Moral distress is a common phenomenon among nurses and is related to the complicated work environments and complex nature of ethical situations in day-to-day nursing practice. Moral distress impacts nurses as well as patient care and the health care system. Few strategies have been identified for instructors to effectively engage with learners when communicating about moral distress. We discuss two key curricular and pedagogical strategies that should be utilized when learning about moral distress: difficult knowledge’ and ‘terror management theory’. Whether (...) it is with new nursing students or experienced nurses, there is necessary learning that needs to occur on moral distress. Difficult knowledge’ and ‘terror management theory’, when implemented, can provide a starting point for both the learner and the instructor to discuss the emotionally difficult and complex topic of moral distress. Knowledge about moral distress has the potential to mitigate its negative effects, therefore it is vital to consider educational strategies to teach nurses about this complex phenomenon. (shrink)

As COVID-19 keeps impacting the world, its impact is felt differently by people of different sexes and genders. International guidelines and research on gender inequalities and women’s rights during the pandemic have been published. However, data from Taiwan is lacking. This study aims to fill the gap to increase our knowledge regarding this issue and provide policy recommendations. This study is part of a more extensive project in response to the fourth state report concerning the implementation of the Convention on (...) the Elimination of All Forms of Discrimination against Women in Taiwan in 2022. We have drawn on the guidelines and documents published by the United Nations human rights bodies, conducted interviews with advocacy and professional practitioners, and hosted a study group comprising students and teachers from the National Taiwan University College of Public Health to supplement the interview data. The data were analyzed thematically. The results include five themes: (1) particular health risks to carers (primarily women); (2) COVID-related measures’ impact on women’s health and health behaviors; (3) highly gendered psychological maladjustment; (4) increase in gender-based violence and domestic violence; and (5) mental health inequities and intersectionality. The study has global implications for societies of similar sociopolitical contexts and developmental statuses. To truly live up to the standard of CEDAW and other international human rights principles, we ask that central and local government be more aware of these lived experiences and adjust their policies accordingly, accounting for gender sensitivity. (shrink)

The General Medical Council (GMC) instructs doctors to act ‘reasonably’ in obtaining consent from patients. However, the GMC does not explain what it means to be reasonable: it is left to doctors to figure out the substance of this instruction. The GMC relies on the Supreme Court’s judgment in Montgomery v Lanarkshire Health Board; and it can be assumed that the judges’ idea of reasonability is adopted. The aim of this paper is to flesh out this idea of reasonability. This (...) idea is commonly personified as the audience that has to be satisfied by the doctor’s justification for offering, or withholding, certain treatments and related information. In case law, this audience shifted from a reasonable doctor to a ‘reasonable person in the patient’s position’; and Montgomery expands the audience to include ‘particular’ patients, too. Senior judges have clarified that the reasonable person is a normative ideal, and not a sociological construct; but they do not set out the characteristics of this ideal. John Rawls has conceived the reasonable person-ideal as one that pursues fair terms of co-operation with other members of society. An alternative ideal can be inferred from the feminist ethic of care. However, the reasonable patient from Montgomery does not align with either theoretical ideal; but, instead, is an entirely rational being. Such a conception conflicts with both real-life constraints on rationality and the doctor’s duty to care for the patient, and it challenges the practice of medicine. (shrink)

Nudges are means to influence the will formation of people to make specific choices more likely. My focus is on nudges that are supposed to improve the health condition of individuals and populations over and above the direct prevention of disease. I point out epistemic and moral problems with these types of nudges, which lead to my conclusion that health-enhancing nudges fail. They fail because we cannot know which choices enhance individual health—properly understood in a holistic way—and because health-enhancing nudges (...) are often themselves bad for our health. They can be bad for our health because they assume inferior agency in their targets and accordingly regularly lead to appropriate resentment and anger—strong emotions which go along with an increased risk of health impairments. Briefly, health-enhancing nudges fail because they are based on persistent ignorance and on a presumptuous attitude. (shrink)

Population policy has taken two divergent trajectories. In the developing part of the world, controlling population growth has been a major tune of the debate more than a half-century ago. In the more developed part of the world, an inverse pattern results in the discussion over the facilitation of population growth. The ethical debates on population policy have primarily focused on the former and ignored the latter. This paper proposes a more comprehensive account that justifies states’ population policy interventions. We (...) first consider the reasons that support pro-natalist policies to enhance fertility rates and argue that these policies are ethically problematic. We then establish an ethics of population policy grounded on account of self-sustaining the body politic, which consists of four criteria: survival, replacement, accountability, and solidarity. We discuss the implications of this account regarding birth-control and pro-natalist policies, as well as non-procreative policies such as immigration, adoption, and unintended baby-saving strategies. (shrink)

