Background In nursing homes, residents’ relatives represent important sources of support for nurses. However, in the heightened stress of emergency situations, interaction between nurses and relatives can raise ethical challenges. Research objectives The present analysis aimed at elaborating a typology of nurses’ experience of ethical support and challenges in their interaction with relatives in emergency situations. Research design Thirty-three semi-structured interviews and six focus groups were conducted with nurses from different nursing homes in Germany. Data were analysed according to Mayring’s (...) method of qualitative content analysis. Participants and research context Participants were licensed nurses working in nursing homes. Ethical considerations Ethical approval was granted by Ostfalia University of Applied Sciences (02.07.2020) and the Ethics Committee of Hannover Medical School (Nr. 8866_BO_K_2020; 27.01.2020). Interviewees were anonymised and focus group were pseudonymised during transcription. All participants provided written consent. Findings/results In emergency situations, relatives can represent important sources of support for nurses. However, they may also give rise to different challenges, relating to four ethical conflicts: (1) the challenge of meeting the information needs of relatives while providing appropriate care to all residents; (2) the challenge of managing relatives’ demands for hospitalisation when hospitalisation is not deemed necessary by nurses; (3) the challenge of managing relatives’ demands for lifesaving treatment when such treatment contradicts the will of the resident; and (4) the challenge of attempting to initiate hospitalisation when relatives oppose this course of action. Several external factors make these conflicts especially challenging for nurses: fear of legal consequences, a low staffing ratio, and a lack of qualified nursing staff. Conclusions Conflict between nurses and relatives typically revolves around hospitalisation and the initiation of lifesaving treatment. Whether nurses perceive interaction with relatives as supportive or conflictual essentially depends on the quality of the relationship, which may be negatively influenced by a number of external factors. (shrink)

On September 1, 2023, Texas made important revisions to it its decades‐old statute granting legal safe harbor immunity to physicians who withhold or withdraw life‐sustaining treatment over the objection of critically ill patients’ surrogate decision‐makers. However, lawmakers left untouched glaring flaws in a key safeguard for patients—the transfer option. The transfer option is ethically important because, when no hospital is willing to accept the patient in transfer, that fact is taken as strong evidence that the surrogates’ treatment requests fall (...) outside accepted medical practice. But there are serious shortcomings in how the transfer option is carried out in Texas and many other states, which undermines the ethical usefulness of the process. We identify these shortcomings and recommend revisions to state statutes and professional guidelines to overcome them. (shrink)

Polish hospital chaplaincy, because of the unique political and sociological context in which it finds itself, presents a sort of triple beholdenness. It carries particular loyalties to the state, to Catholic doctrine, and above all, it is called to be faithful to the unique suffering person. In this article, I argue that the biggest challenge for Polish chaplaincy resides within the domain of loyalty to the patient, where the profound and immediate need for robust formation of individual Christian conscience (...) through catechesis is needed. Although hospital chaplaincy’s involvement in catechesis and instructing the faithful might not be clearly evident for the reader, nevertheless I prove my point by bringing a story from my practice as a chaplain in one of Poland’s hospitals. (shrink)

RACINE L and PETRUCKA P. Nursing Inquiry 2011; 18: 12–20 Enhancing decolonization and knowledge transfer in nursing research with non-western populations: examining the congruence between primary healthcare and postcolonial feminist approachesThis article is a call for reflection from two distinct programs of research which converge on common interests pertaining to issues of health, social justice, and globalization. One of the authors has developed a research program related to the health and well-being of non-western populations, while the other author has expanded (...) the field of Aboriginal and international research in Canada and abroad. Based on examples drawn from our respective programs of research, we suggest conciliating the philosophy of primary healthcare to postcolonial feminism for decolonizing research and enhancing knowledge transfer with non-western populations. We contend that applying the theoretical and methodological strengths of these two approaches is a means to decolonize nursing research and to avoid western neocolonization. In conciliating primary health care and postcolonial feminism, the goal is to enhance the pragmatic relevance of postcolonial feminism to generate resistance through transformative research for achieving social justice. In tapping into the synergistic and complementary epistemological assumptions of the philosophy of primary health care and postcolonial ‘feminisms’, nurse researchers reinforce the anti-oppresive goals of postcolonial feminist research. Consequently, this approach may enhance both decolonization and knowledge transfer through strategies like photovoice. (shrink)

Abstract In light of the complexity of unfolding disasters, the diversity of rapidly evolving events, the enormous amount of generated information, and the huge pool of casualties, emergency responders (ERs) may be overwhelmed and in consequence poor decisions may be made. In fact, the possibility of transporting the wounded victims to one of several hospitals and the dynamic changes in healthcare resource availability make the decision process more complex. To tackle this problem, we propose a multicriteria decision support service, based (...) on the Analytic Hierarchy Process (AHP) method, that aims to avoid overcrowding and outpacing the capacity of a hospital to effectively provide the best care to victims by finding out the most appropriate hospital that meets the victims’ needs. The proposed approach searches for the most appropriate healthcare institution that can effectively deal with the victims’ needs by considering the availability of the needed resources in the hospital, the victim’s wait time to receive the healthcare, and the transfer time that represents the hospital proximity to the disaster site. The evaluation and validation results showed that the assignment of hospitals was done successfully considering the needs of each victim and without overwhelming any single hospital. (shrink)

We refer to hospitalized convicted hunger strikers in Padua Hospital who decided to fast for specific reasons, often demanding, to be heard by the judge, to complain about the existing custodial situation or to claim unjust treatment. The medical ethics of hunger strikers are debated because the use of force feeding by physicians is widely condemned as unethical, but courts, in Italy, sometimes order to transfer the convicted person to hospital and oblige healthcare practitioners to perform forcible feeding. (...) This can engender a profound insecurity for the physicians taking action on the one hand, while preventing patients from fully availing themselves of this principle of self-determination on the other. Physicians are mainly concerned about how to manage this situation and they may request ethical consultation. When it comes to managing hospitalized hunger strikers, the ethics consultant may be able to facilitate the relationship between physicians and hunger strikers, enhance the latter’s trust in the former, ensuring that strikers are aware of the risks associated with their fasting, and helping them to arrive of their own free will at the right decision concerning their behavior and their demands. (shrink)

_Avoiding Emotions, Living Emotions_ explores the psychoanalytic encounter and examines how emotions are formed and experienced by both the patient and analyst. The author narrates key theoretical concepts through the presentation of clinical material from adult and child analysis and emphasises the importance of being able to foster these narrations. Offering new insights into how the mind works, topics of discussion include: Bion’s thinking and its fertilization: clinical implications variations on transference and countertransference image and narration. Providing the reader with (...) clinical exercises and case reports, this book will be of great interest to psychoanalysts, psychotherapists and psychiatrists, as well as being a helpful tool in psychoanalytic and psychotherapeutic work on a day-to-day basis. (shrink)

Mitochondrial/nuclear transfer (M/NT) to avoid the transmission of serious mitochondrial disease raises complex and challenging ethical, legal and social issues (ELSI). In February 2015, the United Kingdom became the first country in the world to legalize M/NT, making the heated debate surrounding this technology even more relevant. This critical interpretive review identified 95 relevant papers discussing the ELSI of M/NT, including original research articles, government-commissioned reports, editorials, letters to editors and research news. The review presents and synthesizes the arguments present (...) in the literature in relation to the most commonly raised themes: terminology; identity, relationships and parenthood; potential harm; reproductive autonomy; available alternatives; consent; impact on specific interest groups; resources; “slippery slope”; creation, use and destruction of human embryos; and beneficence. The review concludes by identifying those ELSI that are specific to M/NT and by calling for follow-up longitudinal clinical and psychosocial research in order to equip future ELSI debate with empirical evidence. (shrink)

