The work of the French Lithuanian Jewish philosopher, Emmanuel Levinas, describes a perceptive rethinking of the possibility of concrete acts of goodness in the world, a rethinking never more necessary than now, in the wake of the cruel realities of the twentieth century—ten million dead in the First World War, forty million dead in the Second World War, Hiroshima, Nagasaki, the Soviet gulags, the grand slaughter of Mao’s “Great Leap Forward,” the pointless and gory Vietnam War, the Cambodian self-genocide and (...) many an attempted extermination from the face of the earth of entire nations of indigenous peoples. The list of horrors goes on and on—daily holocausts that do not distinguish between the civilian and the soldier, the guilty and the innocent, those deserving of life and those less deserving. (shrink)

The Findlay & Walker model of saccade generation does not appear to account fully for saccadic performance deficits observed in schizophrenia patients. It would be enhanced by inclusion of a frontally mediated, central executive function system. A review of schizophrenia patients' antisaccade task deficits provides an example of the role of higher cortical functioning in saccade generation.

The aim of Language for those who have Nothing is to think psychiatry through the writings of Mikhail Bakhtin. Using the concepts of Dialogism and Polyphony, the Carnival and the Chronotope, a novel means of navigating the clinical landscape is developed. Bakhtin offers language as a social phenomenon and one that is fully embodied. Utterances are shown to be alive and enfleshed and their meanings realised in the context of given social dimensions. The organisation of this book corresponds with carnival (...) practices of taking the high down to the low before replenishing its meaning anew. Thus early discussions of official language and the chronotope become exposed to descending levels of analysis and emphasis. Patients and practitioners are shown to occupy an entirely different spatio-temporal topography. These chronotopes have powerful borders and it is necessary to use the Carnival powers of cunning and deception in order to enter and to leave them. The book provides an overview of practitioners who have attempted such transgression and the author records his own unnerving experience as a pseudopatient. By exploring the context of psychiatry's unofficial voices: its terminology, jokes, parodies, and everyday narratives, the clinical landscape is shown to rely heavily on unofficial dialogues in order to safeguard an official identity. (shrink)

The Anticipatory and Consummatory Interpersonal Pleasure Scale is a psychometric instrument that has been used to indirectly measure social anhedonia in many cross-cultural contexts, such as in Western, European, Eastern, and Israeli samples. However, little is known about the psychometric properties of the ACIPS in Korean samples. The primary goal of this study was to validate the Korean version of the ACIPS among non-help-seeking individuals. The sample consisted of 307 adult individuals who had no current or prior psychiatric history. Participants (...) were administered the ACIPS, along with the Behavioral Inhibition and Behavioral Activation Scales and Beck Depression Inventory. We examined the association of the total ACIPS scores with the other measures. The ACIPS showed good internal consistency. We also explored the factor structure of the Korean translation of the ACIPS using principal component analysis with Promax rotation and Kaiser normalization. Factor analysis yielded a three-factor structure that accounted for 58.8% of the variance. The three-factor model included the following subdomains: interactions involving close relationships, casual interactions, and interactions involving family members. Total BAS and BIS scores were significantly associated with total ACIPS scores, while BDI scores were inversely associated with total ACIPS scores. The current research indicates that the Korean version of the ACIPS is a useful and valid scale. Future directions include using the Korean translation of the ACIPS to elucidate the varying degrees of hedonic capacity in psychiatric patients. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:"To make a difference...":Narrative Desire in Global MedicineByron J. Good and Mary-Jo DelVecchio GoodIf, as Arthur Frank (2002) writes, "moral life, for better and worse, takes place in storytelling," this collection of narratives written by physicians working in field settings in global medicine gives us a glimpse of some aspects of moral experience, practice, and dilemmas in settings of poverty and low health care resources. These essays are (...) written from the midst of practice, in diverse settings in Africa, South Asia, Latin America, the Caribbean, and the United States. The majority of the writers are practitioners of contemporary 'global medicine'—physicians from North America or Europe who spend part of their lives flying into settings of poverty or special need to practice medicine and work with on-going collaborative clinical and public health systems—while a smaller number are working in the societies in which they were born. Although a few work for classic humanitarian organizations or have developed their own local NGO's, the great majority are engaged in the 'hybrid life' described by Robert Riviello and noted by Renée Fox, moving between academic medical centers and distant health care systems that are supported by local governments, major international organizations and funding agencies, and international NGO's like Partners in Health. These diverse forms of practice have become a common model for contemporary clinicians engaged in what has emerged as a new discipline of global health or global medicine, and these narratives give us a glimpse of some of the enduring, as well as newly emerging, forms of moral practice and ethical dilemmas characteristic of today's global medicine.Many of these stories are filled with the tension and pathos that makes clinical narratives powerful to read. Physicians are forced to make unfathomable decisions about whether to resuscitate and keep a baby alive, using all means available, or to let the infant die, whether to carry out a procedure that will save an infant in birth but would put the mother at risk, about how to deal with a cancer found in a very advanced state. However, virtually all of the stories transcend these classical stories of the decisions physicians are forced to make by being placed in settings of great scarcity of resources, which stand in particular contrast to the academic medical settings in North America or Europe where many of these global medicine specialists have trained and many continue to practice. The unspeakable inequality of resources emerges throughout these narratives as a kind of master theme, as the underlying moral, as opposed to plot, which gives meaning and sense to the stories. For those who practice medicine in such settings, global inequalities and scarcity of medical resources are deeply felt. They produce the rage that Jeffrey Deal describes. ("I learned to despise American churches during that time, a time when my world encompassed a dying newborn in Sudan, as well as the air conditioned padded seats [End Page 121] of our affluent suburban church.") They produce the distinctive experiences of helplessness and pain felt by clinicians who cannot separate how they would be able to treat such a patient at home from how they have to practice in these settings. For those clinicians working in their own societies, scarcity of resources often produces deep anger at the corrupt governments that fail to support basic human services for the great majority of their population. ("We were temporary actors performing in the cynical play of scarcity on permanent display in Port-au-Prince," writes Haitian physician Paul Pierre about his experience prior to joining Partners in Health.)But for those who regularly travel back and forth across the divide between rich and poor, whether across national boundaries or within their own society, the challenge to live a moral life is unendingly complicated. While becoming a part of a struggle for global justice with colleagues and advocates from both sides of the divide, few of the narrators can avoid personal feelings of ambivalence and guilt at being able to easily move from one side of that divide to the other back home. Many fantasize about giving up their lives in the north to devote themselves... (shrink)

