The American Board of Internal Medicine (ABIM) Foundation has recently initiated a campaign called “Choosing Wisely,” which is aimed at reducing “low-value” care services. Lists of low-value care services are being developed and the ABIM Foundation is urging the American Medical Association and other organizations to get behind the lists, disseminate them, and implement them. Yet, there are many ethical questions that remain about the development, dissemination, and implementation of these low-value care lists. In (...) this paper I argue for conceptual clarity with respect to the label “low-value care.” Thus far it has not been precisely defined, and I argue that there are actually 10 distinct categories of low-value care. I discuss the ethical challenges and considerations associated with each category. I also provide arguments that can be used to justify the reduction of some of these categories of low-value care. These arguments rely on Rawlsian and Hegelian notions of justice, as well as on concepts about the fiduciary obligations of physicians. Finally, I outline the various mechanisms that could be utilized for the reduction of low-value care (i.e., incentives, punishments, nonrational influences such as appeals to social norms, emotions, or ego, and creation of conditions that make avoidance easy such as defaults and reminders). I provide normative guidelines for the use of each. (shrink)

BackgroundDefensive practice occurs when physicians provide services, such as tests, treatments and referrals, mainly to reduce their perceived legal or reputational risks, rather than to advance patient care. This behaviour is counter to physicians’ ethical responsibilities, yet is widely reported in surveys of doctors in various countries. There is a lack of qualitative research on the drivers of defensive practice, which is needed to inform strategies to prevent this ethically problematic behaviour.MethodsA qualitative interview study investigated the views and experiences (...) of physicians in Australia on defensive practice and its contribution to low value care. Interviewees were recruited based on interest in medico-legal issues or experience in a health service involved in ‘Choosing Wisely’ initiatives. Semi-structured interviews averaged 60 min in length. Data were coded using the Theoretical Domains Framework, which encapsulates theories of behaviour and behaviour change.ResultsAll participants (n = 17) perceived defensive practice as a problem and a contributor to low value care. Behavioural drivers of defensive practice spanned seven domains in the TDF: knowledge, focused on inadequate knowledge of the law and the risks of low value care; skills, emphasising patient communication and clinical decision-making skills; professional role and identity, particularly clinicians’ perception of patient expectations and concern for their professional reputation; beliefs about consequences, especially perceptions of the beneficial and harmful consequences of defensive practice; environmental context and resources, including processes for handling patient complaints; social influences, focused on group norms that encourage or discourage defensive behaviour; and emotions, especially fear of missing a diagnosis. Overall, defensive practice is motivated by physicians’ desire to avoid criticism or scrutiny from a range of sources, and censure from their professional peers can be a more potent driver than perceived legal consequences.ConclusionsThe findings call for strengthening knowledge and skills, for example, to improve clinicians’ understanding of the law and their awareness of the risks of low value care and using effective communication strategies with patients. Importantly, supportive cultures of practice and organisational environments are needed to create conditions in which clinicians feel confident in avoiding defensive practice and other forms of low value care. (shrink)

Parents in the US and other societies are increasingly refusing to vaccinate their children, even though popular anti-vaccine myths – e.g. ‘vaccines cause autism’ – have been debunked. This book explains the epistemic and moral failures that lead some parents to refuse to vaccinate their children. First, some parents have good reasons not to defer to the expertise of physicians, and to rely instead upon their own judgments about how to care for their children. Unfortunately, epistemic self-reliance systematically distorts (...) beliefs in areas of inquiry in which expertise is required. Second, vaccine refusers and mainstream medical authorities are often committed to different values surrounding health and safety. For example, while vaccine advocates stress that vaccines have low rates of serious complications, vaccine refusers often resist vaccination because it is ‘unnatural’ and because they view vaccine-preventable diseases as a ‘natural’ part of childhood. Finally, parents who refuse vaccines rightly resist the utilitarian moral arguments – ‘for the greater good’ – that vaccine advocates sometimes make. Unfortunately, vaccine refusers also sometimes embrace a pernicious hyper-individualism that sanctions free-riding on herd immunity and that cultivates indifference to the interpersonal and social harms that unvaccinated persons may cause. (shrink)

This article develops an approach to ethical globalization based on a feminist, political ethic of care; this is achieved, in part, through a comparison with, and critique of, Thomas Pogge's World Poverty and Human Rights. In his book, Pogge makes the valid and important argument that the global economic order is currently organized such that developed countries have a huge advantage in terms of power and expertise, and that decisions are reached purely and exclusively through self-interest. Pogge uses an (...) institutional rights framework to argue that direct responsibility for global poverty and inequality lies with the citizens of developed countries, since suffering and death are caused by global economic arrangements designed and imposed by our governments. While this argument is certainly compelling, I have argued that it tells us little about the actual effects of globalization on the real people of the South - including women, children and the elderly. As a result, it can offer little in the way of real alternatives or policy prescriptions. As a moral orientation, a care ethic relies on a relational moral ontology, and leads us to consider different values in terms of human flourishing. Moreover, it pushes us to consider the normative implications of aspects of the global political economy which are usually not 'seen' at all, including the global distribution of care work and the corresponding patterns of gender and racial inequality, the underprovision of care and resources for caring work in both the developed and developing world, and the ways in which unpaid or low-paid caring work helps to sustain a cycle of exploitation and inequality on a global scale. (shrink)

Patients with advanced dementia are less likely than those with other terminal illnesses to receive palliative care. Due to the nature and course of dementia, there may be a failure to recognize the terminal stage of the disease. A possible and under-investigated explanation for this healthcare disparity is the healthcare practitioner who plays a primary role in end-of-life decision-making. Two potential areas that might impact provider decision-making are cognitive biases and moral considerations. In this analysis, we demonstrate how the (...) cognitive biases and moral considerations of practitioners related to clinical decision-making are inherent in clinical practice and may impact on providers’ accuracy related to diagnostic and treatment related decision-making associated with patients with advanced dementia. Anchoring, default, availability, representativeness and framing biases are cognitive biases based on the "Two System Model" that relate to decision-making in end-of-life care. In patients with advanced dementia, those biases may result in a tendency to adhere to traditional mandatory care, involving an aggressive approach to care, which values saving lives at all costs, without taking into account the possible suffering and long-term consequences. Aspects such as moral sensitivity and moral courage play an important role in ethical decision-making related to advanced dementia. Investigations of clinical decision-making that include the cognitive biases and ethical considerations of practitioners might advance the comprehensive understanding of the clinical decision-making process related to care of patients with advanced dementia and promote the quality of care given to this population. (shrink)

