological project: the program through which we seek to control nature, to improve the quality and quantity of life. The Technological Project proceeds most efficiently with a free market economy because such a market both promotes competition and encourages innovation. As I argue, the market is a discovery process in which alternatives are tried, tested, and selected (...) by consumer's choices. The alternatives to a free market - primarily central planning and a heavily regulated market - fail adequately to encourage medical innovation. (shrink)

Proposals for health care cost containment emphasize high-value care as a way to control spending without compromising quality. When used in this context, ‘value’ refers to outcomes in relation to cost. To determine where health spending yields the most value, it is necessary to compare the benefits provided by different treatments. While many studies focus narrowly on health gains in assessing value, the notion of benefit is sometimes broadened to include overall quality of (...) life. This paper explores the implications of using subjective quality of life measures for value assessment. This approach is claimed to be more respectful of patients and better capture the perspectival nature of quality of life. Even if this is correct, though, subjective measurement also raises challenging issues of interpersonal comparability when used to study health outcomes. Because such measures do not readily distinguish benefits due to medical interventions from benefits due to personal or other factors, they are not easily applied to the assessment of treatment value. I argue that when the outcome of interest in value assessment is broadened to include quality of life, the cost side of these measures should also be broadened. I show how one philosophical theory of well-being, Jason Raibley’s “agential flourishing” theory, can be adapted for use in quality of life research to better fit the needs and aims of value assessment in health care. Finally, I briefly note some implications of this argument for debates about fairness in health care allocations. (shrink)

As web instruction becomes more and more prevalent at universities across the country, instructors of ethics are being encouraged to develop online courses to meet the needs of a diverse array of students. Web instruction is often viewed as a cost-saving technique, where large numbers of students can be reached by distance education in an effort to conserve classroom and instructor resources. In practice, however, the reverse is often true: online courses require more of faculty time and effort than (...) do many traditional classes. Based on personal experience teaching an online course in health care ethics for students in the Allied Health Professions, it is evident that there are both benefits and challenges in teaching online courses, particularly in ethics. Examples of benefits are (1) the asynchronous nature of web instruction allows students to progress through the course at their own pace and at times that are convenient given their clinical responsibilities; (2) web courses allow for a standardization of content and quality of instruction over a diversity of programs; and (3) examples can be tailored to the differing experiences of students in the course. Some challenges to teaching online ethics courses include (1) the fact that online instruction benefits visual learners and disadvantages those lacking good reading comprehension or strong writing skills; (2) developing meaningful student-student and student-instructor interaction; and (3) teaching ethics involves teaching a process rather than a product. Allowing students to apply their knowledge to real-world cases in their disciplines and encouraging them to share experiences from clinical practice is an effective way to meet several of these challenges. Building an online community is another good way to increase the interaction of students and their engagement with the material. (shrink)

This study brings together two important literatures together in the one volume. One concerns the role of quality assessments in social policy, especially health policy. The second concerns ethical and social issues raised by prenatal testing for disability. Hitherto, these two literatures have had little contact with each other: few scholars have written about both, or have compared the two domains in a systematic way, while people with disabilities and disability scholars are underrepresented in recent discussion on (...) class='Hi'>health policy and quality of assessment. This book turns the perspectives of disability scholars on issues that have largely been the province of health methodology, policy and philosophy, while angling philosophical policy analysis on problems that have largely been the province of disability scholarship. This volume will be sought after by bioethicists, philosophers, and specialists in disability studies and healthcare economics. (shrink)

Background: In health, ethics is an essential aspect of practice and care and guarantees a better quality of life for patients and their caregivers. Objective: To outline a conceptual analysis of quality of life and ethics, identifying attributes, contexts and magnitudes for health. Method: A qualitative design about quality of life and ethics in health, considering the evolutionary approach in order to analyse the concept. To collect the data, a search (...) was done using the keywords ethic*, quality of life and health. After, in total, 152 studies were found, finalizing seven relevant studies for the proposed concept analysis. Findings and discussion: Of seven studies analysed, their main results were shown by means of antecedents, consequences and attributes of the concepts. The three final attributes that synthesize the concept of quality of life and ethics in health were highlighted: Ethics dilemmas and quality of life; Human ethics and quality of life; and Ethics of care and quality of life. In fact, the attributes and context clearly reveal that ethics and quality of life influence the ability to solve ethical dilemmas, guarantee human ethics in healthcare and impact ethics in healthcare for the production of effective health policies and care that encompasses professional quality of life as well. Conclusion: The magnitude of ethical knowledge in each professional discipline permits cultivating a solidary attitude and developing the willingness to improve healthcare. The right to access, dignity and respect in care delivery are rooted in behaviours and are spontaneously applied in practice to the extent that they play an ethical role. (shrink)