The ipsilesional arm of stroke patients often has functionally limiting deficits in motor control and dexterity that depend on the side of the brain that is lesioned and that increase with the severity of paretic arm impairment. However, remediation of the ipsilesional arm has yet to be integrated into the usual standard of care for upper limb rehabilitation in stroke, largely due to a lack of translational research examining the effects of ipsilesional-arm intervention. We now ask whether ipsilesional-arm training, tailored (...) to the hemisphere-specific nature of ipsilesional-arm motor deficits in participants with moderate to severe contralesional paresis, improves ipsilesional arm performance and generalizes to improve functional independence. We assessed the effects of this intervention on ipsilesional arm unilateral performance [Jebsen–Taylor Hand Function Test ], ipsilesional grip strength, contralesional arm impairment level [Fugl–Meyer Assessment ], and functional independence [Functional independence measure ]. Intervention occurred over a 3 week period for 1.5 h/session, three times each week. All sessions included virtual reality tasks that targeted the specific motor control deficits associated with either left or right hemisphere damage, followed by graded dexterity training in real-world tasks. We also exposed participants to 3 weeks of sham training to control for the non-specific effects of therapy visits and interactions. We conducted five test-sessions: two pre-tests and three post-tests. Our results indicate substantial improvements in the less-impaired arm performance, without detriment to the paretic arm that transferred to improved functional independence in all three posttests, indicating durability of training effects for at least 3 weeks. We provide evidence for establishing the basis of a rehabilitation approach that includes evaluation and remediation of the ipsilesional arm in moderately to severely impaired stroke survivors. This study was originally a crossover design; however, we were unable to complete the second arm of the study due to the COVID-19 pandemic. We report the results from the first arm of the planned design as a longitudinal study. (shrink)

The article explored the fact that various bioethical principles underlie the evaluation of the patient’s status and role in therapeutic interactions in written medical documents. We have found that characterization of biomedical, social and behavioural aspects of the patient’s existence relies on such bioethical principles as obligation, truthfulness, respect for human rights and dignity, the patient’s good. A few facts of the violation of the principle of respect for human rights and dignity consisting in verbal stigmatization (...) have been provided. Bioethical perspective is also taken to evaluate the mode and extent of the patient’s involvement in a medical interaction, which are either negatively or positively assessed based on the patient’s compliance and good. (shrink)

The image of “the good nurse” is mainly studied from the perspective of nurses, which often does not match the image held by patients. Therefore, a descriptive study was conducted to examine oncology patients’ perceptions of “the good nurse” and the influence of patient- and context-related variables. A cross-sectional, comparative, descriptive design was used. The sample comprised 557 oncology patients at one of six Flemish hospitals, where they were treated in an oncology day-care unit, oncology hospital ward, (...) or palliative care unit. Data were collected using the Flemish Care-Q instrument. Factor analysis summarised the most important characteristics of “the good nurse”. We reassessed the reliability and construct validity of the Flemish Care-Q and examined the influence of patient- and context-related variables on patient perceptions. Using factor analysis, we grouped the different items of the Flemish Care-Q according to three characteristics: “the good nurse” (I) has a supportive and communicative attitude towards patient and family, (II) is competent and employs a professional attitude, and (III) demonstrates personal involvement towards patient and family. Median factor scores of Factors I, II, and III, respectively, were 8.00, 9.00, and 8.00 (varying from 1, not important, to 10, very important). In order of importance, Factors II, I, and III were identified as valuable characteristics of “the good nurse”. Gender, care setting, and province were influential variables. As perceived by oncology patients, “the good nurse” has a broad range of qualities, of which competence and professionalism are the most valuable. (shrink)

