In this paper we explore the relation between health-care needs and patients’ desires within shared decision-making in a context of priority setting in health care. We begin by outlining some general characteristics of the concept of health-care need as well as the notions of SDM and desire. Secondly we will discuss how to distinguish between needs and desires for health care. Thirdly we present three cases which all aim to bring out (...) and discuss a number of queries which seem to arise due to the double focus on a patient’s need and what that patient desires. These queries regard the following themes: the objectivity and moral force of needs, the prediction about what kind of patients which will appear on a micro level, implications for ranking in priority setting, difficulties regarding assessing and comparing benefits, and implications for evidence-based medicine. (shrink)

abstract The argument that scarce health care resources should be distributed so that patients in ‘need’ are given priority for treatment is rarely contested. In this paper, we argue that if need is to play a significant role in distributive decisions it is crucial that what is meant by need can be precisely articulated. Following a discussion of the general features of health care need, we propose three principal interpretations of need, (...) each of which focuses on separate intuitions. Although this account may not be a completely exhaustive reflection of what people mean when they refer to need, the three interpretations provide a starting‐point for further debate of what the concept means in its specific application. We discuss combined interpretations, the meaning of grading needs, and compare needs‐based priority setting to social welfare maximisation. (shrink)

Assessments of health care needs are embedded in contracts for health services. Such contracts are the formal link between the identification of health care needs and the purchasing of services to satisfy those needs. They are a central part of the procedural relationship between the British health service (NHS) and the satisfaction of human needs. To evaluate contracts it is necessary to investigate this relationship. A number of headings under which it may be possible (...) to begin to evaluate contracts are described, and the potential of a ‘universalist’ approach to interrogate contract-based decision-making is briefly discussed. (shrink)

One generally considered plausible way to allocate resources in health care is according to people’s needs. In this paper I focus on a somewhat overlooked issue, that is the conceptual structure of health care needs. It is argued that what conceptual understanding of needs one has is decisive in the assessment of what qualifies as a health care need and what does not. The aim for this paper is a clarification of the concept (...) of health care need with a starting point in the general philosophical discussion about needs. I outline three approaches to the concept of need and argue that they all share the same conceptual underpinnings. The concept of need is then analyzed in terms of a subject x needing some object y in order to achieve some goal z. I then discuss the relevant features of the object y and the goal z which make a given need qualify as a health care need and not just a need for anything. (shrink)

The debate about rationing health care often assumes that we can measure the health-care needs of groups and individuals. As this book makes clear, we are only just starting to develop a framework within which to measure health needs, predict the outcomes of treatments and define the conflicting priorities that influence resource allocation.

This paper aims to provide an argument for saying that a publicly funded health care system, available to all free at the point of delivery, is morally superior to a market system, and to provide a framework for deciding questions about which forms of health care should be included in such a public system. The argument presents health care as a ‘head’, in the sense of something to which human beings are morally entitled as (...) a necessary condition for a life worthy of human dignity. Alternative arguments for similar conclusions, proposed by Daniels and Buchanan, are critically examined and rejected. (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)

A couple and their five‐year‐old daughter are in a car accident. The parents are not expected to survive. The child is transported to a children's hospital, and urgent treatment decisions must be made. Whom should the attending physician approach to make decisions for the child? When such cases arise in, for example, the hospitals where we work, the social worker or chaplain is instructed to use the Illinois Health Care Surrogacy Act as a guidepost to identify a decision‐maker. (...) But in our state and the country overall, the limitations of such statutes leave hospital workers to make a judgment call among friends, family, and clergy who may come forward. While surrogate decision‐making statutes comprehensively address surrogate decision‐makers for adults, a patchwork of laws—permanency statutes, kinship provider statutes, standby guardianship statutes, and, in some cases, surrogate decision‐making statutes—provide variable decision‐making pathways for children. (shrink)

This commentary explores Medicaid's role for children with special health care needs today and considers how changes to Medicaid's federal financing structure under a per capita cap or block grant could affect coverage for these children.

Bringing the 12.8% of children with special healthcare needs into the national response to the childhood obesity epidemic will require new information, a view of health promotion beyond that which occurs within healthcare systems, and services and supports in addition to the multi-sectoral strategies presently designed for children overall. These efforts are necessary to protect the health of the nation's 9.4 million children with special health care needs now and long-term.

