Hastings Center Report, Volume 52, Issue 2, Page 32-40, March‐April 2022.

This article addresses two components of the new governing architecture that help to reform the delivery of health care and to control costs of the health care system: the Center for Medicare and Medicaid Innovation and the Independent Payment Advisory Board. The republican controlled federal government has partially disassembled these two components, threatening the effectiveness of federal delivery system reform and cost control initiatives.

Providing a groundbreaking approach to reinventing health care, this book is a practical guide to placing patient healing back at the center of the hospital's mission. Drawing on a wealth of practical experience, the authors show health care professionals how to decrease costs and improve quality by restructuring hospital services around patients and their needs and by utilizing design and architecture to enhance the healing environment. Using the core concepts of systems theory, extensive research, and (...) lessons from pioneering hospitals, they present state-of-the-art health care practices that heal as well as cure. (shrink)

Evidence shows that changes in the architecture, design, and decor of health care facilities can improve patient care and in the long run reduce expenses. These essays detail the state of the research, look inside two hospitals that put some of these innovations into practice, and consider how design fits into the moral mission ofhealth care.

This article reflects on the implications of the concept of health and the questions it poses for moral philosophy, psychology, and the panoply of professions that are involved in the practices of care and in the ethics of individual rights, dignity, and autonomy. Significant among these questions is what we call “the predicament of agency.” The predicament involves the ethical tensions—arising within the broad concept of health and flourishing, but also in concrete everyday practices and relationships—between supporting (...) individual health outcomes and supporting health and flourishing through respect for autonomy and self-direction. Three ways of addressing the predicament of agency are discussed: by reinterpreting the nature and requirements of autonomy (a) by appeal to reason, (b) by designing or curating contextual conditions influencing choice (often called “choice architecture” or “nudging”) in ways that constrain autonomy but do not violate its core value, and (c) by appeal to relational judgment and reflective professional practice. The article argues that each of these lines of thought is important, but none is a panacea, and none is free from conceptual confusions and ethical pitfalls of its own. The relational approach is the most promising in pointing beyond the predicament of agency—not so much by resolving it as by showing how it can be worked through without either turning our back on caring or turning caring into management and manipulation. (PsycINFO Database Record (c) 2016 APA, all rights reserved). (shrink)

In July 1993, the Scottish Highlands Centre for Human Caring sponsored a conference with the title Exploring the Spirituality in Caring. The papers given at the conference and included in this volume are offered as a contribution to the debate that must take place in nursing and in the wider context of health care provision. Ann Bradshaw's paper puts the debate in context arguing that nursing is fundamentally a loving response to the human being created in the image (...) of God. (shrink)

Aiming at the problem of insufficient health monitoring of the elderly in the existing home care system, this paper designs a health information analysis and early warning system based on the Internet of Things technology, which can monitor the physiological data of the elderly in real time. It also can be based on the elderly real-time monitoring data, physical examination data, and other types of health data, which can be used to predict diseases, so as to (...) achieve “early detection and early treatment” of diseases. First, analyse and design the architecture and content of the home care monitoring system based on the Internet of Things. Secondly, based on the collected heart rate, blood pressure, and three-axis acceleration information of the elderly, it is analysed to determine whether the elderly are in danger of falling, and the designed system is used for early warning. Finally, this paper analyses the prediction algorithm theory of the disease prediction module in the health monitoring software of the home care system. In order to improve the accuracy of prediction, the DS evidence theory is used to optimize the traditional BP neural network algorithm and conduct experimental tests. The test results show that the health information analysis and early warning software of the home care system meet actual needs and achieve the expected goals. (shrink)

Abstract“Choices” about nonmedical aging‐related matters, such as housing, are weirdly extreme in the long last stage of life in America. In my experiences accompanying my parents to consultations with physicians, elder‐care lawyers, and social service providers, a middle‐class older adult's presumed choices are the high‐end assisted living facility—or the Medicaid spend‐down. Nothing in between. Experts in aging and housing are calling attention to this “forgotten middle”—the millions of older Americans like my mother, people who are neither rich nor poor (...) and whose needs in this long last stage of life cannot reliably be met through publicly funded health insurance or personal savings. (shrink)