In this companion volume to their 1981 work, A Philosophical Basis of Medical Practice, Pellegrino and Thomasma examine the principle of beneficence and its role in the practice of medicine. Their analysis, which is grounded in a thorough-going philosophy of medicine, addresses a wide array of practical and ethical concerns that are a part of health care decision-making today. Among these issues are the withdrawing and withholding of nutrition and hydration, competency assessment, the requirements for valid surrogate decision-making, quality-of-life determinations, (...) the allocation of scarce health care resources, medical gatekeeping, and for-profit medicine. The authors argue for the restoration of beneficence to its place as the fundamental principle of medical ethics. They maintain that to be guided by beneficence a physician must perform a right and good healing action which is consonant with the individual patient 's values. In order to act in the patient 's best interests, or the patient 's good, the physician and patient must discern what that good is. This knowledge is gained only through a process of dialogue between patient and/or family and physician which respects and honors the patient 's autonomous self-understanding and choice in the matter of treatment options. This emphasis on a dialogical discernment of the patient 's good rejects the assumption long held in medicine that what is considered to be the medical good is necessarily the good for this patient. In viewing autonomy as a necessary condition of beneficence, the authors move beyond a trend in the medical ethics literature which identifies beneficence with paternalism. In their analysis of beneficence, the authors reject the current emphasis on rights- and duty-based ethical systems in favor of a virtue-based theory which is grounded in the physician- patient relationship. This book's provocative contributions to medical ethics will be of great interest not only to physicians and other health professionals, but also to ethicists, students, patients, families, and all others concerned with the relationship of professional to patient and patient to professional in health care today. (shrink)

This paradox raises the problem of reconciling the existence of moral evil with the rationality of the moral good. There seem to be two forms of moral evil, that which we commit and that which is committed against us. But there is in fact only one. For the second form is moral evil in the agent but not in the patient. The fact that we suffer from the moral failure of others indeed contradicts the demands of the (...) class='Hi'>good. But this contradiction consists in the moral failure of the agent, not in the pain of the patient. Hence, there is no special problem of reconciling the evil committed against us with the demands of the good. For that reduces to the problem of reconciling the moral failure of the agent with those demands. (shrink)

This article describes the findings of a mixed method literature review that examined the perceptions of elderly patients and residents of a good nurse in nursing homes, hospitals and home care. According to elderly patients and residents, good nurses are individuals who have the necessary technical and psychosocial skills to care for patients. They are at their disposal, promptly recognising the patients' needs. Good nurses like their job and are sincere and affectionate. They are understanding and caring. (...) They do not hesitate to enter into a trust-based relationship with their patients. Knowing and understanding how elderly patients and nursing home residents perceive ‘the good nurse’ is crucial for providing quality care and for promoting better patient outcomes in geriatric care. (shrink)

This article describes the findings of a mixed method literature review that examined the perceptions of elderly patients and residents of a good nurse in nursing homes, hospitals and home care. According to elderly patients and residents, good nurses are individuals who have the necessary technical and psychosocial skills to care for patients. They are at their disposal, promptly recognising the patients' needs. Good nurses like their job and are sincere and affectionate. They are understanding and caring. (...) They do not hesitate to enter into a trust-based relationship with their patients. Knowing and understanding how elderly patients and nursing home residents perceive ‘the good nurse’ is crucial for providing quality care and for promoting better patient outcomes in geriatric care. (shrink)

Nurses and ethicists worry that the implementation of care at a distance or telecare will impoverish patient care by taking out ‘the heart’ of the clinical work. This means that telecare is feared to induce the neglect of patients, and to possibly hinder the development of a personal relation between nurse and patient. This study aims to analyse whether these worries are warranted by analysing Dutch care practices using telemonitoring in care for chronic patients in the Netherlands. How (...) do clinical practices of nursing change when telecare devices are introduced and what this means for notions and norms of good nursing? The paper concludes that at this point the practices studied do not warrant the fear of negligence and compromised relations. Quite the contrary; in the practices studied, telecare lead to more frequent and more specialised contacts between nurses and patients. The paper concludes by reflecting on the ethical implications of these changes. (shrink)

Book reviewed in this article: For the Patient's Good: The Restoration of Beneficence in Health Care. By Edmund D. Pellegrino and David C. Thomasma.