The seriousness of the COVID-19 pandemic requires a look into the implementation of drug registration rules for COVID-19 vaccines. Amidst the surrounding exigencies, vaccines being a biological product, require comprehensive and continuing pre and post registration rules to ensure their safety and efficacy. The study focuses on Malaysia which has rules on drug registration that have been successfully applied to vaccines. The study shows that the rules have been tailor-made to emergency situations. At the moment, special rules have been introduced (...) including to allow use of COVID-19 vaccines as unregistered product. Recognition of COVID-19 Vaccines Global Access (COVAX) facility and requirement for government sale only, are among the safety valves. The study shows that these however are temporary measures against the backdrops of possible entry of private players in the vaccination process. Therefore, regulatory responses to intellectual property (IP) related conditions underlying drug registration, and measures to ensure risk management involved in vaccine production, approval and administration are needed in the progressive rules pending further development of research in the area. (shrink)

The informed consent is an ethical and legal requirement for potential participants to enroll in a study. There is ample of evidence that understanding consent information and enrollment is challenging for participants in clinical trials. On the other hand, the reasoning process behind decision-making in HIV clinical trials remains mostly unexplored. This study aims to examine the decision-making process of people living with HIV currently participating in antiretroviral clinical trials and their understanding of informed consent. We conducted a qualitative socio-constructivist (...) study using semi-structured interviews. Eleven participants were selected by purposive sampling in Argentina until data saturation was reached. A content analysis was performed. The findings highlight the fact that some participants decided to enroll on the spot, while others made the decision a few days later. In all cases, the decision was based on different aspects of trust (in doctors, in the clinical research site, in the clinical trials system) but also on emotions associated with HIV and/or treatment. Moreover, while people living with HIV felt truly informed after the consent dialogue with a researcher, consent forms were unintelligible and unfriendly. The immediacy of patient decision-making has rarely been described before. Enrollment in an HIV clinical trial is mainly a trust-based decision but this does not contradict the ethical values of autonomy, voluntariness, non-manipulation, and non‐exploitation. Thus, trust is a key issue to be included in reshaping professional practices to ensure the integrity of the informed consent process. (shrink)

Rising health insurance costs and the cost of living crisis are likely leading to an increase in unpaid health insurance bills in many countries. In Switzerland, a particularly drastic measure to sanction defaulting insurance payers is employed. Since 2012, Swiss cantons – who have to cover most of the bills of defaulting payers - are allowed by federal law to blacklist them and to restrict their access to medical care to emergencies.In our paper, we briefly describe blacklisting in the context (...) of the Swiss healthcare system before we examine the ethical issues involved in light of what is known about its social and health impacts. We found no evidence that blacklisting serves as an effective way of recovering unpaid health insurance contributions or of strengthening solidarity within the health insurance system. Furthermore, the ambiguous definitions of what constitutes an emergency treatment and the incompatibility of the denial of medical care with the obligation to provide professional assistance complicate the implementation of blacklists and expose care providers to enormous pressure.Therefore, we conclude that blacklists and the (partial) denial of medical care not only pose profound ethical problems but are also unsuitable for fulfilling the purpose for which they were introduced. (shrink)

Respecting patient autonomy through the process of soliciting informed consent is a cornerstone of clinical ethics. In pediatrics, until a child becomes an adult or legally emancipated, that ethical tenet takes the form of respect for parental decision-making authority. In instances of respecting religious beliefs, doing so is not always apparent and sometimes the challenge lies not only in the healthcare provider’s familiarity of religious restrictions but also their knowledge of medical interventions themselves which might conflict with those restrictions. We (...) examine a case of a newborn receiving animal-derived surfactant, a common scenario in neonatology, and present considerations for providers to weigh when confronting when such an intervention might conflict with parent’s religious beliefs. We end with strategizing ways to address this issue as a medical community. (shrink)

Background: Severity plays an essential role in healthcare priority setting. Still, severity is an under-theorised concept. One controversy concerns whether severity should be risk- and/or time-sensitive. The aim of this article is to provide a normative analysis of this question. Methods: A reflective equilibrium approach is used, where judgements and arguments concerning severity in preventive situations are related to overall normative judgements and background theories in priority-setting, aiming for consistency. Analysis, discussion, and conclusions: There is an argument for taking the (...) risk of developing a condition into account, and we do this when we consider the risk of dying in the severity assessment. If severity is discounted according to risk, this will ‘dilute’ severity, depending on how well we are able to delineate the population, which is dependent on the current level of knowledge. This will potentially have a more far-reaching effect when considering primary prevention, potentially the de-prioritisation of effective preventive treatments in relation to acute, less-effective treatments. The risk arguments are dependent on which population is being assessed. If we focus on the whole population at risk, with T 0 as the relevant population, this supports the risk argument. If we instead focus on the population of as-yet (at T 0 ) unidentified individuals who will develop the condition at T 1, risk will become irrelevant, and severity will not be risk sensitive. The strongest argument for time-sensitive severity (or for discounting future severity) is the future development of technology. On a short timescale, this will differ between different diagnoses, supporting individualised discounting. On a large timescale, a more general discounting might be acceptable. However, we need to also consider the systemic effects of allowing severity to be risk- and time-sensitive. (shrink)