This book contains a sustained defense of the Quality Adjusted Life Years (QALY) approach to resource allocation in health care. According to this approach resources should be allocated in such a way that the number of QALYs gained is maximized. The authors place this approach within a broader preference Utilitarian framework and argue that it is a special case of consequentialism specifically relevant to the health care field. The first two chapters of the book give (...) a basic introduction to the health care economic aspects of QALYs and a basic introduction to the purpose of ethical reasoning. The three subsequent chapters form the core of the book and contain a systematic defense of the QALY approach against all the main criticisms that have been put forward in the literature. The final chapter contains the results of a survey of the attitudes and reasoning of the Australian public with regard to resource allocation. (shrink)

Background: The advances in science and technology increasingly lead to the appearance of ethical issues and to the complexity of care. Therefore, it is important to define the ethics position of students studying in health departments so that high quality patient care can be achieved. Objectives: The aim of this study was to examine the ethics position of the students at Shool of Health of an University in western Turkey. Methods: The study design (...) was descriptive and cross-sectional. The study population included 540 first, second, third, and fourth year students from the Departments of Nursing, Midwifery, and Rescue and Disaster Management in the 2013–2014 academic year. Data were collected with a Personal Identification Form and The Ethics Position Questionnaire. Obtained data were analyzed with Chi-square test, Confirmatory Factor Analysis, and Nested Analysis of Variance. Ethical considerations: Before conducting the research, approval was obtained from Ege University Clinical Research Ethics Committee in İzmir and written informed consent was taken from all the participants. Findings: There was no significant difference in the mean scores for the Ethics Position Questionnaire between the students in terms of years and fields of study. Although the mean scores for the subscale idealism did not differ between fields of study, the mean scores significantly differed between years of study. However, the mean scores for the subscale relativism did not differ in terms of years and fields of study. Discussion: Whether students are idealistic or relativistic in terms of ethical judgment will be effective in ethical decision-making skills during patient care. Therefore, we need to define the factors that influence students’ ethics position in the future. Conclusion: It is suggested that the courses and practices that teach students to be aware of their ethics position to create an ethical outlook can be placed in the curriculum in health schools. (shrink)

Commodification of health care is a central tenet of managed care as it functions in the United States. As a result, price, cost, quality, availability, and distribution of health care are increasingly left to the workings of the competitive marketplace. This essay examines the conceptual, ethical, and practical implications of commodification, particularly as it affects the healing relationship between health professionals and their patients. It concludes that health care is not a (...) commodity, that treating it as such is deleterious to the ethics of patient care, and that health is a human good that a good society has an obligation to protect from the market ethos. (shrink)

The United States has a population of three hundred million, according to latest Census Bureau estimates. Forty-seven million, including many non-citizens, are uninsured. That is, 16% of the total United States population has no health insurance. Millions more have inadequate coverage and are in danger of losing that. Private, corporatized medical coverage, structured by the insurance industry, is the basis for the current system. This article is an attempt to lay out the principal health care issues, to (...) look at the alternatives and the cost of those alternatives, and to try to determine whether there is a particular regime that, despite its imperfections, is the best available to us now. (shrink)

Definition of the problem Interprofessional learning of nursing trainees and medical students offers numerous opportunities for future cooperation aiming to provide high-quality care for patients. Arguments Expert panels, therefore, demand early integration of interprofessional teaching and learning structures in order to be able to achieve effective and sustainable improvements in practice. In Germany, interprofessional learning formats are increasingly used in undergraduate education of the two professions in selected—compulsory and optional—themes and courses. Conclusion So far, the field of (...) class='Hi'>health care ethics has scarcely been taken into consideration. The article examines the situation of interprofessional ethics teaching in Germany and highlights its opportunities and limitations against the background of a pilot project. (shrink)