This article deals with nurses’ ethical concerns raised by the consequences of changes in governmental and institutional policies on nursing practice and patient care. The aims of this project were to explore perspectives of registered nurses who provide or manage direct patient care on policies that affect nursing and patient care, and to provide input to policy makers for the development of more patient-centred policies. Four focus groups were conducted with a total of 36 registered nurse (...) participants. The project team identified major themes that emerged in the analysis of transcripts of the focus group discussions. The four major themes were: effects of policy focused on cost containment, effects on quality of care, effects on patient education and access to needed services, and effects on nurses and nursing. The participants identified primarily negative effects of changes in national health policy and legislation that influence institutional policies on patient care and nursing practice. The effects of identified policy changes raised concerns about meeting nurses’ ethical obligations to patients and families. Participants specified key points for consideration by legislators and other policy makers. They viewed nurses who are involved in direct patient care as a critical resource for legislators and other policy makers in the development of public and institutional policies that affect nursing and patient care. (shrink)

This article discusses findings from a mixed method literature review that investigated cancer patients’ perceptions of what constitutes a good nurse. To find pertinent articles, we conducted a systematic key word search of five journal databases (1998—2008). The application of carefully constructed inclusion criteria and critical appraisal identified 12 relevant articles. According to the patients, good nurses were shown to be characterized by specific, but inter-related, attitudes, skills and knowledge; they engage in person-to-person relationships, respect the uniqueness of (...) patients, and provide support. Professional and trained skills as well as broad and specific nursing and non-nursing knowledge are important. The analysis revealed that these characteristics nurtured patient well-being, which manifests as optimism, trust, hope, support, confirmation, safety and comfort. Cancer patients’ perceptions of what constitutes a good nurse represent an important source of knowledge that will enable the development of more comprehensive and practice-based views on good nursing care for such patients. These perceptions help us to understand how nurses effectively make a difference in cancer patient care. (shrink)

This study analyzes the ideals of responsibility and accountability, asking such questions as when it is legitimate to blame top officials of an organization for mistakes made by personnel below them in the bureaucratic hierarchy; when things go wrong in a large and complex organization like the Canadian Forces, who is responsible and accountable; and whether a plea of ignorance is a good excuse. The study also analyzes the doctrine of ministerial responsibility in both the British and Canadian parliamentary (...) traditions, asking whether it is realistic to expect that a government minister should be held responsible for everything that goes wrong in his/her department. Finally, traditional military values are examined, considering the kinds of attitudes and values expected from Canada's armed forces and the differences between the military and civilian sectors. (shrink)

In their target article “Two Minds, One Patient,” Moore and colleagues’ (2022) stated goal is “to help clinicians, ethicists, and patients locate [the] source” (38) of a patient’s ambivalence in or...

Volume 19, Issue 12, December 2019, Page 44-45.

In this article we examine the figure of the doctor in animated debates around public sector medicine in contemporary South Africa. The loss of health professionals from the South African public system is a key contributor to the present healthcare crisis. South African medical schools have revised curricula to engage trainee doctors with a broader set of social concerns, but the disjunctures between training, health systems failures, and a high disease burden call into question whether junior doctors are adequately prepared (...) or whether conditions of care extend beyond medical training. A concern with 'resilience' suggests a correct ethical relation to a putative obligation to provide care in a struggling system. By examining the ways in which trainee doctors are expected to 'cope' with the demands of medical practice, to adopt the correct moral posture in relation to the urgency of care, and to enact a desirable ethical relation to the broader social and political context of medical practice, we examine the picture of humanist concern that animates the subjectivities and techniques of the self called for by this training, and advocate for endurance as an alternative framework for understanding the political and ethical relations between doctors, patients and health systems. (shrink)

Tort law is an important tool in enforcing a minimal level of good behavior. But what is appropriate for law is not necessarily appropriate for ethics or for norms of professional practice.

This paper sets out to discuss what precisely is meant by ‘‘benefit" when we talk of the requirement that the health care system concern itself with health gain or with maximizing beneficial health care. In particular I argue that in discharging the duty to do what is most beneficial we need to choose between rival conceptions of what is meant by beneficial. One is the patient's conception of benefit and the second is the provider's or funder's conception of benefit. (...) I argue that it is the patient's conception of benefit which is paramount and that if this is followed it commits us to a conception of patient care which must be blind to prognosis in so far as prognosis is thought to bear upon issues of prioritisation or resource allocation. (shrink)

This paper sets out to discuss what precisely is meant by ‘‘benefit" when we talk of the requirement that the health care system concern itself with health gain or with maximizing beneficial health care. In particular I argue that in discharging the duty to do what is most beneficial we need to choose between rival conceptions of what is meant by beneficial. One is the patient's conception of benefit and the second is the provider's or funder's conception of benefit. (...) I argue that it is the patient's conception of benefit which is paramount and that if this is followed it commits us to a conception of patient care which must be blind to prognosis in so far as prognosis is thought to bear upon issues of prioritisation or resource allocation. (shrink)

Democracy has been a flawed hegemony since the fall of communism. Its flexibility, its commitment to equality of representation, and its recognition of the legitimacy of opposition politics are all positive features for political institutions. But democracy has many deficiencies: it is all too easily held hostage by powerful interests; it often fails to advance social justice; and it does not cope well with a number of features of the political landscape, such as political identities, boundary disputes, and environmental crises. (...) Although democracy is valuable it fits uneasily with other political values and is in many respects less than equal to the demands it confronts. In this volume prominent political theorists and social scientists present original discussions of such central issues. Democracy's Values deals with the nature and value of democracy, particularly the tensions between it and such goods as justice, equality, efficiency, and freedom. (shrink)