Background A persistent devaluation of care-work, difficult working conditions, and low salaries have led to challenges with staff recruitment and retention in the homecare sector in France. A new homecare organization adopting an innovative organizational model recently experimented an hourly payment method yielding positive outcomes. Objectives Using Tronto’s caring framework, this paper analyzes the strategies used by the founders as they developed their innovative model and the nursing activities performed during home visits. Design A longitudinal qualitative study was conducted (...) between 2017 and 2023. Homecare nursing teams were shadowed for 1–2 days per year yielding detailed field notes on caregiving activities, both before and after the new payment method. Secondary data included reports, videos, articles, and unpublished documents found online. Ethical considerations While there is no requirement in France to obtain ethical approval in non-interventional research, verbal consent was obtained by all participants prior to their involvement in the study; confidentiality and anonymity were strictly maintained; and pseudonyms were assigned to protect identities. Findings 63 interviews and 185 h of shadowing and observations were conducted. Results revealed a virtuous cycle of caring facilitated and encouraged by new incentives that resonated with nurses’ professional ethics. The favorable working environment and the hourly payment method enabled nurses to provide caregiving in accordance with their values. Conclusions As the new hourly payment experiment is scaled-up nationally, it is imperative that it is not isolated from the organizational model. Without the underpinning values and principles, the hourly payment method alone is unlikely to shift the value attributed to caring. (shrink)

Background: Equity in providing care is also a major value in the nursing profession. Equitable care aims to provide the entire population with safe, efficient, reliable, and quality nursing services at all levels of health. Objectives: This study was conducted to explain the process of the realization of equity in nursing care. Research design: This qualitative study uses Glaser’s approach to grounded theory. Participants and research context: Sample selection began with convenience sampling and continued with purposive (...) sampling. A total of 27 people were ultimately selected as the study subjects. Data were mainly collected through unstructured in-depth individual interviews plus observation and field notes. The data were then analyzed using the “Six C’s” coding family of Glaser. Ethical considerations: The study protocol was approved by the Tehran University of Medical Sciences (91D1302870). Written informed consent was also obtained from all subjects. Findings: According to the findings, participants’ main concern in providing equitable care is the rationing of nursing care. The identification of participants’ main concern led to the emergence of the core category of the study, that is, “nurses’ domination.” The other categories revolving around the core category were conceptualized according to the six C’s coding family: “nurses being dominated,” “nurses’ ineffective power in the health system,” “low attention to equitable care in health system,” “lack of clarity in measuring equitable care,” “the health structure’s inconsistency with equity,” and “the inefficiency of the care system.” Conclusion: There is a mutual relationship between providing fair care and nurses’ perceptions of equity. Nurses who have themselves experienced equity can provide their patients the experience of equity. This mutual relationship is actualized in a context in which fair care is clearly defined and demanded. (shrink)

We can make a difference in shaping the future by ensuring that computers "serve human needs." By making explicit the enduring values that we hold dear we can guide computer system designers and developers for the next decade, century, and thereafter. After setting our high-level goals we can pursue the components and seek the process for fulfilling them. High-level goals might include peace, excellent health care, adequate nutrition, accessible education, communication, freedom of expression, support for creative exploration, safety, and (...) socially constructive entertainment. Computer technology can help attain these high-level goals if we clearly state measurable objectives, obtain participation of professionals, and design effective human-computer interfaces. Design considerations include adequate attention to individual differences among users, support of social and organizational structures, design for reliability and safety, provision of access by the elderly, handicapped, or illiterate, and appropriate user controlled adaptation. With suitable theories and empirical research we can achieve ease of learning, rapid performance, low error rates, and good retention over time, while preserving high subjective satisfaction. To raise the consciousness of designers and achieve these goals, we must generate an international debate, stimulate discussions within organizations, and interact with other intellectual communities. This paper calls for a focus on the "you" and "I" in developing improved user interface research and systems, offers a Declaration of Responsibility, and proposes a Social Impact Statement for major computing projects. (shrink)

Background: Ambulance professionals often address conflicts between ethical values. As individuals’ values represent basic convictions of what is right or good and motivate behaviour, research is needed to understand their value profiles. Objectives: To translate and adapt the Managerial Values Profile to Spanish and Swedish, and measure the presence of utilitarianism, moral rights and/or social justice in ambulance professionals’ value profiles in Spain and Sweden. Methods: The instrument was translated and culturally adapted. A content validity index was calculated. (...) Pilot tests were carried out with 46 participants. Ethical considerations: This study conforms to the ethical principles for research involving human subjects and adheres to national laws and regulations concerning informed consent and confidentiality. Findings: Spanish professionals favoured justice and Swedish professionals’ rights in their ambulance organizations. Both countries favoured utilitarianism least. Gender differences across countries showed that males favoured rights. Spanish female professionals favoured justice most strongly of all. Discussion: Swedes favour rights while Spaniards favour justice. Both contexts scored low on utilitarianism focusing on total population effect, preferring the opposite, individualized approach of the rights and justice perspectives. Organizational investment in a utilitarian perspective might jeopardize ambulance professionals’ moral right to make individual assessments based on the needs of the patient at hand. Utilitarianism and a caring ethos appear as stark opposites. However, a caring ethos in its turn might well involve unreasonable demands on the individual carer’s professional role. Since both the justice and rights perspectives portrayed in the survey mainly concern relationship to the organization and peers within the organization, this relationship might at worst be given priority over the equal treatment and moral rights of the patient. Conclusion: A balanced view on ethical perspectives is needed to make professionals observant and ready to act optimally – especially if these perspectives are used in patient care. Research is needed to clarify how justice and rights are prioritized by ambulance services and whether or not these organization-related values are also implemented in patient care. (shrink)