Although the obesity epidemic appears to have affected all segments of the U.S. population, its impact on children with special health care needs has received little attention. “Children with special health care needs” is a term used in the U.S. to describe children who come to the attention of health care providers and policy makers because they need different services and supports than other children. Government, at both the federal and state levels, has (...) long felt a particular responsibility for safeguarding the health of children with special needs. The definition “children with special health care needs,” in fact, was developed by a work group established by the U.S. Maternal and Child Health Bureau to assist states in their efforts to develop community systems of services for children with complex medical and behavioral conditions. (shrink)

In one of the televised debates among Republican primary candidates for the 2012 U.S. presidential election, moderator Wolf Blitzer presented this hypothetical case to candidate Ron Paul:A healthy 30 year old young man has a good job, makes a good living, but decides — you know what — ‘I’m not going to spend 200 or 300 dollars a month for health insurance because I’m healthy, I don’t need it.’ But something terrible happens, all of a sudden he needs (...) it. Who’s going to pay if he goes into a coma?Paul, known for his libertarian views, initially responded that the patient “should assume responsibility for himself,” and that he should have purchased a major medical policy before he became ill. (shrink)

This paper aims to provide an argument for saying that a publicly funded health care system, available to all free at the point of delivery, is morally superior to a market system, and to provide a framework for deciding questions about which forms of health care should be included in such a public system. The argument presents health care as a ‘head’, in the sense of something to which human beings are morally entitled as (...) a necessary condition for a life worthy of human dignity. Alternative arguments for similar conclusions, proposed by Daniels and Buchanan, are critically examined and rejected. (shrink)

Primary research on HIV/AIDS in India has predominantly focused on known risk groups such as sex workers, STI clinic attendees and long-distance truck drivers, and has largely been undertaken in urban areas. There is evidence of HIV spreading to rural areas but very little is known about the context of the infection or about issues relating to health and social impact on people living with HIV/AIDS. In-depth interviews with nineteen men and women infected with HIV who live in rural (...) areas were used to collect experiences of testing and treatment, the social impacts of living with HIV and differential impacts on women and men. Eight focus group discussions with groups drawn from the general population in the four villages were used to provide an analysis of community level views about HIV/AIDS. While men reported contracting HIV from sex workers in the cities, women considered their husbands to be the source of their infection. Correct knowledge about HIV transmission co-existed with misconceptions. Men and women tested for HIV reported inadequate counselling and sought treatment from traditional healers as well as professionals. Owing to the general pattern of husbands being the first to contract HIV women faced a substantial burden, with few resources remaining for their own or their children’s care after meeting the needs of sick husbands. Stigma and social isolation following widowhood were common, with an enforced return to the natal home. Implications for potential educational and service interventions are discussed within the context of gender and social relations. (shrink)

The migratory flows of recent decades that have exercised Europe as a socio-political and economic entity have produced extensive responses and interventions from European gender scholars. One relatively recent phenomenon in this context is the question of reparative surgical interventions, specifically clitoral reconstruction, in cases where women who have migrated to Europe have experienced female genital cutting. Clitoral reconstruction, which this article begins to explore, is recent in part because the related surgery was only established in the 1990s and is (...) to date only practised in a few European countries, and in part because the research with women who ask for and have undergone such surgery has also only recently begun. This article is therefore an initial attempt to map some of the related terrain and to suggest further work that needs to be done in this increasingly important area. (shrink)

According to HealthCare.gov, by improving access to quality health for all Americans, the Affordable Care Act (ACA) will reduce disparities in health insurance coverage. One way this will happen under the provisions of the ACA is by creating a new health insurance marketplace (a health insurance exchange) by 2014 in which “all people will have a choice for quality, affordable health insurance even if a job loss, job switch, move or illness occurs”. This does (...) not mean that everyone will have whatever insurance coverage he or she wants. The provisions of the ACA require that each of the four benefit categories of plans (known as bronze, silver, gold and platinum) provides no less than the benefits available in an “essential health benefits package”. However, without a clear understanding of what criteria must be satisfied for health care to be essential, the ACA’s requirement is much too vague and open to multiple, potentially conflicting interpretations. Indeed, without such understanding, in the rush to provide health insurance coverage to as many people as is economically feasible, we may replace one kind of disparity (lack of health insurance) with another kind of disparity (lack of adequate health insurance). Thus, this paper explores the concept of “essential benefits”, arguing that the “essential health benefits package” in the ACA should be one that optimally satisfies the basic needs of the people covered. (shrink)