Background:The acquisition of experience is a major concern for nurses in intensive care units. Although the emotional component of the clinical practice of these nurses has been widely studied, greater examination is required to determine how this component influences their learning and practical experience.Objective:To discover the relationships between emotion, memory and learning and the impacts on nursing clinical practice.Research design:This is a qualitative phenomenological study. The data were collected from open, in-depth interviews. A total of 22 intensive care unit nurses (...) participated in this research between January 2012 and December 2014.Ethical considerations:The School of Nursing Ethics Committee approved the study, which complied with ethical principles and required informed consent.Findings:We found a clear relationship between emotion, memory and the acquisition of experience. This relationship grouped three dimensions: (1) satisfaction, to relieve the patient’s pain or discomfort, give confidence and a sense of security to the patient, enable the presence of family members into the intensive care unit and provide family members with a realistic view of the patient’s situation; (2) error experience, which nurses feel when a patient dies, when they fail to accompany a patient in his or her decision to abandon the struggle to live or when they fail to lend support to the patient’s family; and (3) the feel bad–feel good paradox, which occurs when a mistake in the patient’s care or handling of his or her family is repaired.Conclusion:Emotion is a capacity that impacts on nurses’ experience and influences improvements in clinical practice. Recalling stories of satisfaction helps to reinforce good practice, while recalling stories of errors helps to identify difficulties in the profession and recognise new forms of action. The articulation of emotional competencies may support the development of nursing ethics in the intensive care unit to protect and defend their patients and improve their relationships with families in order to maximise the potential for patient care. (shrink)

There are good reasons — both medical and moral — for wanting to redistribute health care resources, and American hospitals and physicians are already involved in the practice of redistribution. However, such redistribution compromises both patient autonomy and the fiduciary relationship essential to medicine. These important values would be most completely preserved by a system in which patients themselves would be the agents of redistribution, by sharing their medical resources. Consequently, we should see whether patients would be willing (...) to share before we resort to surreptitiously redistributing their resources or denying medical care to some who want and need it. We should change our health care payments systems to allow patients to donate their medical benefits to those in need. (shrink)

Background: Informed consent for genetic tests is a well-established practice. It should be based on good quality information and in keeping with the patient’s values. Existing informed consent assessment tools assess knowledge and values. Nevertheless, there is no consensus on what specific elements need to be discussed or considered in the consent process for genetic tests.Methods: We performed a systematic review to identify all factors involved in the decision-making and consent process about genetic testing, from the perspective of (...) patients. Through public databases, we identified studies reporting factors that influence the decision to accept or decline genetic testing. Studies were included if they reported the perspective of patients or at-risk individuals. All articles were thematically coded.Results: 1989 articles were reviewed: 70 met inclusion criteria and 12 additional articles were identified through the references of included studies. Coding of the 82 articles led to the identification of 45 factors involved in decision-making and consent, which were initially divided into three domains: in favor of, against or with an undetermined influence on genetic testing. Each factor was also divided into three subdomains relating to the informed choice concept: knowledge, values or other. The factors in the “other” subdomain were all related to the context of testing (e.g. timing, cost, influence of family members, etc), and were present in all three domains.Conclusions: We describe the network of factors contributing to decision-making and consent process and identify the context of genetic testing as a third component to influence this process. Future studies should consider the evaluation of contextual factors as an important and relevant component of the consent and decision-making process about genetic tests. Based on these results, we plan to develop and test a more comprehensive tool to assess informed consent for genetic testing. (shrink)

This paper demonstrates how ubuntu relational philosophy may be used to ground beneficial coercive care without necessarily violating a patient’s dignity. Specifically, it argues that ubuntu philosophy is a useful theory for developing necessary conditions for determining a patient’s potential dangerousness; setting reasonable limits to the duty to protect; balancing the long-term good of providing unimpeded therapy for patients who need it with the short-term good of protecting at-risk parties; and advancing a framework for future case (...) law and appropriate regulations in the care of psychotherapy patients. Issues regarding the decision to breach medical confidentiality in psychotherapeutic care are ultimately reserved for the courts. Professional assessment might be an important first step in this process, and court rulings govern most aspects of this assessment. However, current case law, especially in the United States, places an unreasonable expectation on psychotherapists to protect all at-risk parties or foresee that a patient intends to follow through on said threats. It has largely failed to guarantee psychotherapy patients unlimited access to care, while potentially inhibiting future honest communication between patients and health professionals and endangering the safety of others. Of these decisions, the two most prominent are the 1976 Tarasoff decision and the 2016 Volk decision. This paper argues for the possibility of grounding good laws in ubuntu African philosophy in a way that protects others from harm and ensures unimpeded access to care without necessarily breaching medical confidentiality. (shrink)

... Press for their editorial perspicacity, to the National Institutes of Health for the partial financial support they gave me while I was writing some of the chapters, and to Donald Michie for suggesting the title Good Thinking.