The Build-Operate-Transfer (BOT) model is a financing model used especially in the financing of infrastructure projects in developing countries. It is one of the most common methods used by the countries to provide non-budgetary financing. The fact that becoming popular in the world as of the 20th Century, this model started to be implemented in the Islamic countries created the need for examining the model in terms of Islamic law. No substantive studies have been conducted on this matter in Turkey. (...) In the Arab world, the first significant development in this regard was the 23rd Term meeting of Al Baraka Group organized in Mecca in November 2002. Next, the Islamic Fiqh Community, which operates under the Organization of Islamic Cooperation, organized a meeting about the BOT model in 2009. At this meeting, ten experts from different countries presented papers on the BOT model, and a final declaration was announced at the end of the meeting. After this meeting, some independent studies were carried out on the BOT model. However, it was observed that these efforts did not reach a sufficient level, and generally remained within the framework of the papers presented at the meeting. The BOT model is a model that takes place in the form of the transfer of the facility to the relevant public institution or organization free of charge at the end of the period after the depreciation and profit of the invested capital are realized. All expenses are covered by the private enterprise. The public service or activity is operated for a certain period of time by the private enterprise. It was observed that the studies on the BOT model in Turkey mainly dated back to the last quarter of the Twentieth Century. In this context, the Law No. 3996 about the BOT model was enacted on 08 June 1994 in Turkey. Today, the BOT model is actively used in many areas, and the delivery of the service begins after the projects are completed. The BOT model has three main successive stages. In the first stage, the project is completed with the financing of OGS. In the second stage, the operating right of this project would be awarded to the investor in accordance with the contract. In the third stage, the ownership of the facility would be transferred to the relevant public institution. The BOT model was discussed in terms of Islamic law, firstly in general and then in terms of the interests and convictions. The BOT model contains many interests in terms of both the state and the society. In addition, it has certain disadvantages. There are many reasons and aims in selecting the BOT model. The most important of these reasons is the continuation of the projects and the required work without imposing a burden on the public budget. Islamic law has a structure that prioritizes public interest. In this context, the state must observe the public interest in its operations. In the BOT model, the existence of public interest is particularly notable with the projects implemented in the fields of hospitals, roads, bridges, airports and etc. Islamic jurists have different opinions regarding the contracts administered in the BOT model. Some of them consider this model as a new contract that does not exist in the tradition, while others compare it to a traditional contract. The analogies of the traditional contract have been compared to leasing, payment, foundation, fief, corporate (with partnership) and exception contracts. Others, on the other hand, considered the BOT model as an atramentous contract combining several different contracts. It seems difficult to argue that the BOT model is completely similar to any of the classical fiqh contracts. However, as a result of the BOT model, it is considered an agreement with a company to conclude a contract; therefore there is a more prominent similarity to an exception contract. Nonetheless, it is not possible to say that the BOT model fully complies with the traditional exception contract. As a matter of fact, while there is no time determination in the exception contract, the time is determined in the BOT model. In the exception contract, while the material must be completely covered by the private sector, in the BOT model, issues such as the right to land and building construction are covered by the employer. In addition, the classical exception contract does not contain many contracts as in the BOT model; and it is an agreement in which the fee is presented and terminated after the order is placed. Nonetheless, the BOT contract includes three basic contracts (construction-operation-transfer) as well as many contracts related to these contracts. Finally, considering that the BOT model was a contract, the issues in the context of the basic elements that should be included in a contract were discussed in this study. In addition, situations such as ignorance, gharar and interest in terms of affecting the validity of the contract were discussed and dealt with in terms of the BOT contract. (shrink)

Imāmiyya holds that the theory of imāmate must rely on scriptural evidence and designation and that the Imām, the successor to Muḥammad, is in charge of all political and religious issues. The authority of the Imām includes some religious and social duties such as executing the legal punishments, collecting almsgiving, sustaining social order and declaring holy war. The fulfillment of these duties requires actual leadership of the Imām or his deputy. With the beginning of the great occultation in 329/941, there (...) was an uncertainty among the Imāmiyya followers about who would uphold these responsibilities. In this period, Shīʿī ʿulamā began to undertake the duties of the Imām in order to overcome this uncertainty and to avoid the possible schism. In the beginning, this delegation of authority was limited to the religious sphere; but, later, its scope gradually became wider. This process of delegation of power, which covers a long process, needs to be examined in its various periods. In this study, this subject will be considered with special reference to the scholars of the fifth century of hijra (hijrī). An effort is made in this article to reveal how the issues of the Imām’s powers are discussed in the context of the problem of expanding or narrowing the authority of the scholars who played significant roles in systemization of Uṣūlī (rationalist) thought in the period after Shaykh al-Mufīd.Summary: In the issues of Imām/Caliphate which led to political division among Muslims after the Prophet Muḥammad, Imāmī Shīʿa opines that the Imāmate theory relies on scriptural evidence and designation. According to this theory, apart from scriptural evidence and designation, personal qualities such as immaculacy, knowledge, bravery, and vantage are found in Ali, Ḥasan, Ḥusayn and nine people from the lineage of Ḥusayn. The Imām as a successor to the Prophet Muḥammad is a person who has both religious and political power which includes implementation of punishments, collecting alms, ensuring justice, declaring holy war. For the Imāmī Shīʿa, there is a need for imām or his deputy who has absolute power to fulfill these duties.Imāmī Shīʿa, who held that the disappeared twelfth Imām would return back to restore justice in the world, had to confront various problems in finding solutions to some issues related to the existence of Imām himself, as well as theological issues during the period of great occultation. Particularly, the period of great occultation (329/941), in which the link with the Imām was severed completely, the Shīʿī community were uncertain on how to fulfill the responsibilities of the Imām probably due to the lack of religious sources. Shaykh al-Mufīd draws attention to the issue of khums (a one-fifth share of the spoils of war and of other specified forms of income). In this period of uncertainty, the Shiite scholars came into prominence in order to fill the gap and to prevent the social disorder. Referring to a tawqī‘ (rescript) from the Twelfth Imām, they claimed that they would take responsibility for the Twelfth Imām on his behalf. In the beginning, the delegation of the power was limited to the religious sphere. It was gradually extended to other spheres by the contribution of some scholars. It reached the largest dimension with the implementation of “wilāyat al-faqīh” theory.From that period until our times, the era when Sharīf al-Murtaḍā and his disciples lived can be considered as the beginning of this period. In the fifth century when Sharīf al-Murtaḍā and his disciples lived the delegation of power was limited to the religious sphere. In this article, how the scholars who played a role in the systematization of Uṣūlī thought dealt with the issue of the limits of the authority of Imām and how they defined the role of the Imāmī jurists (faqīh) will be examined.Sharīf al-Murtaḍā and his disciples were sometimes cautious on the issue of the delegation of the power of Imām. They, however, pointed out the role of the faqīh in the occultation period in order to overcome the uncertainty. As a matter of fact, Shaykh al-Ṭūsī and al-Qādī Ibn al-Barrāj made significant contributions to the issues of collection and distribution of khums. However, Sallār al-Daylamī’s contribution to the subject is more crucial. He considered khums as the grace of God and believed that it can be allocated by taking into account the share of the Imām. They put forward the views that explained in details the role of the faqīh in the collection and distribution of alms. Even Ibn al-Barrāj opined that in the absence of Imām and his deputy alms are to be allocated to the Faqihs on the ground that they know better how to distribute it. Therefore, in the absence of Imām and his deputy, by suggesting that faqīh must be in charge of collecting and distributing alms, they proposed a remedy in an early period.On the issue of leading the Friday prayer (ṣalāt al-jum‘a), which is one of the social duties of Imām, Sharīf al-Murtaḍā and his disciples considered the presence of the Imām or his deputy as a condition for a valid Friday prayer. In addition to this condition, Al-Ḥalabī, also added that a person who meets the necessary conditions can be also considered in leading Friday prayer. This addition by Ḥalabī was an important contribution to the solution of the problems encountered during the period of great occultation on both Friday prayer and delegation of Imām religious and political authorities to faqīh. On the other hand, Sallār, another disciple of Sharīf al-Murtaḍā, opposed the idea of the faqīh leading the Friday prayer in the absence of the Imām even when the necessary conditions are met. It can be said that this approach of Sallār led to the opinion of some Imāmis which considered Friday prayer unlawful in the absence of Imām. In the occultation period, Sharīf al-Murtaḍā and his disciples showed a cautious attitude about the implementation of the punishments. They argued that only Imām could implement the punishments. However, the major step was taken by Shaykh Ṭūsī on the issue of who implements the punishments in the occultation period. He argued that the Imām’s designated the faqihs to implement the punishments. In addition to this subject, Shiite scholars discussed the issue of whether a Shiite officer under the reigning rule in the occultation period implemented the punishments. On this issue, Sharīf al-Murtaḍā compiled a treaty untitled Mas’ala fi’l-‘amal ma‘a’al-sulṭan. For him, the main criteria are whether such person has necessary responsibilities and qualifications. Sharīf al-Murtaḍā and his disciples also continued their master’s conciliatory attitude. In the final analysis, the contribution of Sharīf al-Murtaḍā and his disciples on the issue of who will undertake the duties and responsibilities of the Imām is crucial in the systematization of the idea of transferal of the power of the Imām to faqīh including political one. In fact, Sharīf al-Murtaḍā’s advice to take part in the existing administrations has been considered a way out for the scholars who want to establish relations with the authorities in the later periods. (shrink)