This article explores the extent to which consumers consider ethics in luxury goods consumption. In particular, it explores whether there is a significant difference between consumers’ propensity to consider ethics in luxury versus commodity purchase and whether consumers are ready to purchase ethical-luxury. Prior research in ethical consumption focuses on low value, commoditized product categories such as food, cosmetics and high street apparel. It is debatable if consumers follow similar ethical consumption patterns in luxury purchases. Findings indicate that consumers’ (...) propensity to consider ethics is significantly lower in luxury purchases when compared to commoditized purchases and explores some of the potential reasons for this reduced propensity to identify or act upon ethical issues in luxury consumption. (shrink)

This book advocates for the philosophical import of care in re-evaluating problems of humanitarianism in the context of the ongoing international refugee and forced migration situation. In doing so, it rethinks the human capacity to care about the suffering of distant others. At a time when emotional resources are running low, there is a need to recast what it means to care, with the aim of generating a productive movement against the rise of value fundamentalism globally—embraced (...) in mantras of ‘good and evil’ and ‘us and them’—and to confront xenophobia and oppressive politics. The author draws upon a wide array of rich traditions, including historical and contemporary writings on self-care and care of the other, to re-examine the intersection of care ethics and justice. She also rethinks the relationship between care and contestation, here analyzed in the aesthetic, ethical, political, and religious domains of human experience. From within the context of this contingent historical repetition of political oppression, the book constructs a reminder not only of what it feels like to care, but how and why we should act upon our care. Care Ethics and the Refugee Crisis is an important contribution to the growing literatures on care ethics and immigration/forced migration in philosophy. It will also appeal to scholars and advanced students working in other disciplines such as political science, refugee and migration studies, and social anthropology. (shrink)

Some physicians in the United States have strong moral objections to the recent bans or near total bans on abortion in this country. The objections are particularly vehement among those who have been abortion providers. They are concerned about the impact of the new restrictions on patients—on their lives and health, especially patients who are socially marginalized and will not be able to travel to “friendly” states to have abortions (i.e., states that legally permit abortions). They are also worried about (...) the status of women, which they fear will be unequal to that of men in a society where women are not permitted to make such intimate decisions about their lives. For these physicians, not to mention their patients, the bans on abortion are morally devastating. They, the physicians, might even feel compelled by their conscience to provide this care—to engage in what some call the “conscientious provision” of care—even though they could lose their careers and their freedom by doing so. There is currently no legal protection for the conscientious provision of abortion care in the U.S., although there is substantial protection for the conscientious refusal of that care. Physicians working in jurisdictions that have abortion bans put themselves at serious legal risk if they defy these bans for reasons of conscience. In general, their freedom of conscience is very low compared to that of physicians who conscientiously refuse to provide abortions in jurisdictions where abortions are still legal. Using theories of conscience and conscientious objection that I develop in Conscience in Reproductive Health Care (Oxford 2020), I argue that this situation is morally untenable. (shrink)

Given that health systems research involves different aims, approaches, and methodologies as compared to more traditional clinical trials, the ethical issues present in HSR may be unique or particularly nuanced. This article outlines eight pertinent ethical issues that are particularly salient in HSR and argues that the ethical review process should be better tailored to ensure more efficient and appropriate oversight of HSR with adequate human protections, especially in low- and middle-income countries. The eight ethical areas we discuss include the (...) nature of intervention, types of research subjects, units of intervention and observation, informed consent, controls and comparisons, risk assessment, inclusion of vulnerable groups, and benefits of research. HSR involving human participants is necessary to ensure health systems strengthening and quality of care and to guide public policy intelligently. Health systems researchers must carefully define their intent and goals and openly clarify the values that may influence the premises and design of protocols. As new types of population-level research activities become more commonplace, it is critical that institutional review board and research ethics committee review processes evolve to evaluate these research protocols in ways that address the nuanced features of these studies. (shrink)

Community care for frail elderly people rests heavily on the work of low-status, paraprofessional home care workers. Home care workers describe their work as highly personalized caring labor that often seeps out of its formal boundaries into informal, unpaid activities. Although these activities are valued by workers, their supervisors, elderly clients, and family members, they represent uncompensated and exploited labor. Cost-cutting trends in home care management that seek to depersonalize home care labor are likely to (...) increase its exploitative potential for paid care workers and, simultaneously, to disadvantage and jeopardize elderly home care clients and their unpaid family caregivers. (shrink)

Among industrialized nations the United States is relatively unique in relying on a mix of public and private financing and delivery of healthcare: federal and federal-state programs, such as Medicare and Medicaid; employment-based health insurance ; and state-subsidized insurance pools for high-risk individuals. In recent years, however, there have been efforts to apply the principles of private employment-based health insurance to the other forms of healthcare, and there is speculation that rising healthcare costs can only be addressed by further extending (...) capitated payment plans. This suggests that U.S. healthcare may increasingly be organized according to market principles. For some, this represents a historic departure from an emphasis on public responsibility for healthcare and a sacrifice of the value principles embodied in health relationships between patient and provider. But defenders of HMOs and a larger role for markets argue that managed care allows for a more rational allocation of scarce healthcare resources by minimizing inefficient low-benefit–high-cost care. More individuals receive essential care if inessential care is eliminated. HMOs are also said to encourage non-HMOs to provide lower priced healthcare. (shrink)