What challenges must a principle of need for prioritisations in health care meet in order to be plausible and practically useful? Some progress in answering this question has recently been made by Hope, Østerdal and Hasman. This article continue their work by suggesting that the characteristic feature of principles of needs is that they are sufficientarian, saying that we have a right to a minimally acceptable or good life or health, but nothing more. Accordingly, principles of (...) needs must answer two distributive questions: when do we have sufficient and how should we prioritise among those who do not yet have a sufficiency? Furthermore, it is argued that Roger Crisp’s theory of need, which combines sufficientarianism with prioritarianism below the threshold of need, is better equipped than alternatives to answer these questions as well as meeting the challenges formulated by Hope, Østerdal and Hasman. However, Crisp’s theory faces two major challenges. First, it has to say something about the currency of distribution: a principle of need must be complemented either with a theory on the human good or a theory about the proper goals of health care. Second, it has to say something about where the threshold should be set. However, any attempt to set a threshold seems morally arbitrary in the light of the sufficientarian idea that those just above the threshold never should be given priority over those just below the threshold. (shrink)

The rhetoric of 'needs' has been used to legitimate all major turns in UK health policy since 1936. This study identifies the ethical, policy and technical issues arising from the concept of needs. In the first part a theory of needs is developed, which takes into account both the philosophical traditions and the practical problems arising in daily health care. In a second part, health systems throughout the world are described and compared, addressing ethical as well (...) as economical questions. Its interdisciplinary approach will make The Need for Healthcare important reading not only for those interested in or employed in the health care sector but also for students of philosophy. (shrink)

The rhetoric of 'needs' has been used to legitimate all major turns in UK health policy since 1936. This study identifies the ethical, policy and technical issues arising from the concept of needs. In the first part a theory of needs is developed, which takes into account both the philosophical traditions and the practical problems arising in daily health care. In a second part, health systems throughout the world are described and compared, addressing ethical as well (...) as economical questions. Its interdisciplinary approach will make _The Need for Healthcare_ important reading not only for those interested in or employed in the health care sector but also for students of philosophy. (shrink)

This book is a collection of articles about communication and ethics in the field of medicine and health care. Common to all the articles is that they are not directly based on empirical investigations. The discussions refer to research, but this is research that has already been carried out and documented in existing literature. In this sense the articles belong to what is often called applied philosophy. All the articles address communicative and ethical challenges in patient interaction on (...) the basis of assumptions in modern moral philosophy and philosophy of language. There is a great need for literature that deals more comprehensively with the themes in this book than many introductory books do. It is particularly difficult to find suitable reading material that can be used in teaching at graduate and master levels. This book is designed to meet this need. It is suitable for use in all higher-level courses where the aim is to give students a theoretical understanding of ethical dilemmas and communicative challenges in health care. (shrink)

In health care priority setting different criteria are used to reflect the relevant values that should guide decision-making. During recent years there has been a development of value frameworks implying the use of multiple criteria, a development that has not been accompanied by a structured conceptual and normative analysis of how different criteria relate to each other and to underlying normative considerations. Examples of such criteria are unmet need and severity. In this article these crucial criteria are (...) conceptually clarified and analyzed in relation to each other. We argue that disease-severity and condition-severity should be distinguished and we find the latter concept better reflects underlying normative values. We further argue that unmet need does not fulfil an independent and relevant role in relation to condition-severity except for in some limited situations when having to distinguish between conditions of equal severity. (shrink)

Going through reproductive experiences (especially pregnancy and childbirth) in contemporary Western societies almost inevitably involves interaction with medical practitioners and various medical technologies in institutional context. This has important consequences for women as embodied subjects. A critical appraisal of these consequences—coming dominantly from feminist scholarship—relied on a problematic theory of both technology and the subject, which are in contemporary approaches no longer considered as given, coherent and well individualized wholes, but as complex constellations that are locally situated and that can (...) only be described empirically. In this study, we will be relying on the developments in phenomenological theory to reconceptualize women as technologically mediated embodied subjects and on the new paradigms in philosophy of technology and STS to reconstruct medical technology as situated—with the aim of reconceptualizing their relationship and exploring different possibilities for the mediating role of medical technology. It will be argued that technologization of female reproductive processes and alienating consequences for women are not necessary or directly interrelated. The role of technology varies from case to case and depends mainly on the nontechnological and relational aspects of institutional context, in which medical practitioners play a decisive role. (shrink)