In response to a competitive environment, hospital administrators are pressuring physicians to discharge Medicare patients “sicker and quicker” and to transfer indigent patients from their emergency rooms. This paper compares health administrators' ethics to public expectations regarding financially motivated hospital transfers and discharges. Health administrators use balancing strategies: code morality, survivalism, mission dependency, and tithing. Public expectations, exemplified in P.L. 99–272, P.L. 99–509, and recent case law, are based on norms of potential for patient harm and patient (...) occupancy. These norms are morally preferable to those of health administrators; they reinforce the value of identified lives and the reliability of the health care system. (shrink)

A number of authors from Grotius onwards have proposed that a binding promise transfers a right from promisor to promisee. The promisee now has the right, previously possessed by the promisor, to determine whether the promisor performs the act mentioned in their promise. This proposal runs into problems of detail. The chapter first reformulates the theory so as to avoid these problems. It then considers a more fundamental difficulty raised by Hume and argues that the reformulated theory succumbs to (...) Hume’s critique. The point is illustrated by way of a detailed discussion of the difference between consent and choice. Finally, a new theory of promising based on the idea of an authority interest is proposed. (shrink)

: Advances in medical technology now permit children who need ventilator assistance to live at home rather than in hospitals or institutions. What does this ventilator-dependent life mean to children and their families? The impetus for this essay comes from a study of the moral experience of 12 Canadian families—parents, ventilator-dependent child, and well siblings. These families express great love for their children, take on enormous responsibilities for care, live with uncertainty, and attempt to create "normal" home environments. Nevertheless, they (...) experience social isolation, sometimes even from their extended families and health care providers. Their lives are constrained in many ways. The challenges faced by parents of technology-dependent children raise questions of justice within society and within families. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:'Difficult Patient':A Reflective EssayDaniel McFarlandThe patient who sat across from me knew too much about all brain tumors. According to her, she would never know enough about the one sitting uncomfortably close to her brain's temporal lobe. In her quest for the 'right' answer to her meningioma problem, she became certain that its surgical removal would upend her life, leaving her in neurological taters.She was a small business owner (...) of a practice dedicated to medical massage. Indubitably, she had helped countless clients heal themselves of medical mishaps and avoid or recover from the tyranny of [End Page E13] a medical community that did not always provide respectable, hospitable care. She was certain a craniotomy would end her business, nullifying everything she had spent her life building. She became fluent in the legalese needed to transfer or sell her business in anticipation of surgery. To stave off losing her life's work from a surgical mishap, she sought opinions from a dozen neurosurgeons. They reassured her that a routine surgery like this would be effective with little chance of neurological collateral damage. She did not believe them. In her business she had treated numerous exhausted professionals. Many surgeons with whom she worked professionally frequently referred patients to her. She had seen the poor self-care that many surgeons and doctors brought on themselves in the form of unrelenting stress, drinking, bad eating habits, and even drugs. This made her nervous and untrusting about the care she could receive at the hands of an overworked or impaired surgeon. She scheduled appointments with every neurosurgeon she could find and interviewed them relentlessly, looking for the slightest sign of incompetence, unprofessionalism, antipathy, or lapse in compassion. Given her insistence and dogged nature, she usually found what she was looking for. She would bring her research to the appointments and interview the neurosurgeons on what other doctors had opined. If they were incredulous of research she brought or a technique on which she inquired, they were summarily dismissed.At first glance, which is likely all that she got from many of her visits, these encounters put a spotlight on a 'difficult' patient refusing care. The deeper look that my patient deserved revealed a personal narrative of the oldest child who survived a broken home riddled with drug use and prostitution. She learned to rely on only herself for protection. She took unapologetic control of her fate. Her own mother had at one time offered my patient work as a prostitute. Her father was no better in providing protection and a decent upbringing. He had left her as an eight-year-old with the neglectful mother and four younger siblings to fend for herself, which she did against the odds. She suffered physical, emotional, and spiritual abuse.As an adult, her strong sense of selfhood and boundaries allowed her to have a guarded relationship with both of her parents at a comfortable emotional distance. Her mission and passionate drive to help others heal saved her life. In healing others, she was healing herself. Importantly, her experience marked for her indelibly that while she could do this for herself, others were not reliable and could not heal her. She had only ever trusted and relied upon herself. She was the only one who had never let her down. She was terrified that this might be the first time. The potential surgery risked her cognition, physical capacities, and ability to care for herself. The risk was too great.We met numerous times, uncovering her past, reliving the stories of her tumultuous background, and examining how she established her place in the world away from the horrors of her insecure childhood. She took in my reaction to her stories and saw the horror on my face when I tried to imagine a world where one's parents were not only neglectful but the source of danger. Through my reaction, she may have begun to have some compassion for her own story and put the pieces together. One several occasions, she became enraged when I didn't meet her expectations, or I didn't entertain the diatribe of neurosurgical scholarly work.On one of those... (shrink)