In response to a global population with increasingly complex issues at the end of life, a movement in the U.S. has emerged incorporating doulas into end-of-life care. These end-of-life (EOL) doulas are not just focused on the quality of life, but also the quality of death. Like birth doulas, who provide support for pregnant patients and their families, EOL doulas help alleviate physical and mental discomfort in those who are dying. In this paper, we explore the role of EOL doulas (...) in improving the care of unrepresented patients, who lack decision-making capacity and have no surrogates or documents to guide their healthcare decisions. We argue that EOL doulas may help this traditionally underserved population experience a “good death” by answering several ethical and procedural challenges. As quasi-independent, non-medical members of the healthcare team, they provide a balancing, advocating voice on behalf of the patient, and may also help reduce inappropriate treatment, delays in care, and the overburdening of the public guardianship system. As such, attention should be given to formally defining their place within the healthcare infrastructure. Ultimately, we contend that EOL doulas are key to ensuring optimal, ethical care for unrepresented patient populations. (shrink)

Clinical decision-making concerns the normal and the not normal and is marked by moral discourse. In the area of assisted reproduction technologies, little is known about physicians' attitudes towards their patients, and therefore one aim of this study is to enquire into infertility clinicians' perceptions of their patients. Additionally, this study seeks to establish what kinds of patients are defined by the clinicians as Others, as less appropriate candidates for infertility treatment. In this study, clinical judgements were affected by the (...) gendered nature of patients and by the supposed nature of potential mothers-to-be. The other patients and mothers-to-be were described in terms of their mental, physical and emotional status, and in terms of their lifestyle. The most inappropriate Other mothers-to-be were those who had complicated psychosocial and health problems. A second group were described as single and supposedly lonely women, and as women who were considered too career oriented. The importance of money played a primary role in determining who is supposedly a good mother. Namely, if a woman was too rich or too stingy and career oriented, or too poor, with several psychosocial problems, her capacity for maternal love was questioned. The clinicians' perceptions of the roles of technology and nature in assisted reproduction technologies are also discussed. (shrink)

Trust is indispensable not only for interpersonal relationships and social life, but for good quality healthcare. As manifested in the increasing violence and tension in patient-physician relationships, China has been experiencing a widespread and profound crisis of patient–physician trust. And globally, the crisis of trust is an issue that every society, either developing or developed, has to face in one way or another. Yet, in spite of some pioneering works, the subject of patient-physician trust and mistrust (...) – a crucial matter in healthcare especially because there are numerous ethical implications – has largely been marginalized in bioethics as a global discourse. Drawing lessons as well as inspirations from China, this paper demonstrates the necessity of a trust-oriented bioethics and presents some key theoretical, methodological and philosophical elements of such a bioethics. A trust-oriented bioethics moves beyond the current dominant bioethical paradigms through putting the subject of trust and mistrust in the central agenda of the field, learning from the social sciences, and reviving indigenous moral resources. In order for global bioethics to claim its relevance to the things that truly matter in social life and healthcare, trust should be as vital as such central norms like autonomy and justice and can serve as a potent theoretical framework. (shrink)

Past ages of medical care are condemned in modern philosophical and medical literature as being too paternalistic. The normal account of good medicine in the past was, indeed, paternalistic in an offensive way to modern persons. Imagine a Jean Paul Sartre going to the doctor and being treated without his consent or even his knowledge of what will transpire during treatment! From Hippocratic times until shortly after World War II, medicine operated in a closed, clubby manner. The knowledge learned (...) in medicine was not shared with the patients, who were in general poorly educated and for the most part completely ignorant of the craft of medicine and the physicians (but not, perhaps, of folk medicine). Physicians were cautioned against telling patients too much about their Illness and/or their recovery, perhaps because physicians themselves did not have an enormous armamentarium to confront disease. (shrink)

Purpose The paper aims to investigate whether dissent—within hospices and palliative care units—can be observed with regard to typical characteristics of “good dying”, how statements about dying processes that are not perceived as good are expressed, and finally which ethically significant normative consequences arise from this. Method The study is conducted on the basis of a qualitative interview study in different groups of actors and the relationships of these groups are compared with each other. Results Notions of (...) class='Hi'>good and bad dying are articulated—even dissented upon—not so much by the patients and their relatives themselves as by the professional actors. This is connected with the requirements of a practice, which evidently evokes a need for accountability, namely for communicative assurance. Conclusion An abstract designation of “good dying” is in danger of losing sight of the contextual characteristics of the practice associated with it, which can lead to situations that are problematic from an ethical viewpoint. (shrink)

I am grateful to Drs. Richard Bukata and Jerome Hoffman and the staff of Primary Care Medicals for retrieving and analyzing some of the references used in this paper.