Machine generated contents note: Introduction Chapter 1: The basics of ethical decision-making Chapter 2: Hospital ethics committees and clinical ethicists Chapter 3: The settings of health care ethical dilemmas Chapter 4: Advance directives Chapter 5: Do Not Resuscitate orders and "Code Blue" Chapter 6: Non-beneficial medical interventions Chapter 7: Quality of life and treatment burdens Chapter 8: Patient privacy and confidentiality Chapter 9: Refusing medical treatment Chapter 10: Health care at the end of life (...) Chapter 11: Transplant ethics Chapter 12: Neuroethics Chapter 13: Ethics and reproductive technology Chapter 14: Genetics and ethics Chapter 15: Pediatric ethics Chapter 16: Participating in a research study Appendix A: Resource List Appendix B: Glossary Index. (shrink)

Coercion in mental health care gives rise to many ethical challenges. Many countries have recently implemented state policy programs or development projects aiming to reduce coercive practices and improve their quality. Few studies have explored the possible role of ethics in such initiatives. This study adds to this subject by exploring health professionals’ descriptions of their ethical challenges and strategies in everyday life to ensure morally justified coercion and best practices. Seven semi-structured telephone interviews were (...) carried out in 2012 with key informants in charge of central development projects and quality-assurance work in mental health services in Norway. No facilities used formal clinical ethics support. However, the informants described five areas in which ethics was of importance: moral concerns as implicit parts of local quality improvement initiatives; moral uneasiness and idealism as a motivational source of change; creating a normative basis for development work; value-based leadership; and increased staff reflexivity on coercive practices. The study shows that coercion entails both individual and institutional ethical aspects. Thus, various kinds of moral deliberation and ethics support could contribute to addressing coercion challenges by offering more systematic ways of dealing with moral concerns. However, more strategic use of implicit and institutional ethics is also needed. (shrink)

Together with large biobanks of human samples, medical registries with aggregated data from many clinical centers are vital parts of an infrastructure for maintaining high standards of quality with regard to medical diagnosis and treatment. The rapid development in personalized medicine and pharmaco-genomics only underscores the future need for these infrastructures. However, registries and biobanks have been criticized as constituting great risks to individual privacy. In this article, I suggest that quality with regard to diagnosis and treatment is (...) an inherent, morally normative requirement of health care, and argue that quality concerns in this sense may be balanced with privacy concerns. (shrink)

Pay-for-performance represents an effort to improve the quality of health care by paying physicians more if they meet specified target measures. There are both empirical and theoretical reasons to be deeply suspicious of P4P schemes applied at the level of the individual physician or health provider. Most P4P programs were implemented before there were any good data to demonstrate that they achieved the desired results. Once such schemes were in use, the available data are far from (...) reassuring. Common findings are that providers may do more of the specific procedure that is being measured, but in the process may neglect to do other things that equally affect quality of care. Payers often find that the cost of implementing a P4P program far exceeds the value of the very modest resulting improvements; and payments may unfairly benefit providers who are already meeting quality targets while disadvantaging those who make the most strenuous efforts to improve. (shrink)

This article discusses ethical issues which are raised as a result of the introduction of economic evidence in mental health care in order to rationalise clinical practice. Cost effectiveness studies and guidelines based on such studies are often seen as impartial, neutral instruments which try to reduce the influence of non-scientific factors. However, such rationalising instruments often hide normative assumptions about the goals of treatment, the selection of treatments, the role of the patient, and the just distribution of (...) scarce resources. These issues are dealt with in the context of increased control over clinical practice by third parties. In particular, health insurers have a great interest in economic evidence in clinical care settings in order to control access to and quality of health care. The authors conclude that guideline setting and cost effectiveness analysis may be seen as important instruments for making choices in health care, including mental health care, but that such an approach should always go hand in hand with a social and political debate about the goals of medicine and health care. This article is partly based on the results of a research project on the normative aspects of guideline setting in psychiatry and cardiology which was conducted under the guidance of the Royal Dutch Medical Association. (shrink)

The way health is conceptualized determines the actions taken to protect and promote it and, in turn, the actors responsible for such actions in an increasingly inter-dependent world. This essay presents a brief description of health policies in Peru during the last ten years in order to analyze the implications of paradigms of medical ethics, human rights and quality of care. These paradigms offer distinct ways of formulating, applying and evaluating health policies and understanding (...) the relationship among different actors at various levels. Building upon other detailed analyses of sexual and reproductive health policy in Peru (Coe, 2004; Miranda and Yamin, 2004), as well as critical appraisals of health services models (Gericke, Kurowski, Ranson and Mills, 2005; Krieger, Northridge, Gruskin, Quinn, Kriebel, Davey Smith, Bassett, Rehkopf and Miller, 2003), this article advocates the importance of construing and promoting health as a human right. (shrink)