In 1992, the United States Supreme Court, in Planned Parenthood of Southeastern Pennsylvania v. Casey, upheld the ruling in Roe v. Wade, namely that women have a right “to choose to have an abortion before viability and to obtain it without undue interference from the State.”1 However, since this ruling, some states have imposed regulations that greatly limit this right by restricting access. Texas is a recent example of this. Two proposed restrictions in House Bill 2, which will be discussed (...) in detail below, will force all but eight clinics that are located in metropolitan areas to shut down. The U.S. Supreme Court put the proposed restrictions on hold in October 2014, allowing several clinics to remain open while the restrictions are being appealed in the U.S. Court of Appeals for the Fifth Circuit. If the restrictions are passed, however, those clinics will be forced to shut down and, as a result, many women in Texas will be required to travel more than 100 miles in order to access a safe and legal abortion. Much of the focus of these restrictions has been on women and rightly so. However, I want to turn the attention to physicians. The requirements exacerbate unfair treatment of abortion providers compared with other physicians. Abortion providers face threats from the public—some of which turn into violent attacks—and they are often ostracized by their fellow medical practitioners. There are so few abortion providers to begin with and the proposed requirements limit these physicians’ opportunities to practice the branch of medicine of their choosing. Although the HB 2 requirements may not result in an unconstitutional undue burden on physicians, the challenges created by the bill limit physicians’ abilities to provide abortions. As a result of these limits, HB 2 creates an unconstitutional undue burden for women seeking abortions by creating barriers directed at abortion providers and clinic staff who are willing and able to provide abortions. The first of the two controversial HB 2 requirements is the admitting privileges requirement: “A physician performing or inducing an abortion must, on the date the abortion is performed or induced, have active admitting privileges at a hospital that is located not further than 30 miles from the location at which the abortion is performed or induced.”2 The second requirement is the ambulatory surgical center requirement: “The minimum standards for an abortion facility must be equivalent to the minimum standards adopted under [Texas Health & Safety Code] [...] for ambulatory surgical centres.”3 In order to meet these state-mandated obligations, some abortion clinics would have to spend more than $1 million in upgrades if they wish to remain open. The District Court decided that the ambulatory surgical center requirement places an unconstitutional undue burden on women, and that the two requirements together place an undue burden on women in Texas and especially in the Rio Grande Valley where the nearest clinic is a couple hundred miles away.4 Later, the U.S. Court of Appeals for the Fifth Circuit reversed the District Court’s decision and argued, “the admitting privileges requirement is constitutional on its face.”5 While the regulations are being appealed, the Supreme Court granted a stay of injunction, allowing about twelve abortion clinics to reopen until a final decision regarding the regulations is made. The District Court ruled that the purpose of the two regulations was to create a substantial obstacle for women seeking abortions in Texas. While the defendants argued that the regulations were designed to make abortions safer and reduce risk, the Court decided that this was not the case. An abortion, especially a first-term abortion, is a very safe procedure and is safer than many other routine surgical procedures. As stated in Planned Parenthood v. Casey, “Unnecessary health regulations that have the purpose or effect of presenting a substantial obstacle to a woman seeking an abortion impose an undue burden on the right.”6 The undue burden in this case is imposed, not through restricting women’s access directly, but by restricting physicians’ freedom to perform abortions. The admitting privileges requirement has reduced the number of physicians who can perform abortions and the ambulatory surgical center requirement has reduced the number of clinics where abortions can be performed. The American Medical Association states, “[t]he Principles of Medical Ethics of the AMA do not prohibit a physician from performing an abortion in accordance with good medical practice and under circumstances that do not violate the law.”7 This means that physicians are not required to perform abortions, except in emergency situations, but can as long as the procedure is done safely and does not violate the law. The new Texas regulations, however, are so restrictive that few abortion providers, limited to only four urban areas, can legally perform abortions. Physicians do not have an absolute right to perform abortions as opposed to women who have an absolute right to have access to an abortion. Physicians do face many challenges that other professionals face in terms of obtaining qualifications and finding work. Abortion providers, however, face challenges that most other physicians do not. The restrictions imposed by these regulations exacerbate unfair treatment toward abortion providers and place further obstacles in their path in terms of providing the service they want and are qualified to provide. Both abortion clinics and abortion providers are being treated differently from other medical clinics and physicians. For instance, “grandfathering of existing facilities and the granting of waivers from specific requirements is prohibited for abortion providers, although other types of ambulatory surgical facilities are frequently granted waivers or are grandfathered.”8 Many abortion clinics cannot afford the necessary upgrades. Furthermore, it is extremely expensive to open a brand new clinic that complies with the ambulatory surgical center requirements. Being grandfathered in would be the only option available to abortion clinics that cannot afford the upgrade. However, unfair treatment of abortion clinics and providers is preventing those clinics from being grandfathered into the new system. As a result, many abortion clinics may be forced to close. Admitting privileges are proving difficult or impossible for physicians both to obtain and, for those who have already been granted privileges, to keep. Dr. Sherwood Lynn, an obstetrician-gynecologist who has performed abortions for decades, describes the process of obtaining admitting privileges and the difficulties abortion providers face. After sending in an application a physician must wait for the hospital to send them the required materials, “but if the address of the practice on the application is of an abortion provider or clinic, [the hospital] won’t send [them] the package of materials required. [They] simply can’t apply.”9 Dr. Lynn and several other physicians have surmised that hospitals are only withholding privileges from qualified physicians who perform abortions and that other physicians do not face this discriminatory treatment. Hospitals have also revoked privileges granted to physicians after learning that the physicians perform abortions. For instance, in Texas two doctors, “received notices [...] informing them that their admitting privileges to the University General Hospital of Dallas have been revoked, with the hospital’s CEO claiming the hospital was unaware they were providing abortion care and that the hospital believed such care would damage its reputation.”10 What is curious about this revocation is that, “federal and state laws [...] forbid hospitals from discriminating against doctors who perform abortions,” and yet hospitals are clearly doing just that.11 Dr. Pamela Richter, another abortion provider in Texas, had her temporary admitting privileges revoked with no explanation and because of this, the clinic where she performed abortions, Reproductive Services, can no longer provide abortions at all.12 As the hospital gave no reason for the revocation, it not clear Dr. Richter’s privileges were revoked because she performs abortions. Dr. Richter, however, has performed over 17,000 abortions and her privileges were revoked soon after HB 2 was introduced.13 According to the Texas Hospital Association, giving admitting privileges to doctors who do not work for the hospital is expensive and time-consuming but this does not account for the fact that hospitals are revoking previously granted privileges from physicians whom they learn are providing abortion services.14 As mentioned previously, the District Court found that the admitting privileges requirement and the ambulatory surgical center requirement do not further ensure the health and safety of women undergoing an abortion. Several physicians have testified to this fact. Dr. Lynn stated in an interview: The admitting privileges requirements are [...] absolutely unnecessary. If you have a number of patients waiting for procedures, and something happens and a patient needs to be transferred to a hospital, you’re not going to leave everyone else and go to the hospital. That makes no sense. You’re going to refer that person to a gynecologist at the hospital. There is no safety issue involved here. If a patient shows up with an emergency, every hospital is required to admit that patient. They have to by law.15 It is rare that complications will arise from an abortion performed in a clinic. Dr. Richter, for example, has performed more than 17,000 abortions and not once had to send a patient to a hospital because of complications resulting from the procedure. According to Dr. Lynn even if abortion providers were granted privileges to hospitals, it is unlikely that they will exercise them. In essence, having admitting privileges at a hospital does nothing to further ensure the safety of an already safe procedure. The only result of the admitting privileges requirement is to limit certain physicians’ ability to perform legal abortions. Not only do the HB 2 requirements fail to further ensure the health and safety of women, the HB 2 requirements may actually create more health risks to women who cannot access the eight remaining clinics. The first risk is that the remaining clinics would have an influx of patients that they may not be able to handle, forcing women to wait longer for an appointment. As stated by the District Court, “[e]ven assuming every woman in Texas who wants an abortion [...] could travel to one of the four metropolitan areas where abortions will still be available, the cumulative results of HB 2 are that, at most, eight providers would have to handle the abortion demand of the entire state.”16 Furthermore, “[t]hat the State suggests that these seven or eight providers could meet the demand of the entire state stretches credulity.”17 Abortion is a time sensitive procedure. It is safest when performed early in a pregnancy. The increase in patients to these remaining clinics, assuming all women in Texas can access them, will increase wait times and may force women to have abortions later in pregnancy. In the worst-case scenario, a woman would not see an abortion provider at all before viability. Such instances may be rare, but they are possible. In such cases, women’s access to legal abortions becomes impossible and thereby violate the ruling in Roe. Clinics may be able to avoid the aforementioned problems if they hire more physicians. However, there are two barriers to hiring more physicians. First, as mentioned previously, admitting privileges to Texas hospitals are difficult, if not impossible, for abortion providers to obtain. Second, given the negative treatment of abortion providers by anti-abortion groups, many physicians are not willing to perform abortions. The harassment abortion providers face is unique to those physicians and many physicians will not perform abortions for that reason. In an article published in the Austin Chronicle, anti- abortion activist Abby Johnson, “discusses how her group investigated appraisal district records to find the new location of where an Austin abortion physician plans to work.”18 Johnson states, “These abortionists are feeling the pressure from the pro-life movement in Texas. I think they feel like they’re on the run. And that’s how we want to keep it.”19 If the HB 2 requirements are passed and there remain at most eight abortion providers in Texas, these activists will concentrate on those clinics and, “the dangerous impact of their intimidation tactics will be exacerbated.”20 Even if the number of physicians needed to meet the demand in Texas can obtain admitting privileges and work at one of the remaining clinics, they may choose not to do such work because they are putting themselves at risk. The harm abortion providers face from such anti-abortion groups is not unique to Texas. There are stories from all over the country and from other countries where abortion is legal of physicians receiving death threats. Dr. George Tiller, an abortion provider in Kansas, was killed outside his church and had received numerous death threats prior to this. The HB 2 requirements are making it so that abortion providers either cannot provide their services any longer or will face increased threats and increased danger to themselves. Physicians are allowed to conscientiously object to providing medical interventions in certain circumstances for moral and religious reasons. However, there are limits on this right. According to the American Congress of Obstetricians and Gynecologists, “[w]hen conscientious refusals conflict with moral obligations that are central to the ethical practice of medicine, ethical care requires that the physician provide care despite reservations or that there be resources in place to allow the patient to gain access to care in the presence of conscientious refusal.”21 I would argue fear for one’s safety in the face of immediate threats is perhaps a stronger ground on which to refuse to provide care than a personal belief that abortion is immoral or against one’s religion. ACOG also states, “[p]roviders with moral or religious objections should either practice in proximity to individuals who do not share their views or ensure that referral processes are in place so that patients have access to the service that the physician does not wish to provide.”22 This responsibility has been largely disputed by the medical community but in cases of rape, incest, and health risks to women, referrals must be made without exception. However, under the requirements of HB 2, working in proximity to an abortion provider may not be possible because they are so geographically limited. Referrals are supposed to be made within reason. Some areas of Texas, such as the Rio Grande Valley, are up to 200 miles away from the nearest clinic that would remain open if HB 2 is passed. Referrals may simply not be feasible given the geographical distances and the decreasing number of available physicians. As mentioned above, there are two risks to the health and safety of women as a result of HB 2. The second of these is that if a woman cannot access one of the remaining clinics, she may seek out a more convenient but illegal and unsafe abortion, which is far more likely to result in a dangerous complication. Dr. Lynn states, “[b]ecause of the restrictions lawmakers impose, women will seek abortions illegally, and we’re going to see a rise in septic abortions.”23 Some areas of Texas might effectively revert back to a pre-Roe era where abortions were performed in unsanitary conditions by unqualified people resulting in dangerous medical complications far more often than legal abortion procedures do now. Physicians like Dr. Lynn who want to prevent this from happening generally cannot do so without facing legal sanction. Physicians have a duty to provide safe medical care and if they cannot obtain admitting privileges, they cannot exercise this duty. ACOG released a statement expressing their objections to the new requirements. They state that HB 2 is, “plainly intended to restrict the reproductive rights of women in Texas through a series of requirements that improperly regulate medical practice and interfere with the patient-physician relationship.”24 Executive Vice-President of ACOG, Hal C. Lawrence III stated: The Texas bills set a dangerous precedent of a legislature telling doctors how to practice medicine and how to care for individual patients. ACOG opposes legislative interference, and strongly believes that decisions about medical care must be based on scientific evidence and made by licensed medical professionals, not the state or federal government.25 Abortion is one of only a few areas of medicine where the legislature imposes so many regulations restricting particular physicians’ ability to practice medicine. Not only are abortions providers being regulated by the state, they are also facing clear discrimination from others within the medical community. The state is closing down clinics that do not meet the ambulatory surgical center requirements and hospitals are denying physicians admitting privileges because they perform abortions. In summary, abortion providers are being discriminated against both by the legislature and other members of the medical community. Other physicians who do not perform abortions are not denied admitting privileges on discriminatory grounds. Clinics that cannot afford upgrades to become an ambulatory surgical center are being grandfathered in, while abortion clinics are being forced to close down. Ob-Gyns who conscientiously object to performing abortions and who are not located in close proximity to at least one abortion provider cannot effectively fulfill their duty to refer patients. Lastly, given the barriers these regulations will create, there will likely be a rise in complications resulting from abortions provided under grossly unsafe conditions. Physicians, whose duty it is to provide safe and effective medical care, are being denied the right to exercise this duty. While this denial may not be unconstitutional, it is certainly unjust and discriminatory and creates obstacles that other physicians do not face. Most importantly, these obstacles are creating an undue burden for women. The HB 2 requirements do not increase the health and safety of abortions; all they do is create substantial obstacles for women. In light of these observations, the requirements seem to me to be in clear violation of Casey, in which it was decided that, “[u]nnecessary health regulations that have the purpose or effect of presenting a substantial obstacle to a woman seeking an abortion impose an undue burden on that right.”26 These regulations do just what Casey was meant to prohibit and this is accomplished through limiting physicians’ ability to practice safe abortions across the state of Texas. Therefore, the HB 2 requirements may not impose an undue burden on doctors but they do impose an undue burden on women. PDF available: Rachel Hill, "Texas HB 2," Voices in Bioethics. References: 1 Planned Parenthood of Southeastern Pennsylvania v. Casey, pg. 2. 2 Whole Women’s Health v. Lakey, pg. 2. 3 Ibid. 4 Ibid., 4. 5 Ibid., 2. 6 Planned Parenthood v. Casey, pg. 16 7 AMA Code of Medical Ethics, “Opinion 2.01 – Abortion,” American Medical Association. 8 Whole Women’s Health v. Lakey, pg. 10. 9 Dr. Sherwood Lynn, “A Texas Ob-Gyn Details the Horrific Consequences of Abortion Restrictions,” Cosmopolitan. 10 Feminist Newswire, “Texas Hospitals Revoke Admitting Privileges to Abortion Providers,” Feminist Majority Foundation Blog. 11 Ibid. 12 Ibid. 13 Ibid. 14 Glenn Hegar, “Texas Hospital Association’s Statement of Opposition to Section 2 of the Committee Substitute for Senate Bill 5,” Texas Hospital Association. 15 Dr. Lynn, “A Texas Ob-Gyn.” 16 Whole Women’s Health v. Lakey, pg. 10. 17 Ibid. 18 Mary Tuma, “Undercover Audio Reveals Anti-Abortion Tactics: Anti-abortion activists monitor and track providers, patients,” Austin Chronicle. 19 Ibid. 20 Ibid. 21 Committee on Ethics, “The Limits of Conscientious Refusal in Reproductive Medicine,” The American Congress of Obstetricians and Gynecologists. 22 Ibid. 23 Dr. Lynn, “A Texas Ob-Gyn.” 24 “Ob-Gyns Denounce Texas Abortion Legislation: Senate Bill 1 and House Bill 2 Set Dangerous Precedent,” The American Congress of Obstetricians and Gynecologists. 25 Ibid. 26 Planned Parenthood v. Casey, pg. 16. (shrink)