To better understand the available publications addressing ethical issues in rural health care we sought to identify the ethics literature that specifically focuses on rural America. We wanted to determine the extent to which the rural ethics literature was distributed between general commentaries, descriptive summaries of research, and original research publications. We identified 55 publications that specifically and substantively addressed rural health care ethics, published between 1966 and 2004. Only 7 (13%) of these publications were original (...) research articles while (12) 22% were descriptive summaries of research and 36 (65%) were general commentaries. The majority of publications examined (55%) were clinically focused while 27% addressed organizational ethics and 18% addressed ethical ramifications of rural health care policy at a national or community level. Our findings indicate that there are a limited number of publications focusing on rural health care ethics, suggesting a need for scholars and researchers to more rigorously address rural ethics issues. (shrink)

Health professionals increasingly face patients with complex health problems and this pressurizes them to cooperate. The authors have analyzed how the complexity of health care problems relates to two types of cooperation: consultation and multidisciplinary teamwork (MTW). Moreover, they have analyzed the impact of these two types of cooperation on perceived professional autonomy. Two teams were studied, one team dealing with geriatric patients and another treating oncology patients. The authors conducted semi-structured interviews, studied written documents, held (...) informal discussions and observed the teams at work. Consultation was most likely to take place when a patient had multiple problems. However, if these problems were interrelated, i.e. the solution for one problem interfered with solving another, then MTW was favored. The same was true when the available information was equivocal such that there were conflicting interpretations of a problem. How the professionals perceived the relationship between complexity and the need to cooperate depended on their expertise, their occupational background, and their work orientation. Consultation did not affect the professional autonomy of the health care professionals. MTW however did decrease the perceived level of professional autonomy. The extent to which this occurred seemed to depend on the quality of the interpersonal relations within the team. The findings can help in selecting the most appropriate and efficient type of cooperation based on the complexity of a patient’s problems. They can also help team leaders to stimulate reflection and feedback processes, and medical trainers to develop competencies among students related to such teamwork behaviors. (shrink)

This study explores child health care nurses’ pedagogical knowledge when supporting parents in their parenthood using various teaching practices, that is how to organise and process the content during parent education groups in primary health care. The aim is to identify teaching practices used by child health care nurses and to analyse such practices with regard to Aristotle's three forms of knowledge to comprehensively examine child health care nurses’ use of knowledge in (...) practice. A qualitative methodological design alongside the analysis of video‐recordings was used. The results showed that child health care nurses used four teaching practices: lecturing, demonstration, conversation and supervision. Their use of episteme was prominent, but they also seemed to master techne in combination with episteme during the first three teaching practices. During the conversation teaching practice, the child health nurses rarely succeeded. Consequently, they missed opportunities to identify mothers’ expressed concerns and to act in the best interests of both the mothers and their infants by the use of phronesis. In health care, however, theoretical episteme is superordinate to productive knowledge or phronesis, which also became evident in this study. Nevertheless, more interactive pedagogical practices are needed if more use of phronesis is to become a reality in parent education groups. (shrink)

Should organ transplants be given to patients who have waited the longest, or need it most urgently, or those whose survival prospects are the best? The rationing of health care is universal and inevitable, taking place in poor and affluent countries, in publicly funded and private health care systems. Someone must budget for as well as dispense health care whilst aging populations severely stretch the availability of resources. The Ethics of Health (...) class='Hi'>Care Rationing is a clear and much-needed introduction to this increasingly important topic, considering and assessing the major ethical problems and dilemmas about the allocation, scarcity and rationing of health care. Beginning with a helpful overview of why rationing is an ethical problem, the authors examine the following key topics: What is the value of health? How can it be measured? What does it mean that a treatment is "good value for money"? What sort of distributive principles - utilitarian, egalitarian or prioritarian - should we rely on when thinking about health care rationing? Does rationing health care unfairly discriminate against the elderly and people with disabilities? Should patients be held responsible for their health? Why does the debate on responsibility for health lead to issues about socioeconomic status and social inequality? Throughout the book, examples from the US, UK and other countries are used to illustrate the ethical issues at stake. Additional features such as chapter summaries, annotated further reading and discussion questions make this an ideal starting point for students new to the subject, not only in philosophy but also in closely related fields such as politics, health economics, public health, medicine, nursing and social work. (shrink)