In this paper, we consider how dignity is discursively constructed in the context of work dominated by physicality and dirt. Based on semi-structured interviews with garbage workers, our analysis considers how the deprivations they experience are cast through discourses intended to construct their individual and collective worth. We consider the manner in which dignity maybe denied to such workers through popular repudiations of individuality and status. We demonstrate how this positioning arises from contact with physical dirt, and associations with socially (...) dirty work based on ascriptions of servility, abuse and ambivalence. We go on to consider how garbage workers respond to this positioning through discourses of ‘everyday heroism’. Heroism is evoked through three inter-related narratives that speaks to a particular type of masculinity. The first takes the form of a classic process of reframing and recalibration through which workers not only renegotiate their public position and status, but also point to the inherent value to be had in working with dirt as part of that which we identify as a process of ‘affirmation’. The second narrative arises from the imposition of favourable social and occupational comparisons that effectively elevate garbage collectors’ social position. The third discourse—and previously unobserved in respect of garbage work—centres on paternalistic practices of care. Combined, these discourses disrupt the generally held view that dirty work is antithetical to heroism and wounds dignity. (shrink)

Background and aim Healthcare professionals are regularly exposed to moral challenges in patient care potentially compromising quality of care and safety of patients. Preventive clinical ethics support aims to identify and address moral problems in patient care at an early stage of their development. This study investigates the occurrence, risk factors, early indicators, decision parameters, consequences and preventive measures of moral problems. Method Semi-structured expert interviews were conducted with 20 interprofessional healthcare professionals from 2 university hospitals in (...) Basel, Switzerland. A Likert scale questionnaire was completed by the interviewees and analysed using descriptive and inferential statistics. Results Healthcare professionals are frequently exposed to a variety of moral problems, such as end-of-life decisions, resource allocation and assessing the patient's will or decisional capacity. Thirty-four different risk factors for moral problems are identified, e.g. patient vulnerability, divergent values or world views, inadequate resources or poor ethical climate. Twenty-one early indicators are recognised such as disagreement between healthcare professionals, patients and relatives, emotional disturbances, gut feeling or conflict of conscience. A variety of preventive measures are suggested and presented in a preventive clinical ethics support process model. The most helpful measures are early ethical conversations with colleagues, early team-internal ethical case discussions and an ethics-trained contact person on the ward. Ethics training, kerbside consultations, proactive ethics consultations, ethics screening and rounds are also considered helpful. Conclusions Clinical ethics support services should not only offer reactive and complex, but also proactive and low-threshold support for healthcare professionals, patients and relatives. (shrink)

The Scandinavian welfare states have public health care systems which have universal coverage and traditionally low influence of private insurance and private provision. Due to raises in costs, elaborate public control of health care, and a significant technological development in health care, priority setting came on the public agenda comparatively early in the Scandinavian countries. The development of health care priority setting has been partly homogeneous and appears to follow certain phases. This can be of broader (...) interest as it may shed light on alternative models and strategies in health care priority setting. Some general trends have been identified: from principles to procedures, from closed to open processes, and from experts to participation. Five general approaches have been recognized: The moral principles and values based approach, the moral principles and economic assessment approach, the procedural approach, the expert based practice defining approach, and the participatory practice defining approach. There are pros and cons with all of these approaches. For the time being the fifth approach appears attractive, but its lack of true participation and the lack of clear success criteria may pose significant challenges in the future. (shrink)

Social scientists have drawn attention to the role of hype and optimistic visions of the future in providing momentum to biomedical innovation projects by encouraging innovation alliances. In this article, we show how less optimistic, uncertain, and modest visions of the future can also provide innovation projects with momentum. Scholars have highlighted the need for clinicians to carefully manage the expectations of their prospective patients. Using the example of a pioneering clinical team providing deep brain stimulation to children and young (...) people with movement disorders, we show how clinicians confront this requirement by drawing on their professional knowledge and clinical expertise to construct visions of the future with their prospective patients; visions which are personalized, modest, and tainted with uncertainty. We refer to this vision-constructing work as recalibration, and we argue that recalibration enables clinicians to manage the tension between the highly optimistic and hyped visions of the future that surround novel biomedical interventions, and the exigencies of delivering those interventions in a clinical setting. Drawing on work from science and technology studies, we suggest that recalibration enrolls patients in an innovation alliance by creating a shared understanding of how the “effectiveness” of an innovation shall be judged. (shrink)

Given that health systems research involves different aims, approaches, and methodologies as compared to more traditional clinical trials, the ethical issues present in HSR may be unique or particularly nuanced. This article outlines eight pertinent ethical issues that are particularly salient in HSR and argues that the ethical review process should be better tailored to ensure more efficient and appropriate oversight of HSR with adequate human protections, especially in low- and middle-income countries. The eight ethical areas we discuss include the (...) nature of intervention, types of research subjects, units of intervention and observation, informed consent, controls and comparisons, risk assessment, inclusion of vulnerable groups, and benefits of research. HSR involving human participants is necessary to ensure health systems strengthening and quality of care and to guide public policy intelligently. Health systems researchers must carefully define their intent and goals and openly clarify the values that may influence the premises and design of protocols. As new types of population-level research activities become more commonplace, it is critical that institutional review board and research ethics committee review processes evolve to evaluate these research protocols in ways that address the nuanced features of these studies. (shrink)

This article contributes to carework scholarship by examining the nexus of gender, class, and race in long-term care facilities. We draw out a family ideology at work that promotes good care of residents and thus benefits nursing homes. We also found that careworkers value fictive kin relationships with residents, yet we uncover how the family model may be used to exploit these low-income careworkers. Reflecting a subordinate and racialized version of being “part of the family,” we call (...) for an ethic of reciprocity and for concrete change toward valuing equally the humanity of those who need and those who give care. (shrink)

Background End-of-life decisions for neonates with adverse prognosis are controversial and raise ethical and legal issues. In Greece, data on physicians’ profiles, motivation, values and attitudes underlying such decisions and the correlation with their background are scarce. The aim was to investigate neonatologists' attitudes in Neonatal Intensive Care Units and correlate them with self-reported practices of end-of-life decisions and with their background data. Methods A structured questionnaire was distributed to all 28 Neonatal Intensive Care Units in Greece. One (...) hundred and sixty two out of 260 eligible physicians answered anonymously the questionnaire. Demographic and professional characteristics, self-reported practices and opinions were included in the questionnaire, along with a questionnaire of 12 items measuring physicians’ attitude and views ranging from value of life to quality of life approach. Results Continuation of treatment in neonates with adverse prognosis without adding further therapeutic interventions was the most commonly reported EoL practice, when compared to withdrawal of mechanical ventilation. Physicians with a high attitude score were more likely to limit, while those with a low score were more likely for continuation of intensive care. Physicians’ educational level, involvement in research, religion and position on the existing legal framework were factors that affected the attitude score. Conclusions Physicians presented with varying end-of-life practices. Limiting interventions in neonates with poor prognosis was strongly related to their attitudes. The most important predictors for physicians' attitudes were religiousness and belief for Greek legal system reform. (shrink)