In the context of health care the aim of the article is to bring another meaning to the concept “need” that goes beyond the human activity; the drive to satisfy needs. Another meaning incorporates an ethical and existential nature of life phenomena. An example from empirical research on living with a chronic disease as seen from the patient’s point of view provides the basis for arguing another meaning of the concept “need”. The meanings and nuances in the life (...) phenomena of hope, doubt and life courage are exemplified in qualitative interviews with chronic sufferers. A combination of empirical research and Danish life philosophy. Research has shown that the interaction between the professional health care provider and the patient and family may lead to a more or less unconscious and inappropriate administration of power. Research also indicates that by overlooking or ignoring the existential qualities in human life and suffering, the professional health care provider may deprive the patient and family of their room for action. To add a deeper understanding of the existential meaning of being a person with an illness, the article shows the different human dimensions concerning life phenomena and needs. Developing sensitive, situation-specific attention offers a response to the challenge faced by health care providers in collaboration with the patient: How can we open our eyes to the most significant features of the situation which arise on the onset of illness. (shrink)

Wearable sensors are an integral part of the new telemedicine concept supporting the idea that Information Technologies will improve the quality and efficiency of healthcare. The use of sensors in diagnosis, treatment and monitoring of patients not only potentially changes medical practice but also one’s relationship with one’s body and mind, as well as the role and responsibilities of patients and healthcare professionals. In this paper, we focus on knowledge assessment of the online communities of Fitbit and the Quantified (...) Self movement. Through their online forums, we investigate how users’ knowledge claims, shared experiences and imaginations about wearable sensors interrogate or confirm the narratives through which they are introduced to the publics. Citizen initiatives like the Quantified Self movement claim the right to ‘own’ the sensor generated data. But how these data can be used through traditional healthcare systems is an open question. More importantly, wearable sensors trigger a social function that is transformative of the current idea of care and healthcare, focused on sharing, socialising and collectively reflecting about individual problems. Whether this is aligned with current policy making about healthcare, whose central narrative is focused on efficiency and productivity, is to be seen. (shrink)

There is an increasing body of research on what kind of ethical challenges health care professionals experience regarding the quality of care. In the Netherlands the Dutch Health Care Inspectorate is responsible for monitoring and regulating the quality of health care. No research exists on what kind of ethical challenges inspectors experience during the regulation process itself. In a pilot study we used moral case deliberation as method in order to reflect (...) upon inspectors’ ethical challenges. The objective of this paper is to give an overview of the ethical challenges which health care inspectors encounter in their daily work. A thematic qualitative analysis was performed on cases that were collected from health care inspectors in a moral case deliberation pilot study. Eight themes were identified in health care regulation. These can be divided in two categories: work content and internal collaboration. The work of the health care inspectorate is morally loaded and our recommendation is that some form of ethics support is provided for health care inspectors. (shrink)

Acceptance of elderly or marginal health individuals as kidney donors is debated, with practices varying between centres. Transplant recipients, live kidney donors and health-care professionals caring for patients with renal failure were surveyed regarding their views on live donor kidney transplantation (LDKT) of marginal health (diabetes, hypertension, atherosclerosis, obesity, etc.) and elderly donors. Participants were recruited within a tertiary renal and transplant centre and invited to participate in focus groups and structured interviews. They also completed an (...) anonymous questionnaire. Of 464 participants who completed the questionnaire (36% health-care professionals and 64% patients), 49% and 64%, respectively, stated that marginal and elderly donors should be accepted for LDKT. In the structured interviews, emphasis was given to presenting to donor, recipient and their respective families a calculated risk regarding the effect that either a nephrectomy or transplant has on long-term quality of life. Participants stated that an independent third party in addition to the transplant team should discuss involved risks. Issues of ‘how desperate’ the recipient's situation is should also be considered. Health-care professionals stated that regardless of the strength of will of an individual to donate a kidney (despite age, health problems or personal risk), they should always have the right to say ‘no’ if performing a specific LDKT was against their professional and ethical values. About half of those surveyed considered that marginal health and elderly donors were acceptable for LDKT. Emphasis was given to the explanation to donors and recipients of the risks involved in such transplantation. (shrink)