Ethicists and physicians all over the world have been working on triage protocols to plan for the possibility that the Covid‐19 pandemic will result in shortages of intensive care unit beds, ventilators, blood products, or medications. In reflecting on those protocols, many health care workers have noticed that, outside the pandemic shortage situation, we routinely supply patients in the ICU with invasive and painful care that will not help the patients survive even their hospitalization. This is the kind of pointless (...) care that even the most basic protocol would triage against. Perhaps this widespread reflection on triage standards will draw our attention to our ongoing custom of supplying burdensome and inefficacious care to those near the end of life—care that most health care providers would not want for themselves. This essay argues that reflecting on triage could help us improve end‐of‐life care. (shrink)

The idea of a data transfer agreement (DTA) template for the South African (SA) research community is receiving increasing attention. Whiledeveloping such a DTA template is certainly a worthwhile project, questions regarding the project’s practical execution should be addressed,including how to best operationalise the envisioned DTA template, and the content of the envisioned DTA template. It is proposed that anempowerment approach be followed in operationalising the envisioned DTA template, which is contrasted with the regulatory approachfollowed with the material transfer agreement (...) that the Minister of Health promulgated in 2018. While the regulatory approach would entailgovernment making the use of the envisioned DTA template compulsory regardless of the quality of such a template, the empowermentapproach, by contrast, entails a focus on developing a high-quality, professionally drafted DTA template for the SA research community andmaking the use thereof a matter of own choice. Regarding the content of the envisioned DTA template, four hot-button content provisionsare analysed, and it is argued that SA research institutions and researchers should be empowered to: (i) have clarity and legal certaintyregarding their ownership of data, where relevant; (ii) be able to commercialise their research findings without unnecessary contractualconstraints; (iii) avoid falling into the trap of unlawful benefit sharing with research participants; and (iv) be aware that their legal role asresponsible parties, where relevant, cannot be contracted out via a DTA. (shrink)

Knowledge hiding is known to have negative consequences on organizational performance. The existing literature mainly focuses on the identification of antecedents and consequences of knowledge hiding. The studies pertaining to the top management role in creating a culture that stops concealing knowledge within an organization are limited. To fill that gap, the paper empirically address the knowledge sharing culture and to explore the management support to avoid knowledge hiding culture in an organization. This study based on an empirical study carried (...) out in a United Kingdom-based laboratory within a high-tech global corporation, in which the atmosphere appeared conducive to knowledge sharing, and knowledge transfer appeared voluntary and spontaneous. The paper seeks to address why members of the case organization is reluctant about knowledge hiding among themselves. The study reveals that the management role is important in creating a culture that help discourage employees to withhold knowledge. The paper identifies the actions that top management takes to stop concealing knowledge within an organization. This study has provided several contributions. The findings of the study may be useful to managers and practitioners. For managers, this paper presents some important organizational factors that can be nurtured to avoid a knowledge-hiding culture in the organization. They can also take the management actions of the case organization as lessons to create a culture that encourage their employees to avoid knowledge hiding behavior. (shrink)

Too often in a hospital setting, forgiveness is thought to be automatic—given if a physician makes the apology. But this is cheap grace: a forgiveness achieved without the participation of the injured party. We must remember that forgiveness must be given, and devise new practices to see that it can be.