This article is an attempt by Japanese physicians to introduce the practice patterns and moral justification of Japanese critical care to the world. Japanese health care is characterized by the fact that the fee schedule does not reward high technology medicine, such as surgery and critical care. In spite of the low reimbursement, our critical care practice pattern is characterized by continuing futile treatment for terminal patients in the intensive care unit (ICU). This apparently wasteful (...) practice can be explained by fundamental Japanese cultural values, social factors in Japan, the availability of extensive insurance coverage, physicians' psychological factors, lack of cost-benefit considerations and the pragmatic approach the Japanese take to situations. We attempt to make some brief suggestions regarding the improvement of our critical care practices. Although we can not fully present quantitative data to support our argument, this article represents our real-world approaches to the ethical issues in the ICU in Japan. (shrink)

The use of the Quality Adjusted Life-Year (QALY) as a measure of the benefit obtained from health care expenditure has been attacked on the ground that it gives a lower value to preserving the lives of people with a permanent disability or illness than to preserving the lives of those who are healthy and not disabled. The reason for this is that the quality of life of those with illness or disability is ranked, on the QALY scale, below (...) that of someone without a disability or illness. Hence we can, other things being equal, gain more QALYs by saving the lives of those without a permanent disability or illness than by saving the lives of those who are disadvantaged in these ways. But to do so puts these disadvantaged people under a kind of double jeopardy. Not only do they suffer from the disability or illness, but because of it, a low priority is given to forms of health care that can preserve their lives. This, so the objection runs, is unjust or unfair. This article assesses this objection to the use of QALYs as a basis for allocating health care resources. It seeks to determine what is sound in the double jeopardy objection, and then to show that the defender of QALYs has an adequate response to it. (shrink)

The World Health Organisation (WHO) is leading a global effort to deliver improved diagnostic testing to people living in low‐resource settings. A reliance on the healthcare technologies marketplace and industry, shapes many aspects of the WHO project, and in this situation normative guidance comes by way of the ASSURED criteria — Affordable, Sensitive, Specific, User‐friendly, Rapid and robust, Equipment‐free, and Delivered. While generally improving access to diagnostics, I argue that the ASSURED approach to distributive justice — efficiency — and assessment (...) of worth — productivity — may constrain efforts to deliver timely and accurate diagnosis in the developing world equitably by holding back new and innovative diagnostics and indirectly encouraging program and device design that may unfairly discriminate against certain groups. Even as we try to overcome the problem of global healthcare injustice, we may be entrenching disadvantage. I present my critique of ASSURED by 1) referencing Boltanski and Thévenot's theory of orders of worth to highlight the industrial and market foundations of the ASSURED guidelines; 2) comparing ASSURED with other normative guides that elevate the importance of civic responsibility in evaluations of distributive justice; 3) presenting a case study of the failed promise of microfluidic diagnostic devices. I conclude that a new approach to normative guidance is required to assess the value of developing world diagnostics, preferably, one that does not force global public goods into the marketplace. (shrink)

Nursing research in palliative care raises specific and challenging ethical issues. Questions have arisen about whether such research is morally justified, given the low likelihood of direct benefit to dying patients as research participants. The Canadian Code of ethics for registered nurses outlines eight primary values intended to guide nursing practice. We use these values to explore the moral dimensions of research with the palliative care population. Our conclusion is that palliative care research is needed to foster (...) excellent care for these patients and their families, but that nurses must remain constantly vigilant to ensure that participants are protected from resultant harms. Through this exploration we highlight particular considerations that nurse researchers must contemplate when accessing a vulnerable population. (shrink)

Purpose: The purpose of the study was to investigate the impact of religion on values and behaviour in Kenya.Methodology: The paper adopted a desk top research design. The design involves a literature review of existing studies relating to the research topic. Desk top research is usually considered as a low-cost technique compared to other research designs.Results: Based on the literature review, the study concluded that religion has positive impact on values and behavior. The study further concludes that a belief in (...) fearful and punishing aspects of supernatural agents is associated with honest behavior, whereas a belief in the kind, loving aspects of gods is less relevant.Unique contribution to theory, practice and policy: The study recommended that policy makers should review policies involving religion by changing commonly held beliefs regarding the Constitution and religion. The study also recommended that religious leaders and parents take special care of the religious formation of children, especially during the transition period from childhood to adolescence, when they are most likely to lose their religious faith. (shrink)

This essay is an array of several taxonomies of values which bear on medicine. The first is a rather low-level list of types of values, meant to be adequate to observational data collection about human valuing. It proceeds to a discussion of levels of valuing so that senses of higher and lower values are articulated. Next, it offers a consideration of intrinsic versus extrinsic and of fundamental versus domestic (or mediating, enabling) values, along with the notions of a practice and (...) virtues. Finally it offers an analysis of clusters of value types along the lines of personal values, social values and professional values acting as interlocking force fields affecting the judgments, reactions and decisions of persons working in health care. In addition to the anticipated elucidation contained in the dialectic, two conclusions are intended: (1) the topic of values in medicine is staggeringly complex, and (2) a medical career is in the best sense a tragic fate in that a noble calling is doomed to many failures because of an inability to reconcile conflicts of values as much as because techniques cannot accomplish everything. (shrink)