Physicians and institutional providers face expanding liability exposure today, in spite of state tort reform legislation and public awareness of the costs of malpractice for providers. Standards of practice are evolving rapidly; new medical technologies are being introduced at a rapid rate; information is proliferating as to treatment efficacy, patient risk, and diseases generally. Tort standards mirror this change. As medical standards of care evolve, they provide a benchmark against which to measure provider failure. The liability exposure of physicians (...) is affected by the generation of data, including outcomes data usable to profile physician practice, and statistical data that allows for predictions as to treatment efficacy, and patient prognosis; obligations to inform patients and third parties of risk created by contagious disease and other sources of harm; obligations of physicians to disclose risks that the provider creates for the patient; obligations to disclose conflicts of interest arising out of the practice setting; and duties arising from new epidemiological knowledge. (shrink)

Proposed solutions to the problems of this country's health care system range along a spectrum from central planning to free market. Central planners and free market advocates provide various ethical justifications for the policies they propose. The crucial flaw in the philosophical rationale of central planning is failure to distinguish between normative and metanormative principles, which leads to mistaken understanding of the nature of rights. Natural rights, based on the principle of noninterference, provide the link between individual morality (...) and social order. Free markets, the practical expression of natural rights, are uniquely capable of achieving the goals that central planners seek but find beyond their grasp. The history of this country's health care system and the experiences of other nations provide evidence of the superiority of free markets in reaching for the goals of universal access, control of costs, and sustaining the quality of health care. (shrink)

Institutional review boards distinguish health care quality improvement and health care quality improvement research based primarily on the rigor of the methods used and the purported generalizability of the knowledge gained. Neither of these criteria holds up upon scrutiny. Rather, this apparently false dichotomy may foster under-protection of participants in QI projects and over-protection of participants within QIR.

The Institute of Medicine reporting on the quality of health care in America recommends six aims for achieving the health care system we could have. Together with the Institute for Healthcare Improvement Triple Aim initiative, a framework has emerged to challenge providers, educators, and policymakers to remake the health care system according to specific objectives: to provide care that is safe, effective, patient-centered, timely, efficient, and equitable to more people at a price (...) we can afford. Complicating this mission of better prevention and better care at a lower cost is a daunting demographic: January of 2011 marked the month and year that the first of the baby boomers turned 65. The U.S. Census Bureau in May 2010 projected the number of Americans of this age and over to reach 88 million by 2050, more than double the current figure of 40.2 million. Parekh and Barton forecast in stark detail what it will be like to address these burgeoning numbers of older Americans with comorbidities, including the fact that over 20% of the population currently experiences at least two chronic medical conditions. (shrink)

Recently, moral deliberation within care institutions is gaining more attention in medical ethics. Ongoing dialogues about ethical issues are considered as a vehicle for quality improvement of health care practices. The rise of ethical conversation methods can be understood against the broader development within medical ethics in which interaction and dialogue are seen as alternatives for both theoretical or individual reflection on ethical questions. In other disciplines, intersubjectivity is also seen as a way to (...) handle practical problems, and methodologies have emerged to deal with dynamic processes of practice improvement. An example is responsive evaluation. In this article we investigate the relationship between moral deliberation and responsive evaluation, describe their common basis in dialogical ethics and pragmatic hermeneutics, and explore the relevance of both for improving the quality of care. The synergy between the approaches is illustrated by a case example in which both play a distinct and complementary role. It concerns the implementation of quality criteria for coercion in Dutch psychiatry. (shrink)

The health sector is facing many challenges, and there is a need to maintain the delivery of high‐quality health‐care. Issues related to equity and access to health‐care have emerged in a context of an economic recession in which the sustainability of the health system depends on everyone, including the actions and decisions of professionals. Therefore, nurses and their skills may be the answer to ethical, professional and community health management, but this recession (...) could lead to major problems in the education of nurses in daily health‐care practice. Due to the limited availability of resources, nurses are increasingly taking leadership positions, continuing to develop their critical abilities and thinking skills, and considering sciences such as deontology and ethics. The main goals of this study were to reflect on the economic recession and its impact on health‐care and to demonstrate the contribution of nursing to the sustainability of health‐care and in the promotion of individuals' dignity. The authors conclude that health‐care depends on economic redistribution and, in this context, needs to be equitable and fair. Nurses have the responsibility to develop their profession according to the underlying sciences and can therefore strategically help the healthcare system. (shrink)

This article considers the moral notion of care in the context of Quality of Care discourses. Whilst care has clear normative implications for the delivery of health care it is less clear how Quality of Care, something that is centrally involved in the governance of UK health care, relates to practice.