Ideas of nudging, choice architecture, and libertarian paternalism have sparked much controversy. Some find in them a long-sought optimal harmonization of the commitments to beneficent, welfare-increasing influence and to respecting persons, whereas people on the opposite end see in them an especially sinister form of control. One area in which these ideas are of greatest importance is health care, where improving people's decisions, under the constraint of respect for persons, is a vital concern. Nudging Health: (...) class='Hi'>Health Law and Behavioral Economics, edited by Glenn Cohen, Holly Fernandez Lynch, and Christopher Robertson, is the first book dedicated to this important topic. This anthology of twenty-four chapters, with section introductions and a foreword by Cass Sunstein, presents a wide spectrum of perspectives on both the promise and the difficulties in applying choice architecture to health care. The short and readable chapters, written for the book, cover questions of public health law and policy, clinical practice, medical ethics, and political philosophy. They present a synopsis of the types of questions that nudging brings up in health care broadly construed, offer new analyses, and provide much fodder for thought. (shrink)

How should medical services be distributed within society? Who should pay for them? Is it right that large amounts should be spent on sophisticated technology and expensive operations, or would the resources be better employed in, for instance, less costly preventive measures? These and others are the questions addreses in this book. Norman Daniels examines some of the dilemmas thrown up by conflicting demands for medical attention, and goes on to advance a theory of justice in the distribution of (...) class='Hi'>health care. The central argument is that health care, both preventive and acute, has a crucial effect on equality of opportunity, and that a principle guaranteeing equality of opportunity must underly the distribution of health-care services. Access to care, preventive measures, treatment of the elderly, and the obligations of doctors and medical administrations are fully discussed, and the theory is shown to underwrite various practical policies in the area. (shrink)

Equipoise is an essential condition to justify a clinical trial. The term, describes a state of uncertainty: the data suggest but do not prove a drug's safety and efficacy The only way to resolve this uncertainty is further study In many cases, a clinical trial seems to be the most efficient way to prove safety and efficacy Equipoise is therefore not an esoteric philosophic construct applied to research ethics. Rather, since it is vital for the justification of clinical trials, it (...) is part of how society regulates medical progress. Where there is equipoise, drug design and development proceeds according to Food and Drug Administration and Health and Human Services regulations. When that equipoise ends, a drug is either not approved or becomes standard care. (shrink)

Equipoise is an essential condition to justify a clinical trial. The term, describes a state of uncertainty: the data suggest but do not prove a drug's safety and efficacy The only way to resolve this uncertainty is further study In many cases, a clinical trial seems to be the most efficient way to prove safety and efficacy Equipoise is therefore not an esoteric philosophic construct applied to research ethics. Rather, since it is vital for the justification of clinical trials, it (...) is part of how society regulates medical progress. Where there is equipoise, drug design and development proceeds according to Food and Drug Administration and Health and Human Services regulations. When that equipoise ends, a drug is either not approved or becomes standard care. (shrink)

The paper is an exploration for a conceptual framework for cross-cultural interfacing. The roots of this exploration lie in my personal, functional, social and cultural experiences, and cross-cultural encounters. These encounters in many ways reflect the networking journey of AI & Society, promoting and stimulating the human-centred debate in cross-cultural settings. As a ‘cross-cultural holon’, AI & Society has been questioning the given orthodoxy of the ‘one best way’ and the culture of the ‘exact language’ since its inception 21 years (...) ago. My observation is that even though we now live in a world of multimodal interactive media technologies, some how the interface design has not moved much beyond the functional (observed reality) worldview of our interactions. Even at the functional level, the design perspective remains bounded by the observed reality. It is thus no surprise that when it comes to designing interaction technologies for social and cultural domains such as health care, work, employment, life long learning, the design mainly hovers around the functional skill training, mechanical feedback and objectified evaluation. When we move beyond the functional worldview, and explore our interactions within social and cultural domains, we encounter both the reality (objectified world) and actuality (experienced world) of interactions. At this level, the challenge of the interface is not just coping with the interaction spaces of reality and actuality but also with the ‘in-between’ space of actuality–reality gaps. We explore how the concept of symbiosis enables the interaction in the gaps between actuality and reality, how the concept of the ‘culture of the artificial enables the sharing and pooling experiences, how the concept of valorisation’ enables to find a coherence (commonality) between interactions, and how the concept of cultural holon is used to conceptualise the network architecture of cross-cultural interactions. It is proposed that the way forward to designing cross-cultural interfaces is to first seek a conceptual framework for cross-cultural interaction spaces, and then use this framework to design interfacing systems and tools. (shrink)

The United States, like other countries facing rising health care costs, is pursuing a commitment to interoperable electronic health records. Electronic records, it is thought, have the potential to reduce the risks of error, improve care coordination, monitor care quality, enable patients to participate more fully in care management, and provide the data needed for research and surveillance. Interoperable electronic health records on a national scale — the ideal of a national health (...) information network — seem likely to magnify these advantages. Thus, the recent economic stimulus package contains considerable funding for the development of “health information technology architecture that will support the nationwide electronic exchange and use of health information in a secure, private, and accurate manner.”. (shrink)