Background Professional ethics in nursing exist to guide care and allow for decision-making to be patient-centered. In the current medicolegal landscape post-Roe and in light of bans on gender-affirming care, the decision-making processes of emergency nurses in the clinical environment of care as informed by both professional and personal ethics are an important area of inquiry. Aim The aim of this study was to examine the contribution of moral courage to decision-making by emergency nurses. Research Design A (...) mixed-methods exploratory sequential approach was used, using a standard demographics form and the Nurses Moral Courage Scale to collect quantitative data. These data were used to inform an interview guide for qualitative data collection. Situational analysis was used to analyze the interview data. Ethical Considerations Prior to recruitment, this study was reviewed and approved by the University of Massachusetts IRB (#00003909). Participants were provided with an informed consent document at the time of registration and at the time of interview; participants provided both signed consent and verbal assent. Participants were assigned study codes to maintain anonymity and data were maintained in a secure University cloud. Participants and Research Context US-based emergency nurses working in environments with care limitations. Results 70% of respondents reported that they would speak up if they were aware of a situation that was ethically challenging. Respondents reported that it was fairly easy or very easy to defend their values when addressing ancillary staff, coworkers, authorities outside the organization, patients, and patient families. Respondents reported challenges in defending their professional values to charge nurses, physicians, or administrators. In response to a serious ethical problem, 65.8% of respondents answered that they would bring up the problem for discussion, 21.1% would file an internal report, and 13.2% would report externally. Interview participants reported significant social and professional barriers to acting in response to an ethical violation. Willingness to act centered on personal values and not professional codes of ethics. Conclusions While emergency nurses in this study reported high perceived levels of moral courage, they also reported low willingness to act directly, citing burnout and significant social and professional barriers. Adherence to professional codes of ethics is not the primary driver of moral courage. (shrink)

Next SectionEvidence based medicine is rightly at the core of current medicine. If patients and society put trust in medical professional competency, and on the basis of that competency delegate all kinds of responsibilities to the medical profession, medical professionals had better make sure their competency is state of the art medical science. What goes for the ethics of clinical trials goes for the ethics of medicine as a whole: anything that is scientifically doubtful is, other things being equal, ethically (...) unacceptable. This particularly applies to so called orphaned fields of medicine, those areas where medical research is weak and diverse, where financial incentives are lacking, and where the evidence regarding the aetiology and treatment of disease is much less clear than in laboratory and hospital based medicine. Examples of such orphaned fields are physiotherapy, psychotherapy, medical psychology, and occupational health, which investigate complex syndromes such as RSI, whiplash, chronic low back pain, and chronic fatigue syndrome. It appears that the primary ethical problem in this context is the lack of attention to the orphaned fields. Although we agree that this issue deserves more attention as a matter of potential injustice, we want to argue that, in order to do justice to the interplay of heterogeneous factors that is so typical of the orphaned fields, other ethical models than justice are required. We propose the coordination model as a window through which to view the important ethical issues which relate to the communication and interaction of scientists, health care workers, and patients. (shrink)

Providing access to medicines and health care is one of the most challenging issues facing society today. In this paper the author highlights some of the complexities of the health value chain as well as the problems that the world’s poor have in terms of access to medical care and medicines. He then attempts to delineate the roles and responsibilities of all stakeholders in order to define the specific corporate responsibilities of pharmaceutical companies in the context of (...) the entire responsibility system—the strength of which is determined by its weakest link. Finally, he looks forward to a transformational change being wrought for pro-poor health development by forging new coalitions that cut across both the health and traditional development stakeholders. (shrink)

The recently published Report of theAHAG on the Operation of NHS Research Ethics Committees advocates major reforms of the NHS research ethics committees system. The main implications of the proposed changes and their probable effects on the major stakeholders are described.The Ad Hoc Advisory Group on the operation of NHS research ethics committees, set up in November 2004 by Lord Warner on behalf of the Department of Health, submitted its report in June 2005.1 The report advocates major reforms of the (...) research ethics committee system. The primary aim of the report is to streamline the processes around the approval of research projects and to pursue conformity of governance across Europe. Implicit in the report is the contention that failure to achieve this objective would be harmful to everyone with vested interests in improving health and social care. Moreover, it is stated that the reforms will enhance the mechanisms that protect the interests of all parties concerned.1Being mindful of two published critiques of the Warner Report, we suggest that its alleged benefits should not be taken at face value.2,3 In fact, the reformed system will give rise to moral failings akin to those of the existing system, but will differ from the existing system in its effect on the stakeholders. Thus, whereas the outgoing system has given each stakeholder a unique mixture of benefit and harm, the incoming system offers benefit only to sponsors and researchers and nothing but detriment to participants in research and consumers of its products.In the light of this conclusion, we finally suggest that the Warner Report be construed not merely as an ill-considered document, but rather as an ideological reflection of a long-established hegemonic contract fine-tuning itself to contemporary global challenges.To avoid …. (shrink)

Objectives: Recent legislative changes within the United Kingdom have stimulated professional debate about access to patient data within research. However, there is currently little awareness of public views about such research. The authors sought to explore attitudes of the public, and their lay representatives, towards the use of primary care medical record data for research when patient consent was not being sought.Methods: 49 members of the public and four non-medical members of local community health councils in South Wales, UK (...) gave their views on the value and acceptability of three current research scenarios, each describing access to data without patient consent.Results: Among focus group participants, awareness of research in primary care was low, and the appropriateness of general practitioners as researchers was questioned. There was general support for research but also concerns expressed about data collection without consent. These included lack of respect and patient control over the process. Unauthorised access to data by external agencies was a common fear. Current data collection practices, including population based disease registers elicited much anxiety. The key informants were equally critical of the scenarios and generally less accepting.Conclusions: This exploratory study has highlighted a number of areas of public concern when medical records are accessed for research without patient consent. Public acceptability regarding the use of medical records in research cannot simply be assumed. Further work is required to determine how widespread such views are and to inform those advising on confidentiality issues. (shrink)