In Sweden, efforts to govern end-of-life care through policies have been ongoing since the 1970s. The aim of this study is to analyse how policy narratives on palliative care in Sweden have been formulated and have changed over time since the 1970s up to 2018. We have analysed 65 different policy-documents. After having analysed the empirical material, three policy episodes were identified. In Episode 1, focus was on the need for norms, standards and a psychological end-of-life care with the main (...) goal of solving the alleged deficiencies within end-of-life care in hospital settings. Episode 2 was characterised by an emphasis on prioritising end-of-life care and dying at home, and on the fact that the hospice care philosophy should serve as inspiration. In Episode 3, the need for a palliative care philosophy that transcended all palliative care and the importance of systematic follow-ups and indicators was endorsed. Furthermore, human value and freedom of choice were emphasised. In conclusion, the increase of policy-documents produced by the welfare-state illustrate that death and dying have become matters of public concern and responsibility. Furthermore, significant shifts in policy narratives display how notions of good palliative care change, which in turn may affect both the practice and the content of care at the end of life. (shrink)

Person centered care (PCC) invites ideas of shared responsibility as a direct result of its shared decision making (SDM) process. The intersection of PCC and psychiatric contexts brings about what I refer to as _the responsibility problem_, which seemingly arises when SDM is applied in psychiatric settings due to (1) patients’ potentially diminished capacities for responsibility, (2) tension prompted by professional reasons for and against sharing responsibility with patients, as well as (3) the responsibility/blame dilemma. This paper aims to do (...) away with the responsibility problem through arguing for a functional approach to mental illness, a blameless responsibility ascription to the person with mental illness, as well as a nuanced understanding of SDM as part of an emancipation-oriented PCC model. (shrink)

This study aims to develop a valid and reliable scale to assess whether a physician is inclined to take conscientious objection when asked to perform medical services that clash with his/her personal beliefs. The scale, named the Inclination toward Conscientious Objection Scale, was developed for physicians in Turkey. Face validity, content validity, criterion-related validity, and construct validity of the scale were evaluated in the development process. While measuring criterion-related validity, Student’s t-test was used to identify the groups that did and (...) did not show inclination toward conscientious objection. There were 126 items in the initial item pool, which reduced to 42 after content validity evaluation by five experts. After necessary adjustments, the scale was administered to 224 participants. Both exploratory and confirmatory factor analyses were performed to investigate factor structure. The split-half method was employed to assess scale reliability, and the Spearman-Brown coefficient was calculated. Cronbach’s alpha reliability coefficient was used to estimate the internal consistency of the scale items. The distinctiveness of the items was evaluated using Student’s t-test. The lower and upper 27% groups were compared to assess the distinctiveness of the scale. The items were loaded on four factors that explained 85.46% of the variance: “Conscientious Objection – Medical Profession Relationship,” “Conscientious Objection in Medical Education and Medical Practice,” “Conscientious Objection with regard to the Concept of Rights” and “Conscientious Objection – Physician’s Professional Identity and Role.” The final scale has 40 items, and was found to be valid and reliable with high internal consistency. (shrink)

The last decade has seen significant developments in UK health policy, with are largely claimed to be evidence based. However, such a characterisation ought, in many cases, to be questioned. Policies can be broadly understood as based primarily on either a logical or empirical case. In the absence of relevant empirical evidence, policymakers understandably appeal to logical cases. Once such evidence is available, however, it can inform policy and enable the logical case to be set aside. Such a linear policy (...) process is not always the reality, and logical cases often continue to guide policy decisions in direct opposition to empirical evidence. In this paper, I discuss two recent examples of this disconnect between logical and empirical cases in UK health policy. The first—organ donation—illustrates an example of a significant policy change being made in opposition to the evidence. I refer to this as the improvidence approach. The second—abortion—provides an example of policymakers not making a change that has extensive supporting data. I refer to this using the more recognisable language of the precautionary approach. Ultimately, I argue that both the improvidence and precautionary approaches are examples of problematic public policy where policymakers provide no explicit justification for going against the evidence. (shrink)