A remarkable surge in efforts to assess the quality of life of patients has occurred in recent years in medical research. Philosophical discussions of these developments have focused, on the one hand, on epistemological reservations about the plausibility of measuring quality of life and, on the other hand, on moral and ethical qualms about the meaning of life conveyed in such assessments. Whilst providing an important note of caution, such critiques fail to recognise two basic principles of (...) class='Hi'>quality of life in medical research. Firstly it is intended to provide understanding about groups and categories of patients rather than individuals. Secondly the purpose of such research is to produce generalisations about the relative costs and benefits of specific health care interventions rather than absolute judgements regarding the quality of life of patients per se. Selecting a good quality of life measure for a clinical trial requires balancing criteria such as validity with practical feasibility. Such measures will play an increasingly central role in providing research evidence to improve health care. (shrink)

Despite increasing interests and urgent needs for quality end-of-life care, there is no exact definition of what is the interval referred to as end of life or what end-of-life care is. The purpose of this article is to report our examination of terms related to end-of-life care and define end-of-life care from nursing ethics perspectives. Current terms related to end-of-life care, such as terminal care, hospice care, and palliative care, are (...) based on a medical model and are restrictive in terms of diagnosis and prognosis. Using codes of ethics for nurses as a framework, we attempt to identify people to whom nurses are responsible to provide end-of-life care and develop a definition of end-of-life care that is more inclusive and applicable to a broader range of people who would benefit from end-of-life care by nurses and other health-care providers. (shrink)

Edited by four leading members of the new generation of medical and healthcare ethicists working in the UK, respected worldwide for their work in medical ethics, Principles of Health Care Ethics, Second Edition_is a standard resource for students, professionals, and academics wishing to understand current and future issues in healthcare ethics. With a distinguished international panel of contributors working at the leading edge of academia, this volume presents a comprehensive guide to the field, with state (...) of the art introductions to the wide range of topics in modern healthcare ethics, from consent to human rights, from utilitarianism to feminism, from the doctor-patient relationship to xenotransplantation. This volume is the Second Edition of the highly successful work edited by Professor Raanan Gillon, Emeritus Professor of Medical Ethics at Imperial College London and former editor of the Journal of Medical Ethics, the leading journal in this field. Developments from the First Edition include:_ The focus on ‘Four Principles Method’ is relaxed to cover more different methods in health care ethics. More material on new medical technologies is included, the coverage of issues on the doctor/patient relationship is expanded, and material on ethics and public health is brought together into a new section. (shrink)

Background: Palliative care is an important part of health services. The individualized care perceptions are is critical for supporting individuality during care and providing quality nursing care. Individualized care not only has, as well as having foundation of the philosophy of nursing but also, is also related to the nurses’ empathic tendencies and professional quality of life of nurses. Aim: This study was conducted to examine the relationships between the empathic tendencies, professional (...) quality of life, and individualized care perceptions of palliative care nurses. Research design: This is a cross-sectional study. Participants and research context: The study was conducted with 141 nurses working in palliative care between December 2023 and February 2024. The data of the study were collected using a “Participant Information Form,” the “Emphatic Tendency Scale (ETS),” the “Professional Quality of Life Scale (ProQOL R-IV),” and the “Individualized Care Scale-Nurse Version A (ICS-Nurse-A).” Ethical considerations: Ethics committee approval was obtained to conduct the study. Individuals who agreed to participate in the study were informed of the purpose of the study, and their written consent was obtained. Findings: The participants had moderate levels of empathic tendencies, compassion satisfaction, and burnout, while their compassion fatigue and individualized care perceptions were high. There was a positive correlation between empathic tendencies and individualized care perceptions ( p <.01). Empathic tendency and compassion satisfaction were significant positive predictors of the individualized care perceptions of the participants and respectively explained 13% and 20% of the total variance in their individualized care perceptions. On the other hand, burnout was a significant negative predictor of their individualized care perceptions and explained 5% of the total variance in their individualized care perceptions. Conclusions: High levels of empathic tendencies and compassion satisfaction had positive effects on the individualized care perceptions of palliative care nurses, whereas high levels of burnout had a negative effect on the same variable. (shrink)