Background Family and Community Health Nurses (FCHNs) are at a higher risk of experiencing emotional exhaustion and feelings of low personal accomplishment. Higher levels of professional identity may decrease these negative feelings. Its measurement could produce positive effects for FCHNs and the quality of care they offer. Aim This study aims to evaluate the psychometric properties (validity and reliability) of the Nurses Professional Values Scale-Revised (NPVS-R) on FCHNs in Italy. Research design A cross-sectional research design was used. Participants and (...) research context A convenience sample of FCHNs was recruited in an out-of-hospital setting from Italy. A total of 202 nurses were eligible (mean age of 41.11 ± 10.55 years; 78.2% female). Ethical considerations The study was performed in accordance with the World Medical Association Declaration of Helsinki. Participants were asked for their consent and were guaranteed anonymity in the information collected. The study was approved by the internal review board of the university. Results Confirmatory Factor Analysis (CFA) supported a unidimensional factorial structure of the NPVS-R with an adequate fit to the data. Internal consistency reliability was also supported. The construct validity was further reinforced by the concurrent validity results showing a positive and significant correlation of professional identity with job satisfaction. Conclusion The NPVS-R is a valid and reliable instrument to measure professional identity among FCHNs. It can be used in clinical practice to improve FCHNs’ psychological-emotional feelings and quality of care provided, in research to allow comprehensive understanding of professional identity, and in educational settings to monitor the professional identity levels of Family and Community Health Nursing students. (shrink)

Introduction Nurses’ moral courage (NMC) enhances care quality and patient safety. Nurses’ professional values promote ethical adherence, moral obligation fulfillment, and compliance to prevent ethical violations. It is necessary to explore the current status and influencing factors of moral courage from the perspective of professional values. Aim To investigate the current situation of nurses’ moral courage, analyze the latent profiles of nurses’ moral courage, and explore the influencing factors from the perspective of professional values. Research Design A cross-sectional design (...) was employed. Participants and research context Data were collected through convenient sampling at a tertiary hospital during May 2023 in Wuhan, Hubei province, China. A self-designed web-based questionnaire consisting of demographic characteristics, the Chinese Nurses’ Professional Values Scale-Revised Version (NPVS-R-CV) and the Nurses’ Moral Courage Scale (NMCS) were used for the cross-sectional survey. Latent profile analysis was conducted using the results of 3 explicit indexes of NMCS, and multivariate logistic regression was used to analyze the influencing factors of NMC. Ethical Considerations Research ethics approval (with the code of TJ- IRB 20220543) was obtained from Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. Findings This study included 966 nurses, predominantly female and under 30 years old, with 91.10% holding a bachelor’s degree. Latent profile analysis identified three moral courage profiles: low-level (31.5%), medium-level (47.2%), and high-level (21.3%). Multivariate logistic regression analysis showed significant positive correlations between professional values and moral courage, with head nurses being significantly more likely to exhibit high moral courage (OR = 3.586, p = 0.013). Conclusions The moral courage of nurses can be classified into 3 subgroups. Nurses’ professional values positively correlate with moral courage, with head nurses showing significantly higher levels of moral courage. Strengthening professional values through training can enhance ethical behavior in nursing, potentially improving patient care and safety. (shrink)

It has become something of a dogma in the philosophy of science that modern cosmology has completed Boltzmann's program for explaining the statistical validity of the Second Law of thermodynamics by providing the low entropy initial state needed to ground the asymmetry in entropic behavior that underwrites our inference about the past. This dogma is challenged on several grounds. In particular, it is argued that it is likely that the Boltzmann entropy of the initial state of the universe is an (...) ill-defined or severely hobbled concept. It is also argued that even if the entropy of the initial state of the universe had a well-defined, low value, this would not suffice to explain why thermodynamics works as well as it does for the kinds of systems we care about. Because the role of Boltzmann entropy in our inferences to the past has been vastly overrated, the failure of the Boltzmann program does not pose a serious problem for our knowledge of the past. But it does call a different explanation of why thermodynamics works as well as it does. A suggestion is offered for a different approach. (shrink)

This article discusses the serious problem of the shortage of about 50 000 nurses in Japan today. If efficient measures to solve it are not adopted by administrators, it is clear that the shortage will become still more alarming in the future, in a society with more people in advanced years and in which the numbers in the younger generation will decrease from now on. The main factors behind the Japanese nursing labour shortage are, among others: a rapid increase in (...) the number of hospital beds between 1986 and 1989; poor working conditions; and nurses’ low social position in their places of work. Behind these factors, there has always been a contempt for the art of nursing in our society. Why has Japanese society made light of nursing? Three points can be identified: traditional discrimination against women; our disregard for a religious mentality; and our short history of hospital nursing. To overcome these problems, we must first of all change fundamentally our sense of values, such as love for one another and compassion. We must now reconstruct a caring culture in our society. (shrink)

This paper revisits Ronald Dworkin’s influential position that a person’s advance directive for future health care and medical treatment retains its moral authority beyond the onset of dementia, even when respecting this authority involves foreshortening the life of someone who is happy and content and who no longer remembers or identifies with instructions included within the advance directive. The analysis distils a eudaimonist perspective from Dworkin’s argument and traces variations of this perspective in further arguments for the moral authority (...) of advance directives by other authors. It then critiques a feature of the eudaimonist perspectives within these arguments—namely, the position that dementia has a retroactive negative impact on what a person has previously valued—and challenges the commonly held assumption underlying them that a person’s life and well-being have relatively low value beyond the onset of dementia. Although advance directives have moral authority as a means of guiding one’s future health care, accounts that dismiss the value of the lives and well-being of people living with dementia should be questioned to the extent that such accounts are used to support the moral authority of advance directives stipulating measures to foreshorten individuals’ lives. (shrink)

Many practices available for use in health service psychology are ineffective or harmful. How we describe these practices is important to scientific discourse and science communication with policy-makers and the general public. The label “pseudoscience” is typically applied in these cases, though the meaning of pseudoscience varies widely creating a quagmire for transparent and accurate communication. To clarify this issue, we review several prominent definitions of pseudoscience as well as consider how the term is used amongst psychology scholars and science-communicators. (...) We define two additional terms adapted from the medical literature, contemporary and alternative psychotherapies and low-value practices, and discuss their strengths and limitations. Finally, we recommend the broader category of low-value practices for use due to its definitional clarity, lack of competing definitions, and potential for clarifying research programs. (shrink)

We generalize the construction of lattice-valued models of set theory due to Takeuti, Titani, Kozawa and Ozawa to a wider class of algebras and show that this yields a model of a paraconsistent logic that validates all axioms of the negation-free fragment of Zermelo-Fraenkel set theory.