BackgroundThe Patient Health Questionnaire-9 is the most well-known self-report measure to screen for depressive symptomatology, although discerning which is the factor structure that represents the best fit remains a challenge.ObjectiveThe aim of this study was to analyze the psychometric properties and factorial structure of the Spanish version of the PHQ-9 in a large sample of Ecuadorian college students.MethodsA total of 5,394 students from three Ecuadorian universities were surveyed using a computerized questionnaire within a 4-week assessment period. The PHQ-9 was (...) tested for factorial structure, reliability, and correlations with other mental health-related measures.ResultsThe hierarchical model that included a general factor and three nested factors had a better fit, and such a hierarchical structure remained invariant across sex and age. Total omega value was 0.90 for the total scale and hierarchical omega values were 0.68 for the general factor, as well as 0.34, 0.38, and 0.44 for the respective nested factors. Moreover, PHQ-9 scores were significantly higher among women, although effect sizes of comparison of those sex differences were very small. Finally, the PHQ-9 scores correlated with multiple mental health indicators.DiscussionThe Spanish version of the PHQ-9 showed good psychometric properties among Ecuadorian college students. The hierarchical structure showed the best fit for the data, including not only a dominant general factor, but also the somatic, cognitive/affective and concentration/motor subcomponents. In conclusion, the PHQ-9 tool seems to represent an easy-to-implement screening questionnaire to design preventive programs for those Ecuadorian college students at risk of developing depressive disorders. (shrink)

An original examination of the relevance of behavioral economics for the practice of medical ethics.

The “best interests” of the patient are widely seen as a cornerstone of medical practice. They are the explicit legal standard for medical care in the case of patients who lack capacity to consent to treatment.The best interests of the individual patient have, of course, long been compromised for the sake of other potential patients—in infectious disease control for example. The question of the ethics of such compromise became a hot issue, for UK doctors, about fifteen years ago (...) in the context of health care rationing. At that time the fact that there are insufficient resources to provide all patients, in all circumstances, with the best possible treatment became explicit. Faced with this uncomfortable truth, doctors tended to divide into two camps. Some wanted to play no role in decisions about resource allocation. They continued to be guided by the single ethic of each individual patient's best interests. However, “best interests” could be interpreted as “best” given the treatments that were made available by those who determined the allocation of resources. Others took the opposite approach: since choices had to be made as to the best use of available resources, doctors ought to be playing a significant role in making these choices.This polarisation has softened over time. Doctors have become more at ease with the idea that some treatments are not, given the overall resources, cost-effective, even if they are the best available. Clinical guidelines increasingly are influenced by cost-effectiveness. To provide the best health care overall, within the available resources, doctors aim to provide good care for each individual patient, but they do not always provide the best care. (shrink)

The article considers the history of bioethics formation as a human rights movement aimed at establishing patient autonomy and limiting the practice of uncontrolled medical manipulation of human body, biomedical experimentation on people in the name of science, “public good” and other values. It is shown that the forms of expression and content of the statements of the protesting bioethical expert and the content turned out to be extremely diverse and based on conflicting ethical principles, actually demonstrating total (...) rejection and confrontation of various conceptual arguments and often not contributing to the development of a universal, acceptable to all stakeholders ethical position. The article considers the peculiarities of bioethical protest and philosophical reasoning in connection with the emergence in the field of modern medicine of the diagnosis of brain death and gives a general idea of the intense public perception of this diagnosis. (shrink)

Lithuania was one of the first states in Europe to approve a comprehensive list of patients’ duties under a special Law on the Rights of Patients of 2010. The approval of the catalogue of patients’ duties at the level of a law is based on the restatement of the principle of equal rights of the parties participating in health care relations, and the prevention of consumerism in these relations. The paper distinguishes between general and special patients’ duties. The general duties (...) include the duty to exercise the patient’s rights in good faith, the ban to abuse them, the duties of cooperation and looking after one’s health, as well as the duty of treatment with due respect. The norms that entrench duties of ethical nature should serve to prevent any inappropriate behaviour of patients in health care institutions. Nevertheless, legal application of these provisions and proving the infringements in practice is likely to be complicated. The special duties include: the duty to familiarise oneself against signature with the internal regulations of the health care institution as presented to him or her, other documents prescribed by the health care institution; the duty to present the documents confirming identity; the duty upon receiving information about the health care services prescribed for him or her to confirm in writing his or her consent or refusal with regard to the provision of such health care services in the cases specified by the law; the duty to provide health care professionals with any information about one’s health, to follow the prescriptions and recommendations of health care professionals, to inform health care professionals about any deviations from the prescriptions or the prescribed treatment regime which he or she has accepted. The legal analysis of the contents of the duties has revealed certain unsubstantial obscurities. The analysis of the provision that enables to take sanctions against the patient infringing their duties has revealed that the health care institution may only terminate provision of health care services to the patient if one of the two alternative conditions is fulfilled. I.e. if a person violates his or her duties and thereby causes danger to their own and other patients’ health and life, or prevents them from receiving high quality health care services. The conclusions show that application of this provision may be problematic: first, due to the juridical technique of the wording of the norm; second – due to complicated substantiating that the patient prevented or prevents other patients from receiving high quality health care services; third – due to the conflict of this provision with the provision of the Law of the Republic of Lithuania on Medical Practice, which provides that a doctor may refuse provision of health care services in cases of real threat to his or her own life; and fourth – the norm does not provide for the right to terminate the provision of services in cases of threat to health and/or life of health care workers (non-specialists). (shrink)