Failings in patient care and quality in NHS Trusts have become a recurring theme over the past few years. In this paper, we examine the Care Quality Commission’s Guidance about Compliance: Essential Standards of Quality and Safety and ask how NHS Trusts might be better supported in fulfilling the regulations specified therein. We argue that clinical ethics committees (CECs) have a role to play in this regard. We make this argument by attending to the (...) many ethical elements that are highlighted in the Commission’s Regulations and by providing practical examples of how CECs can (and in some case already do) provide ethics support to health professionals and trusts. Although CECs have been traditionally associated with case consultation, i.e., discrete problems caused by individual circumstances, in the previous 10 years the literature suggests that clinical ethics services have become more integrated into the life of the health care organization and are increasing construed as proactive agents of systematic change. We provide evidence from a recent survey of UK clinical ethics services that this trend is present in the UK. (shrink)

In recent years a number of commentators have discussed the importance of measuring quality of life in health care. We want to know whether an intervention will help people to live better, not just longer, and whether some treatments cause more trouble than they are worth. New technologies promise wondrous benefits. But when millions of people have no insured access to health care, and when many others face increasingly stringent limits on care, technologies’ high (...) costs require us to choose what we should do from the broader universe of what we can do.The challenges to measuring QL are formidable. Researchers debate whether to measure general QL or disease-specific QL; whether to focus on functional status such as the patient's ability to walk and dress himself, or on the value people ascribe to that functional status; whether to seek the values of the general public, or to concentrate on people actually affected by a given disease or disability. (shrink)

End-of-life disputes in Ontario are currently overwhelmingly assessed through the singular lens of patient autonomy. The current dispute resolution mechanism does not adequately consider evidence-based medical guidelines, standards of care, the patient’s best interests, expert opinion, or distributive justice. We discuss two cases adjudicated by the Consent and Capacity board of Ontario that demonstrate the over emphasis on patient autonomy. Current health care policy and the Health Care Consent Act also place emphasis on patient autonomy (...) without considering other ethically defensible factors. We argue that current policy and legislation require amendment, and unless there are measures undertaken to modify them, both the quality of care provided and the long-term capabilities of the health care system to remain publicly-funded, comprehensive and equitable, are at stake. (shrink)

Guidelines orient best practices in medicine, yet, in health care, many real world constraints limit their optimal realization. Since guideline implementation problems are not systematically anticipated, they will be discovered only post facto, in a learning curve period, while the already implemented guideline is tweaked, debugged and adapted. This learning process comes with costs to human health and quality of life. Despite such predictable hazard, the study and modeling of medical guideline implementation is still seldom pursued. (...) In this article we argue that to systematically identify, predict and prevent medical guideline implementation errors is both an epistemic responsibility and an ethical imperative in health care, in order to properly provide beneficence, minimize or avoid harm, show respect for persons, and administer justice. Furthermore, we suggest that implementation knowledge is best achieved technically by providing simulation modeling studies to anticipate the realization of medical guidelines, in multiple contexts, with system and scenario analysis, in its alignment with the emerging field of implementation science and in recognition of learning health systems. It follows from both claims that it is an ethical imperative and an epistemic responsibility to simulate medical guidelines in context to minimize harm in health care, before guideline implementation. (shrink)