A treaty to regulate the global antimicrobial commons can be appropriately framed around the model provided by multilateral environmental agreements. At the same time, it is not clear that a comprehensive treaty is the only possible entry point and other options, such as an agreement on technology transfer or funding may be apt starting points. Any legal instrument adopted to regulate the global antimicrobial commons needs to reflect the global South-North dichotomy and integrate the principle of common but differentiated responsibilities (...) and respective capabilities. Further, it would need to go beyond environmental instruments that have been structured around the sovereign interests of negotiating states even when dealing with issues of global concern, such as climate change. The proposed legal instrument would also need to be based not just on the precautionary principle as a marker of the necessity to address the negative environmental and health impacts, but also be based on the interests of patients and integrate concerns raised in terms of the human right to health. (shrink)

This commentary defines what shared yet differentiated ethical responsibilities to tackle antimicrobial resistance (AMR) mean, by introducing a threefold principled account of AMR global governance. It argues that the principles of solidarity, subsidiarity, and stewardship can be especially helpful for further justifying some of the universal, differentiated, and individual responsibilities that Van Katwyk et al propose. The upshot of my threefold principled account of AMR global governance is a less ambitious AMR treaty, one that can only justify (i) universal duties (...) of global coordination (as per the principle of solidarity); (ii) differentiated duties to local communities, which bear the primary AMR responsibilities (as per the principle of subsidiarity); and (iii) individualized duties for ensuring truthful, evidence-based, consistent, and timely shared accountable communication (as per the principle of stewardship). (shrink)

Antimicrobial resistance is one of the greatest public health crises of our time. The natural biological process that causes microbes to become resistant to antimicrobial drugs presents a complex social challenge requiring more effective and sustainable management of the global antimicrobial commons—the common pool of effective antimicrobials. This special issue of Health Care Analysis explores the potential of two legal approaches—one long-term and one short-term—for managing the antimicrobial commons. The first article explores the lessons for antimicrobial resistance that can be (...) learned from recent climate change agreements, and the second article explores how existing international laws can be adapted to better support global action in the short-term. (shrink)

An international legal agreement governing the global antimicrobial commons would represent the strongest commitment mechanism for achieving collective action on antimicrobial resistance (AMR). Since AMR has important similarities to climate change—both are common pool resource challenges that require massive, long-term political commitments—the first article in this special issue draws lessons from various climate agreements that could be applicable for developing a grand bargain on AMR. We consider the similarities and differences between the Paris Climate Agreement and current governance structures for (...) AMR, and identify the merits and challenges associated with different international forums for developing a long-term international agreement on AMR. To be effective, fair, and feasible, an enduring legal agreement on AMR will require a combination of universal, differentiated, and individualized requirements, nationally determined contributions that are regularly reviewed and ratcheted up in level of ambition, a regular independent scientific stocktake to support evidence informed policymaking, and a concrete global goal to rally support. (shrink)

Antimicrobial resistance (AMR) is an urgent threat to global public health and development. Mitigating this threat requires substantial short-term action on key AMR priorities. While international legal agreements are the strongest mechanism for ensuring collaboration among countries, negotiating new international agreements can be a slow process. In the second article in this special issue, we consider whether harnessing existing international legal agreements offers an opportunity to increase collective action on AMR goals in the short-term. We highlight ten AMR priorities and (...) several strategies for achieving these goals using existing “legal hooks” that draw on elements of international environmental, trade and health laws governing related matters that could be used as they exist or revised to include AMR. We also consider the institutional mandates of international authorities to highlight areas where additional steps could be taken on AMR without constitutional changes. Overall, we identify 37 possible mechanisms to strengthen AMR governance using the International Health Regulations, the Agreement on the Application of Sanitary and Phytosanitary Measures, the Agreement on Trade-Related Aspects of Intellectual Property Rights, the Agreement on Technical Barriers to Trade, the International Convention on the Harmonized Commodity Description and Coding System, and the Basel, Rotterdam, and Stockholm conventions. Although we identify many shorter-term opportunities for addressing AMR using existing legal hooks, none of these options are capable of comprehensively addressing all global governance challenges related to AMR, such that they should be pursued simultaneously with longer-term approaches including a dedicated international legal agreement on AMR. (shrink)

Time-tested commons characterize by having instituted sanctioning mechanisms that are sensitive to the circumstances and motivations of non-compliers. As a proposed Global Antimicrobial Commons cannot cost-effectively develop sanctioning mechanisms that are consistently sensitive to the circumstances of the global poor, I suggest concentrating on establishing a wider set of incentives that encourages both compliance and participation.