Background: Use of patients’ medical data for secondary purposes such as health research, audit, and service planning is well established in the UK. However, the governance environment, as well as public understanding about this work, have lagged behind. We aimed to systematically review the literature on UK and Irish public views of patient data used in research, critically analysing such views though an established biomedical ethics framework, to draw out potential strategies for future good practice guidance and inform (...) ethical and privacy debates. Methods: We searched three databases using terms such as patient, public, opinion, and electronic health records. Empirical studies were eligible for inclusion if they surveyed healthcare users, patients or the public in UK and Ireland and examined attitudes, opinions or beliefs about the use of patient data for medical research. Results were synthesised into broad themes using a framework analysis. Results: Out of 13,492 papers and reports screened, 20 papers or reports were eligible. While there was a widespread willingness to share patient data for research for the common good, this very rarely led to unqualified support. The public expressed two generalised concerns about the potential risks to their privacy. The first of these concerns related to a party’s competence in keeping data secure, while the second was associated with the motivation a party might have to use the data. Conclusions: The public evaluates trustworthiness of research organisations by assessing their competence in data-handling and motivation for accessing the data. Public attitudes around data-sharing exemplified several principles which are also widely accepted in biomedical ethics. This provides a framework for understanding public attitudes, which should be considered in the development in any guidance for regulators and data custodians. We propose four salient questions which decision makers should address when evaluating proposals for the secondary use of data. (shrink)

The ethical pre-condition of randomised controlled trials is, at present, the presence of equipoise. This refers to an opinion of the investigator that there is uncertainty as to the merits of the treatments being compared. It is argued that since the decision to enrol is the potential subject’s, the investigator’s opinion is not ethically relevant. It is proposed instead that equipoise be patient-centred, and that a trial is in equipoise for a patient when enrolling gives them the same (...) chance of a good outcome as not enrolling. It is shown that trial enrolment is normally easily the best strategy for achieving a good outcome, and that trials currently thought to be unethical may be in patient-centred equipoise. This is so for three reasons: (1) patients in trials receive superior care, (2) trial enrolment minimises the risk of being a victim of a therapeutic disaster and (3) health professionals make mistakes, and a 50% chance of receiving the worse treatment until a trial reports is always better than any chance of receiving the worse treatment indefinitely. It is concluded that so long as the standard of professional conduct is the furtherance of patients’ objective interests randomised controlled trials are ethical. (shrink)

Most donated organs in the United States come from brain dead donors, while a small percentage come from patients who die in “controlled,” or expected, circumstances, typically after the family or surrogate makes a decision to withdraw life support. The number of organs available for transplant could be substantially if donations were permitted in “uncontrolled” circumstances–that is, from people who die unexpectedly, often outside the hospital. According to projections from the Institute of Medicine, establishing programs permitting “uncontrolled donation after circulatory (...) determination of death,” or uDCDD, throughout the United States has the potential to provide 22,000 more donation opportunities annually. In contrast, U.S. controlled donation after circulatory determination of death, or cDCDD, cases have increased progressively over the past decade from 87 to 848 donors, but currently account for only 10.6 percent of all deceased donors. Following the IOM recommendations, several projects exploring the feasibility of uDCDD were funded by the federal government, including a grant from the Health Resources and Services Administration that supported a pilot project in New York City in which the authors of this article participated.A key feature of our protocol, and indeed of many uDCDD protocols, is the initiation of preservation methods such as chest compressions and extracorporeal membrane oxygenation shortly after death in order to perfuse and preserve the donor's organs. Critics of uDCDD argue that the means of determining death deviates from generally ascribed principles. They assert that reinstituting circulation in order to preserve organs has the effect of “undoing” the prior determination of death. The result is that cDCDD is widely accepted and practiced routinely even though it only marginally increases the number of organs available for transplantation, and uDCDD is widely considered unacceptable despite being ethically embraced and proven to significantly increase organ donation opportunities in other countries. This article explores the evolution of this counterintuitive state of affairs and calls for a policy that, in line with the IOM report, allows for both cDCDD and uDCDD protocols. (shrink)

Burnout among physicians, nurses, and students is a serious problem in U.S. healthcare that reflects inattentive management practices, outmoded images of the “good” provider as selflessly ignoring the care of the self, and an overarching rubric of Patient Centered Care that leaves professional self-care out of the equation. We ask herein if expanding PCC to Patient and Professional Centered Care would be a useful idea to make provider self-care an explicit part of mission statements, a major part (...) of management strategies and institutional goal setting, and of educational programs. We offer several practical suggestions for PPCC implementation, including structuring healthcare systems so as to nurture professional meaning, integrity, and inter-personal reflective emotional processing as a buffer against burnout and as a key to better patient care. It should not bring into question the primacy of practitioner commitment to the good of patients, nor should it be taken to suggest in any way a shift in focus away from patients’ values and respect for patient autonomy. PPCC asserts that the respect for patient’s values and autonomous choices properly remains the ethical benchmark of modern healthcare systems, along with altruistic professional commitment to the optimal care of patients. However, it enunciates an explicit commitment to structuring systems that allow for and actively encourage the professional well-being and wellness upon which good patient care depends. (shrink)