Every successful health care system should be based on some general humanistic ideals. However, the nationally organized health care systems of most European countries usually suffer from a deficiency in common ethical values based on universal human principles. When transitional societies, such as that of Bosnia-Herzegovina are concerned, health care organizational models are even more dysfunctional. The sources of a dysfunction in medical care system of Bosnia-Herzegovina are manifold and mutually controversial, including a (...) lack of shared principles, an inappropriate involvement of politicians in medical care and practice, administrative difficulties arising from superficial communication systems, as well as economic limits concerned with the financing of health care. The deficiency of a moral culture of medicine, which is correlated to a general collapse of morality is also responsible for many problems affecting various aspects of life including medical care. Hence, medical ethics from a virtue perspective is becoming an important ingredient of any improvement deigned to provide better-quality medical care. The aim of this paper is to underline the influence of humanism on the organization of health care systems and the ethics of medical interrelations in the society of Bosnia-Herzegovina. It is not intended to diagnose or resolve the problems, but to analyze them. It is also a critique of specific socio-political-economic influences on this health care system, inquiring if well-educated individuals in the virtues, which are involved in medical practice and education, would counteract them. In conclusion, humanism creates a universal ethical structure, which is based on human values such as fidelity, trust, benevolence, intellectual honesty, courage, compassion and truthfulness. These values should represent the standard around which medical care is organized. Since the health care system in Bosnia-Herzegovina is not entirely founded upon humanistic ideals, addressing the socio-political-economic conditions that constantly undermine those values is a prerequisite for any much-needed improvements of the medical care. (shrink)

Healthcare policy and academic literature have promoted improving the transitional care of young people leaving child and adolescent mental health services. Despite the availability of guidance on good practice, there seems to be no readily accessible, coherent ethical analysis of transition. The ethical principles of non-maleficence, beneficence, justice and respect for autonomy can be used to justify the need for further enquiry into the ethical pros and cons of this drive to improve transitional care. The objective of (...) this systematic review was therefore to systematically search for existing ethical literature on child- to adult-orientated health service transitions and to critically appraise and collate the literature, whether empirical or normative. A wide range of bioethics, biomedical and legal databases, grey literature and bioethics journals were searched. Ancestral and forward searches of identified papers were undertaken. Key words related to transition, adolescence and young adulthood, ethics, law and health. The timeframe was January 2000 to at least March 2016. Titles, abstracts and, where necessary, full articles were screened and duplicates removed. All included articles were critically appraised and a narrative synthesis produced. Eighty two thousand four hundred eighty one titles were screened, from which 96 abstracts were checked. Forty seven full documents were scrutinised, leading to inclusion of two papers. Ancestral and forward searches yielded four further articles. In total, one commentary, three qualitative empirical studies and two clinical ethics papers were found. All focused on young people with complex care needs and disabilities. The three empirical papers had methodological flaws. The two ethical papers were written from a clinical ethics context rather than using a bioethical format. No literature identified specifically addressed the ethical challenges of balancing the delivery of transitional care to those who need it and the risk of pathologizing transient and self-limited distress and dysfunction, which may be normal during adolescence. There is very little research on ethical aspects of transitional care. Most existing studies come from services for young people with complex care needs and disabilities. There is much scope for improvement in the amount and quality of empirical research and ethical analysis in this area. (shrink)

IntroductionThere is a significant disparity in the United States between the health care received by children with special health care needs versus physically healthy children.ObjectiveThe objective of the paper is to show that children with special needs receive less than adequate health care overall. This disparity affects the quality of life for these children and influences their ability to live their lives to their full potential.MethodsResearch was conducted by examining multiple studies with a (...) focus on six major factors that play a role in creating this disparity.ResultsThe findings show an alarming trend in the access and delivery of health care to children with special health care needs.ConclusionsSolutions to correcting the disparities are possible, but it will take a full understanding of the issues, perseverance, dedication, and hard work on the part of families, physicians, legislators, and others genuinely interested in creating an equal health care system for all children. (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 availability of free health care to all citizens has been regarded as a great achievement of the Soviet society. In recent decades, however, decreased funding of the state-run health care system has led to a deterioration in the quality and quantity of available medical equipment and services. More than 50 percent of the Russian population is dissatisfied with the health care system and the attitudes and moral standards of their health (...) class='Hi'>care providers. This article discusses the degree, nature, and some of the causes of the public's dissatisfaction and concludes with a preliminary look toward the future of the Russian health care system. (shrink)

Computer-based information and communication technologies continue to transform the delivery of health care and the conception and scientific understanding of the human body and the diseases that afflict it. While information technology has the potential to improve the quality and efficiency of patient care, it also raises important ethical and social issues. This IRIE theme issue seeks to provide a forum to identify, analyse and discuss the ethical and social issues raised by various applications of information (...) and communication technology in medicine and health care. The contributions give a flavour of the extraordinarily broad landscape shaped by the intersection of medicine, computing and ethics. In fact, their diversity suggests that much more work is needed to clarify issues and approaches, and to provide practical tools for clinicians. (shrink)