Colin Cheyne has argued that under certain circumstances an internalist or deontological theory of epistemic justification will give rise to a paradox. The paradox, he argues, arises when a principle of epistemic justification is both justifiably believed (in terms of the theory) and false. To avoid this paradox, Cheyne recommends abandoning the principle of justification-transference, which states that acts of believing made on the basis of a justifiably-believed principle are themselves justified. Since such a principle seems essential to any internalist (...) theory of justified believing, internalist theories may also need to be abandoned. I argue that while some theories of epistemic justification may indeed give rise to this paradox, an internalist or deontological theory of subjective justification will avoid it. The reason for this is that a false principle of justified believing does not render acts of believing subjectively unjustified, provided that the agent does not realize that the principle is false. (shrink)

How do professionals working in pre-implantation genetic diagnosis reflect upon their decision making with regard to ethical challenges arising in everyday practice? Two focus group discussions were held with staff of reproductive genetic clinics: one in Utrecht with PGD-professionals from Dutch PGD-centres and one in Prague with PGD-professionals working in centres in different European countries. Both meetings consisted of two parts, exploring participants’ views regarding treatment requests for conditions that may not fulfill traditional indications criteria for PGD, and treatment and (...) transfer requests involving welfare-of-the-child considerations. There was general support for the view that people who come for PGD will have their own good reasons to consider the condition they wish to avoid as serious. But whereas PGD-professionals in the international group tended to stress the applicants’ legal right to eventually have the treatment they want, participants in the Dutch group sketched a picture of shared decision-making, where professionals would go ahead with treatment in cases where they are able to understand the reasonableness of the request in the light of the couple’s reproductive history or family experience. In the international focus group there was little support for guidance stating that welfare-of-the child considerations should be taken into account. This was different in the Dutch focus group, where shared decision-making also had the role of reassuring professionals that applicants had adequately considered possible implications for the welfare of the child. (shrink)

Dr. Brown, a hospitalist, admits Mark, a patient transferred from a local jail for management of cellulitis. The patient, who was taken into custody two days prior to hospital admission, has a history of intravenous heroin use. Mark explains that he had been prescribed buprenorphine-naloxone maintenance therapy for opioid use disorder for several years prior to being arrested and had not used other opioids during that time. As a policy, the jail where Mark is detained does not prescribe opioid (...) agonists, and his maintenance therapy was stopped upon his arrival there. Dr. Brown discovers that Mark is diaphoretic and appears distressed. Mark's symptoms suggest to Dr. Brown that, in addition to having cellulitis, Mark is actively withdrawing from opioids. Mark tells Dr. Brown that he has felt “horrible” since his buprenorphine-naloxone therapy was stopped and that he now has intense cravings for opioids. He asks Dr. Brown to help alleviate the withdrawal symptoms. Dr. Brown, who is accustomed to treating opioid withdrawal with opioid replacement therapy, wonders if she should initiate ORT for Mark while he is in the hospital. (shrink)

Ethics consultation is a commonly applied mechanism to address clinical ethical dilemmas. However, there is little information on the viewpoints of health care providers towards the relevance of ethics committees and appropriate application of ethics consultation in clinical practice. We sought to use qualitative methodology to evaluate free-text responses to a case-based survey to identify thematically the views of health care professionals towards the role of ethics committees in resolving clinical ethical dilemmas. Using an iterative and reflexive model we identified (...) themes that health care providers support a role for ethics committees and hospitals in resolving clinical ethical dilemmas, that the role should be one of mediation, rather than prescription, but that ultimately legal exposure was dispositive compared to ethical theory. The identified theme of legal fears suggests that the mediation role of ethics committees is viewed by health care professionals primarily as a practical means to avoid more worrisome medico-legal conflict. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Medical Tourism:Crossing Borders to Access Health CareHarriet Hutson Gray (bio) and Susan Cartier Poland (bio)Traveling abroad for one's health has a long history for the upper social classes who sought spas, mineral baths, innovative therapies, and the fair climate of the Mediterranean as destinations to improve their health. The newest trend in the first decade of the twenty-first century has the middle class traveling from developed countries to those (...) with emerging economies to avoid treatment delays, prohibitive costs for life-saving procedures, or simply high costs for elective surgery. Others leave to have access to assisted suicide in countries that have legalized it: Belgium, The Netherlands, and Switzerland. This new era of globalization in health care has arrived without the benefit of international standards, government oversight, or ethical and legal review.Howard Staab, a self-employed carpenter from North Carolina, flew to India for his medically necessary heart surgery, scheduled a side trip to the Taj Mahal, and returned home to work in North Carolina. He spent a total of less than $10,000, instead of the $200,000 required from the local hospital (I, Milstein and Smith 2006).At first blush, the outsourcing of medical care to India seems to be a particular solution for a particular problem. However, the particularity of Mr. Staab is not unique. His experience is emblematic of those patients in the United States with a medical need for major and elective procedures, but who also must bear the total cost of these procedures. These middle-class, under-insured Americans go abroad.In tandem with increasingly aggressive marketing campaigns, American hospitals and companies have begun to leverage their connections in Asia to grow the medical tourism business into a major economic force. What are the consequences of this?Several authors point to the effect on the host country's population, particularly the poor, to be pushed farther down the queue to receive adequate, affordable care. Resources are applied to the foreign trade instead of building the local [End Page 193] medical infrastructure. Another potential problem is the obligation of the home-country physician to provide follow-up care. What are the legal ramifications when the procedure was illegal to begin with? Are there opportunities for redress for medical errors?These factors may be converging into a "perfect storm" for health care in the U.S., in which the potential participation of the major insurance companies in promoting offshore care will be the tipping point in the precarious structure that represents the economic currents in health care. Third-party administrators and self-funded employers may be on the cutting edge in 2009 by providing incentives to employees to travel overseas for care.I. Economic ConsiderationsConnell, John. Medical Tourism: Sea, Sun, Sand and... Surgery. Tourism Management 27: 1093–1100, 2006.As evidence of the interest of traditional tour operators in this newer twist on the industry, the author explores medical tourism as an element of the growth of world tourism. In promoting medical tourism, he urges consideration of such issues as the privatization of health care, the foundational role of technology, and uneven access to health resources.Dunn, Philip. Medical Tourism Takes Flight. H and HN: Hospitals and Health Networks: 40–44, November 2007.Writing for U.S. health care executives, Dunn emphasizes that the reality of medical tourism competes with the local medical center for patients and their insurance dollars in a significant way. He examines the possibility that U.S. insurance plans soon may offer to pay for what is currently a cash only business and that the economic impact to the local medical center could be significant or even devastating.Frontiers of Health Services Management [Selected Articles] 24 (2), Winter 2007.In "Managing Healthcare Services in the Global Marketplace" (pp. 3–18), Bruce J. Fried and Dean M. Harris consider legal, ethical, and financial implications of the international workforce. In "Globalization of Health Care" (pp. 19–30), Lynn Schroth and Ruthy Khawahja point out that the transfer of comprehensive management expertise and intellectual property from U.S. medical centers to international sites is driving the success of collaboration between U.S. and foreign health care centers. In "Is... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Not the End We Planned ForAnonymous FourIn 1997, my four–year–old daughter was diagnosed with a high–risk medulablastoma. She underwent the current treatment program at that time. She suffered multiple complications from the treatment and developed seizures, which caused her to lose her sight and 80% of her hearing. These all contributed to her manifesting many behavioral issues, making her a danger to herself and others. Also during this time, (...) she developed large amounts of brain atrophy from the maximum radiation dose she had been given. In August of 2010, Emily was still deteriorating, her seizures were uncontrollable, and her quality of life was extremely poor. A meeting to discuss how to care for my child if an acute crisis presented was held. The meeting included her parents, oncologist, endocrinologist, pediatric neurologist, social worker and the head of medical ethics. We discussed what course of action would be best for her nothing could be done to reverse her condition or prevent further deterioration. A POLST is a physician order for life sustaining treatment and is appropriate if the doctor feel that the patient has a good chance of death in the next year. The purpose of this document is to have a plan in place in case the patient has a life threatening crises. We chose to put a POLST in place with specific instructions not to intubate. This was a hard decision to make for a parent, but we all felt it was the best choice for her.A few months after the POLST was entered, in November, 2010, I came home from the store and my daughter’s caregivers told me she had complained of a headache different from her usual headaches. They gave her Tylenol with codeine and she went to bed about 4 p.m. When I checked her later she seemed fi ne, merely sleeping her headache off. We [End Page 30] decided to let her sleep some more. Around 8 p.m the caregivers came and got me because they could not wake her up to go to the bathroom, which was her normal routine. I immediately went to try and wake her up but could not. I ran my thumb up the bottom of her foot and there was no reflex response. I yelled for her father that we needed to immediately go to the hospital.We took her to the ER at the local hospital that treated her close to the house. We told them we did know what was happening with her but that there was a POLST in place in her chart. They started lines, a nasogastric tube, and sent her for a CT, which showed massive amounts of blood in her brain. I repeated again to the ER staff and physician that there was a POLST in place but no one acknowledged my statement. I asked for a different physician, one that would respect the POLST, and was told there was no one else nor was there a neurosurgeon available. The attending physician insisted she be intubated in order to be transferred to a partner hospital (more than 20 minutes away) where there was a neurosurgeon on duty. I asked him to please call her oncologist at which point he yelled at me that, “he was not calling anyone else and that she needed to be intubated and transferred to the other hospital.” By this time, four hours had passed and I knew she had not gotten any medication for pain, so I told the physician to go ahead and transfer her since I knew the hospital we were at would not admit her for palliative care. She was then intubated, in violation of the POLST, and transferred to the other hospital where the neurosurgeon there told us what we already feared: That she had experienced a massive bleed in her brain. We requested she be extubated and be given palliative care to make her comfortable until she passed away.It is tragic that our daughter’s last hours involved aggressive medical treatment. As parents we hoped to avoid any additional suffering for our child, we did everything we knew to do to insure aggressive... (shrink)