The concept of need is often proposed as providing an additional or alternative criterion to cost-effectiveness in making allocation decisions in health care. If it is to be of practical value it must be sufficiently precisely characterized to be useful to decision makers. This will require both an account of how degree of need for an intervention is to be determined and a prioritization rule that clarifies how degree of need and the cost of the (...) intervention interact in determining the relative priority of the intervention. Three common features of health care interventions must be accommodated in a comprehensive theory of need: the probabilistic nature of prognosis (with and without the intervention); the time course of effects; and the fact that the most effective treatments often combine more than one intervention. These common features are problematic for the concept of need. We outline various approaches to prioritization on the basis of need and argue that some approaches are more promising than others. (shrink)

The argument for children's rights in health care has been long in the making. The success of this position is reflected in the 1995 American Academy of Pediatrics recommendations for the role of children in health care decisionmaking, which suggest that children be given greater voice as they mature. But there are good moral and practical reasons for exercising caution in these health care situations, especially when the child and parents disagree. Parents need (...) the moral and legal space within which to make decisions that will facilitate their child's long‐term autonomy, not only her present‐day autonomy. Moreover, third‐party intrusion, by physicians or the state, should be resisted unless negligent and abusive decisions are in the making. (shrink)

Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who want and could be benefitted by that good will not receive it. One reflection of our ambivalence towards health care rationing is reflected in our resistance to having it distributed in a market like most other goods—most Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another (...) commodity to be distributed by markets. Despite this widespread view, we are the only developed country without some form of universal health insurance, and so for the 46 million Americans without health insurance their access to health care often does depend on their ability to pay for it. Rationing largely remains a topic that the public, their elected leaders, and many health care professionals prefer to avoid. Ever-growing costs of health care will increasingly force the practice and issue of health care resource prioritization and rationing into the open for public, professional, and political attention. This paper explores some of the features of those practices and issues that make them especially ethically and politically difficult. Those issues will not be easily resolved, but avoiding them will not avoid the need or reality of rationing, it will only mean that it will go on covertly and unexamined. That will lead neither to better or more legitimate prioritization and rationing decisions. (shrink)

Little is known about health care professionals’ perceptions regarding what it means to treat patients and families with respect and dignity in the intensive care unit (ICU) setting. To address this gap, we conducted nine focus groups with different types of health care professionals (attending physicians, residents/fellows, nurses, social workers, pastoral care, etc.) working in either a medical or surgical ICU within the same academic health system. We identified three major thematic domains, namely, (...) intrapersonal (attitudes and beliefs), interpersonal (behaviors), and system (contextual) factors that influence treatment with respect and dignity. Participants suggested strategies for improving treatment of patients and families in the ICU with respect and dignity, as well as the related need for enhancing respect among the multidisciplinary team of clinicians. Implementing these strategies will require innovative educational interventions and leadership. Future research should focus on the design and evaluation of such interventions on the quality of care. (shrink)

Global Health involves, among many things the intensified travelling of people, resources, technologies, knowledge, standards, and ideas. This book describes what happens when innovations are transferred to new settings: What work is needed to make them work, but also how they change the setting into which they are introduced.

Digital health includes applications for smartphones and smart speakers as well as more traditional ways to access health information electronically, such as through your health care provider's online web‐based patient portal. As the number of digital health offerings—such as smartphone health trackers and web‐based patient portals—grows, what benefit do ethics, or bioethics, perspectives bring to digital health product development? For starters, the field of bioethics is concerned about issues of social justice, including equitable (...) benefit and minimization and fair distribution of the burden of harms. Researchers who employ user‐centered design methods should consider what digital health applications and products would look like if issues like equity and accessibility were foregrounded throughout design and development. One group whose needs are often neglected in the design of digital health products is older adults. Many people anticipate that the digital divide among older adults will close as the current generation of tech‐savvy consumers ages up. But since technology is constantly evolving, this divide may be constantly recreated. As bioethics moves ever further into the technology era, I want it to be mindful of the creation of digital health care disparities. (shrink)

This article will examine the Catholic concept of global justice within a health care framework as it relates to women's needs for delivery doctors in the developing world and women's demands for assisted reproduction in the developed world. I will first discuss justice as a theory, situating it within Catholic social teachings. The Catholic perspective on global justice in health care demands that everyone have access to basic needs before elective treatments are offered to the wealthy. (...) After exploring specific discrepancies in global health care justice, I will point to the need for delivery doctors in the developing world to provide basic assistance to women who hazard many pregnancies as a priority before offering assisted reproduction to women in the developed world. The wide disparities between maternal health in the developing world and elective fertility treatments in the developed world are clearly unjust within Catholic social teachings. I conclude this article by offering policy suggestions for moving closer to health care justice via doctor distribution. (shrink)