Jonathan Lowe argues that metaphysics should be restored to a central position in philosophy, as the most fundamental form of inquiry, whose findings underpin those of all other disciplines. He portrays metaphysics as charting the possibilities of existence, by identifying the categories of being and the relations between them. He sets out his own original metaphysical system, within which he seeks to answer many of the deepest questions in philosophy. 'a very rich book... deserves to be read carefully by anyone (...) interested in any of the many subjects he discusses.' Katherine Hawley, British Journal of the Philosophy of Science. (shrink)

Recent literature has highlighted issues of racial discrimination in medicine. In order to explore the sometimes subtle influence of racial determinants in decisions about resource allocation, we present the case of a 53-year-old Australian Aboriginal woman with end-stage renal failure. The epidemiology of renal failure in the Australian Aboriginal population and amongst other indigenous peoples is discussed. We show that the use of utilitarian outcome criteria for resource allocation may embody subtle racial discrimination where consideration is not given to issues (...) of justice, race, culture and gender. It is only where the processes by which resources are allocated are transparent, clearly defined and based upon consultation with individual patients that issues and justice are likely to be adequately addressed. (shrink)

In _The Body in Late-Capitalist USA_, Donald M. Lowe explores the varied social practices that code and construct the body. Arguing that our bodily lives are shaped by a complex of daily and ongoing practices—how we work, what we buy and consume—Lowe contends that as a result of the commodification of these and other social practices in the late-twentieth century, what we often understand to be the needs of the body are in fact means for capital accumulation. Moving beyond studies (...) of representations and images of the body, Lowe focuses on the intersection of body practices, language, and the Social to describe concretely the reality of a lived body. His strongly synthetic work brings together Marxist critique, semiotics, Foucaultian discourse analysis, and systems and communications theory to examine those practices that construct the body under late capitalism: habits of work and consumption, the ways we give birth and raise children, socialization, mental and physical healing, reconstructions and contestations of sexuality and gender. Lowe draws upon a wide range of sources, including government and labor studies and statistics, diagnostic and statistical manuals on mental illness, computer manuals, self-help books, and guides to work-related stress disorders, to illustrate the transformation of the body into a nexus of exchange value in postmodern society. (shrink)

The expressions ‘high quality care’ and ‘low quality care’ are cognitive and linguistic artefacts that help to structure people’s lives and thinking; for example, moves are now afoot internationally to pay bonuses to health professionals for delivering high quality care. United States programmes, most conspicuously, are assuming that high quality care can be validly distinguished from low quality care, and incentivised through bonuses. This distinction is always at least implicit, for high quality care has (...) no meaning without low quality care. Through a ‘deconstructionist reading,’ this article discusses limitations of categorising the quality of care as either high or low. The limitations of this ‘binary opposition’ can include a lack of defining attributes; vagueness and fuzziness at the ‘boundaries’ between high quality care and low quality care; concealment of quality as a continuum; and use of the binary opposition to effect social order and control. Health policy implications of our analysis are discussed. Drawing upon the general medical services contract in the United Kingdom, we suggest an approach to overcoming the oversimplification and imprecision that categorisation tends to produce. (shrink)

The Sarbanes–Oxley Act of 2002 requires company executives to certify financial statements and internal controls as a means of reducing fraud. Many companies have operationalized this by instituting a sub-certification process and requiring lower-level managers to sign certification statements. These lower-level organizational members are often the individuals who are aware of fraud and are in the best position to provide information on the fraudulent act. However, the sub-certification process may have the effect of reducing employees’ intentions to report wrongdoing. We (...) suggest that subordinates with knowledge of a superior who committed a fraudulent act and certified that there is no fraud will feel less personal responsibility to report the act, thus, decreasing reporting intentions. Additionally, we suggest that if the fraud is discovered subsequent to the reports being filed with the Securities and Exchange Commission, employees will perceive lower management responsiveness to investigate the fraud, which will reduce intentions to report. Using an experimental approach, we manipulate two between-participant variables: the presence or absence of sub-certification by the transgressor and the timing of fraud discovery, either before or after the reports have been filed with the SEC. We find that when sub-certification is present, perceived personal responsibility and intentions to report were diminished compared to when sub-certification is absent. Timing of the discovery of the fraudulent act did not influence perceived management responsiveness or reporting intentions. Supplemental analysis shows that personal responsibility partially mediates the relationship between sub-certification and reporting intentions. Our findings suggest that audit committees and senior executives may want to carefully consider the costs and benefits of the sub-certification process. (shrink)

This volume presents the work of Maurice Merleau-Ponty, a great philosopher and social theorist of mid-twentieth century, as a viable alternative to both modernism and postmodernism. Douglas Low argues that Merleau-Ponty's philosophy offers explanations and solves problems that other philosophies grapple with, but do not resolve, given their respective theoretical presuppositions and assumptions. Low brings the work of Merleau-Ponty into critical contact with important thinkers, including Sartre, Heidegger, Derrida, and Marx. He highlights Merleau-Ponty's connection to the early Hegel, especially with (...) regard to the criticism of modernism's "representational consciousness" and its subsequent skepticism with regard to our being in the world. Merleau-Ponty made a concerted effort to solve the problems that come about due to a wide variety of Western dualisms: body and mind, perception and conception, self and other, etc. He frequently does so by demonstrating the connection between these disparate terms, the connection of perception with affect and interest, fact with value, and a broadened view of science with moral and philosophical judgment. Merleau-Ponty's unique contribution is his focus on the lived-through perceiving body and its relationship to abstract thought and language. In his detailed analysis of the work of Merleau-Ponty, Low brings attention to a twentieth-century master capable of altering the landscape of modern and social philosophy in the twenty-first century. (shrink)