The introduction of new medical technologies into a developing country is usually greeted with enthusiasm as the possible benefits become an object of great anticipation and provide new hope for therapy or relief. The prompt utilization of new discoveries and inventions by a medical practitioner serves as a positive indicator of high standing in the professional community. But the transfer of medical technology also involves a transfer of concomitant values. There is a danger that, in the process of adopting a (...) particular technology, the user takes for granted the general utility and desirability of the implements and procedures under consideration without recognizing the socio‐cultural peculiarities of the adopting country. A sensitivity to the social conditions and cultural traditions is important so that the emergence of new values can be examined critically and the transfer of necessary technology can be effected smoothly. In the Philippines, efforts to boost patronage of transplant technology appear to have overlooked this need for socio‐cultural sensitivity. Legislative fiat cannot be used to override deep‐seated values. There is a need to be more sensitive to the possible confrontation of values that the transfer of technology brings in order to avoid the erosion of indigenous socio‐cultural values and minimize the intrusiveness of beneficial medical technology. (shrink)

Although HIV disease has set a new model for resolving the tensions between civil liberties and public health interests, with an unprecedented commitment to individual privacy and autonomy, the resurgence of tuberculosis has sparked new and troublesome concerns. One particularly intense controversy has emerged around the value and appropriateness of single disease hospitals. In HIV disease, the single hospital turns out to be an altogether unsuitable and unnecessary innovation. In the instance of tuberculosis, however, it appears to have a (...) critical and legitimate role, particularly for involuntary commitment of patients who have been non-compliant with treatment regimens. To be sure, that role must be carefully circumscribed and the facilities themselves closely monitored. But a hospital dedicated to tuberculosis now occupies a central place in public policy that is not to be found for HIV disease. What considerations promote this difference, and how a single disease hospital for tuberculosis may avoid the pitfalls that make it so inapposite for HIV, are the two questions this essay will be exploring. (shrink)

Although HIV disease has set a new model for resolving the tensions between civil liberties and public health interests, with an unprecedented commitment to individual privacy and autonomy, the resurgence of tuberculosis has sparked new and troublesome concerns. One particularly intense controversy has emerged around the value and appropriateness of single disease hospitals. In HIV disease, the single hospital turns out to be an altogether unsuitable and unnecessary innovation. In the instance of tuberculosis, however, it appears to have a (...) critical and legitimate role, particularly for involuntary commitment of patients who have been non-compliant with treatment regimens. To be sure, that role must be carefully circumscribed and the facilities themselves closely monitored. But a hospital dedicated to tuberculosis now occupies a central place in public policy that is not to be found for HIV disease. What considerations promote this difference, and how a single disease hospital for tuberculosis may avoid the pitfalls that make it so inapposite for HIV, are the two questions this essay will be exploring. (shrink)

One of the core goals of Digital Health Technologies (DHT) is to transform healthcare services and delivery by shifting primary care from hospitals into the community. However, achieving this goal will rely on the collection, use and storage of large datasets. Some of these datasets will be linked to multiple sources, and may include highly sensitive health information that needs to be transferred across institutional and jurisdictional boundaries. The growth of DHT has outpaced the establishment of clear legal pathways to (...) facilitate the collection, use and transfer of potentially sensitive health data. Our study aimed to address this gap with an ethical code to guide researchers developing DHT with international collaborative partners in Singapore. We generated this code using a modified Policy Delphi process designed to engage stakeholders in the deliberation of health data ethics and governance. This paper reports the outcomes of this process along with the key components of the code and identifies areas for future research. (shrink)

The author reviews the planned withdrawal of healthcare from the primary public hospital, Grady Memorial Hospital, of Atlanta, Georgia. Prior to passage of the Affordable Care Act of 2010, at least half of the patients had no public or private health insurance and their care was financially supported by State and County funding as well as supplementation from Emory University. New administration in the elected positions of the State and County and at the University reached agreement to decrease (...) care. The University President stated that the Hippocratic Oath was no longer valid for salaried physicians who must follow the direction of their business manager. The author, a tenured Professor, was forcibly transferred to the Veterans Hospital, which also was withholding standard medical care, including life-saving medications. Organizing multiple concerned organizations including members of the King Center, the Carter Center, the Open Door Community Center, Gay Rights, etc., (Grady Coalition) multiple public protests were successful in raising the necessary funds to continue adequate care at Grady and begin an investigation of the Veterans Affairs Hospital. (shrink)

Of all the different types of public buildings, hospitals are the biggest energy consumers. Cooling systems for air conditioning and healthcare uses are particularly energy intensive. Forecasting hospital thermal-cooling demand is a remarkable and innovative method capable of improving the overall energy efficiency of an entire cooling system. Predictive models allow users to forecast the activity of water-cooled generators and adapt power generation to the real demand expected for the day ahead, while avoiding inefficient subcooling. In addition, the maintenance (...) costs related to unnecessary starts and stops and power-generator breakdowns occurring over the long term can be reduced. This study is based on the operations of a real hospital facility and details the steps taken to develop an optimal and efficient model based on a genetic methodology that searches for low-complexity models through feature selection, parameter tuning and parsimonious model selection. The methodology, called GAparsimony, has been tested with neural networks, support vector machines and gradient boosting techniques. Finally, a weighted combination of the three best models was created. The new operational method employed herein can be replicated in similar buildings with similar water-cooled generators. (shrink)

This paper examines the ethical conundrum between a hospital's ethos of relieving distress, investigation and treatment, and its concurrent duties under English law to administer tests of decision-making capacity and safeguarding protection where it believes the patient may lack this capacity. Delirium, characterised by a precipitous decline in mental functioning exhibiting the shared symptomology of recoverable depressive disorders and terminal dementia, is not uncommon after emergency admission of elderly patients into acute medical hospital wards. The use of functional (...) capacity testing as a benchmark for decision-making capacity for post-discharge residence has been criticised as outdated, conceptually floored, subjective, lacking central guidance, transparent process, and accountability. A study of patient experience demonstrates the potential for hospital misuse of capacity testing, the failure of functional testing to differentiate decision making capacity from the disability of partial cognitive impairment, and how hospital capacity processes can interact and amplify patient pathology thereby decreasing recovery prospects. Prioritisation of mental capacity obligations above thorough investigation of emergent mental pathology and relief of patient anguish, results in extended detention in medical wards lacking bespoke facilities. Further understanding of patient experience is needed to inform policy with interventions tailored to avoid harm and increase wellbeing. (shrink)

‘Zero tolerance’ of avoidable infection events is explicit in UK and international policy documents describing strategies for the control of healthcare-associated infection. I consider what principles governing avoidable infections acquired in healthcare institutions might be reasonably rejected from the contractualist perspective of Thomas Scanlon. Many hospital infections can be cost-effectively avoided. There would seem to be additional reasons to take the prevention of avoidable infection acquired in hospitals seriously in addition to optimizing the cost-effectiveness of healthcare. (...) These include the irretrievable nature of the harm of some of the infections; the reasonable rejection of avoidable harm when the patient could not rationally consent to the risk of harm and the social consequences such as loss of trust in healthcare providers. Despite these reasons, a principle of ‘zero tolerance’ has implausible implications, promotes unrealistic patient expectations and can be reasonably rejected from the perspective of those who will suffer unacceptable opportunity costs. However, the contractualist perspective would also seem to reject a principle of tolerance of harm when there is a feasible reconfiguration of institutional arrangements that reduces the risk of harm without a redistribution of a proportionate or greater burden to others. (shrink)

What role should legislation or policy play in avoiding the complications of in-vitro fertilization? In this article, we focus on single versus double embryo transfer, and assess three arguments in favour of mandatory single embryo transfer: risks to the mother, risks to resultant children, and costs to society. We highlight significant ethical concerns about each of these. Reproductive autonomy and non-paternalism are strong enough to outweigh the health concerns for the woman. Complications due to non-identity cast doubt on the extent (...) to which children are harmed. Twinning may offer an overall benefit rather than burden to society. Finally, including the future health costs for children in reproductive policy is inconsistent with other decisions. We conclude that mandatory single embryo transfer is not justified and that a number of countries should reconsider their current embryo transfer policy. (shrink)

The problem of divine agency and action is analogous to the problem of human agency and action: How is such agency possible in the absence of a dualistic causal interaction between disparate orders of being? This paper explores nondualistic accounts of divine agency that assert the following: (1) physical monism, (2) antireductionism, (3) physical realization, and (4) divine causal realism. I conclude that a robustly causal deity is incompatible with nonddualism's affirmation of physical monism. Specifically, I argue the incoherence of (...) nondualistic strategies that advocate divine information transfer without energy transfer or the divine downward causation of physical events. Furthermore, I claim that the principle of explanatory exclusion makes any nondualistic, noninterventionist account of divine agency highly dubious. Finally, I suggest that Judaism, Christianity, and Islam can avoid a causally inert deity only if they are willing to deny the current presumption of the causal closure of the physical. (shrink)

It might seem obvious that dealing with death anxiety in the health care system is desirable. Hence, there are either voices that demand more research on how this openness can be fostered or those who consider this topic unworthy of further investigations because of its triviality. The idea behind both deficient perspectives is that the health care system as a communication system can assume the position of a second-order observer who can account for his deficits. However, in terms of Luhmannian (...) systems theory, external perturbations cannot force a functional system to reflect and change the structure of his communications in a certain way. The health care system as a communication system cannot do more than integrating the topic of death anxiety in terms of its functional perpetuation. For example, in hospitals, neither health care staff nor external counselors are able to address existential issues without being affected by functional and structural requirements of the hospital. We present an outline for the justification of the avoidance of death-anxiety related talk in the health care system by reference to systems theory and existential philosophy. (shrink)

Analogical transfer in sequence learning is presented as an example of how the type-2 problem of learning an unbounded number of isomorphic sequences is reduced to the type-1 problem of learning a small finite set of sequences. The commentary illustrates how the difficult problem of appropriate analogical filter creation and selection is addressed while avoiding the trap of strong nativism, and it provides theoretical and experimental evidence for the existence of dissociable mechanisms for type-1 learning and type-2 recoding.

The Emergency Department is a crucial medical treatment unit of hospital specializing in emergency medicine. EDs are responsible for providing immediate healthcare facilities to patients arriving without prior appointment. Thus, evaluating patient satisfaction is of immense importance for efficient service delivery. Very few studies are found in Pakistan, related to patients’ satisfaction and utilization of ED services both from demand and supply perspective of ED-Services Supply Chains. Data was collected to assess 200 patient’s satisfaction towards quality of healthcare services (...) of ED of Sindh Government Qatar Hospital, Orangi town-a tertiary care hospital in Karachi. Structured questionnaire was developed to interview patients and their attendants. Results of SPSS analysis revealed that 55% of patients were transferred to ED within 5 minutes, which shows efficient patient queues and flow management. 64.5% patient’s average LOS was between 40-60 minutes. 71% get the availability of basic facilities in ED. Majority of patients i.e. 96.5% and 90.5%, showed satisfaction with the time spent and treatment given by the doctor. Majority of the patients are satisfied with the services and performance of ED of a tertiary care hospital and 76% patients showed willingness to recommend ED of Government Qatar Hospital, Karachi to others. (shrink)

The Emergency Medical Treatment and Active Labor Act in 1986 was intended to bring an end to incidents of “patient dumping.” However, due to the conflation of various federal legislative provisions, hospitals faced with the prospect of long‐term unreimbursed care of an immigrant patient, whether legally present in the United States or not, are in some cases having such patients transported to another country. These transfers are often being effectuated without patient consent. After an overview of the flaws in (...) the legal system that have effectively encouraged such patient transfers, this essay uses a clinical case to demonstrate how physicians can collaborate with an interdisciplinary team and with family members to ensure that the best interests of immigrant patients are met. Finally, the essay calls on physicians to advocate for the development of hospital policies and practices that will protect patients from international patient dumping. (shrink)

Introduction Hospital delirium is a frequent, serious, costly, and underrecognized acute disorder of attention and cognition. Therefore, the prevention of hospital delirium is not only desirable for patients, caregivers, healthcare professionals, and the health system itself, but also a moral duty. Objective To identify and synthetize the main ethical aspects that arise related to the prevention of hospital delirium in patients 65 years and older. Methods A scoping review was carried out in Embase, Medline, and Web of (...) Science. Articles published in English or Spanish analyzing any pharmacologic, non-pharmacologic, or multicomponent intervention for prevention of delirium in hospitalized patients aged 65 years and over were included. Results Twenty-seven studies were included. Based on the frequency of appearance and the relevance, our findings were organized into three main areas. The first one was related to the principle of nonmaleficence and collected findings about the iatrogenic causes of hospital delirium and the use of restraints systems. The second area analyzed the impact of delirium in patients, families, and healthcare professionals from a relational ethics perspective, and addressed the family presence as a factor to prevent delirium. Finally, the third area is related to the quality of care. Conclusion Prevention of delirium in hospitals is essential to avoid the discomfort and potential clinical complications of patients, as well as the suffering of their relatives, caregivers, and healthcare professionals. Policymakers and healthcare managers are encouraged to make the required efforts to prevent delirium in hospitalized older patients. (shrink)