A significant international development agenda in the practice of nurses supporting families with young children focuses on establishing partnerships between professionals and service users. Qualitative data were generated through interviews and focus groups with 22 nurses from three child and family health service organisations, two in Australia and one in New Zealand. The aim was to explore what is needed in order to sustain partnership in practice, and to investigate how the concept of practice architectures can help understand attempts (...) to enhance partnerships between nurses and families. Implementation of the Family Partnership Model (FPM) is taken as a specific point of reference. Analysis highlights a number of tensions between the goals of FPM and practice architectures relating to opportunities for ongoing learning; the role of individual nurses in shaping the practice; relationships with peers and managers; organisational features; and extra‐organisational factors. The concept of practice architectures shows how changing practice requires more than developing individual knowledge and skills, and avoids treating individuals and context separately. The value of this framework for understanding change with reference to context rather than just individual’s knowledge and skills is demonstrated, particularly with respect to approaches to practice development focused on providing additional training to nurses. (shrink)

The primary objective of The Health Care Ethics Con sultant is to focus attention on an immediate practical problem: the role and responsibilities, the education and training, and the certification and accreditation of health care ethics consultants. The principal questions addressed in this book include: Who should be considered health care ethics consultants? Whom should they advise? What should be their responsi bilities and what kind of training should they have? Should there be some (...) kind of accreditation or certification program to ensure that those who call themselves ethics consultants are in fact qualified to advise, consult, research, and write in health care ethics? The distinguished authors ofthese articles are persons with diverse backgrounds, interests, presumptions, and val ues. Not surprisingly, therefore, diverse responses have emerged to the questions posed. Though the book's chapters are individually authored, they are informed by the group discussions that went on during active workshop sessions, and by knowledge of the contributions of others. All of the chapters meaningfully represent their consensus. This is not to say that there were no disagreements regarding specific details, but rather that there were no fundamental objections on the book's basic content among a panel of authors who share basic premises regarding the role, responsibilities, education, and certifica tion of health care ethics consultants. (shrink)

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

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

The third edition of Health Care Ethics in Canada builds on the commitment to Canadian content established in earlier editions without sacrificing breadth or rigor.

Ethics consultation has become an integral part of the fabric of U.S. health care delivery. This article summarizes the second edition of the Core Competencies for Health Care Ethics Consultation report of the American Society for Bioethics and Humanities. The core knowledge and skills competencies identified in the first edition of Core Competencies have been adopted by various ethics consultation services and education programs, providing evidence of their endorsement as health care ethics consultation (HCEC) (...) standards. This revised report was prompted by thinking in the field that has evolved since the original report. Patients, family members, and health care providers who encounter ethical questions or concerns that ethics consultants could help address deserve access to efficient, effective, and accountable HCEC services. All individuals providing such services should be held to the standards of competence and quality described in the revised report. (shrink)

Scenarios involving the introduction of artificially intelligent (AI) assistive technologies in health care practices raise several ethical issues. In this paper, I discuss four objections to introducing AI assistive technologies in health care practices as replacements of human care. I analyse them as demands for felt care, good care, private care, and real care. I argue that although these objections cannot stand as good reasons for a general and a priori rejection (...) of AI assistive technologies as such or as replacements of human care, they demand us to clarify what is at stake, to develop more comprehensive criteria for good care, and to rethink existing practices of care. In response to these challenges, I propose a (modified) capabilities approach to care and emphasize the inherent social dimension of care. I also discuss the demand for real care by introducing the ‘Care Experience Machine’ thought experiment. I conclude that if we set the standards of care too high when evaluating the introduction of AI assistive technologies in health care, we have to reject many of our existing, low-tech health care practices. (shrink)

"Characterized by breadth of coverage, a refreshingly balanced approach to controversial issues, & a highly readable style."-Theological Studies.

The purpose of this book is to assist health care professionals in understanding some of the complex contemporary issues that they confront and to provide guidance in making decisions. These issues are described and analyzed in the context of philosophical principles and methods in language that is understandable to the professional who is unfamiliar with the study of philosophy and ethics. -from Preface.

In the Caribbean as in many other areas costly biomedical resources and personnel are limited, and more and more people are turning to alternative medicine and folk practitioners for health care. To meet the goal of providing health care for all, research on nonbiomedical therapies is needed, along with legal recognition of folk practitioners to establish standards of practice.

In 1990 the landmark Americans with Disabilities Act (ADA) became federal law with the express purpose to “establish a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities."l The act includes separate titles prohibiting discrimination on the basis of disability in employment, public services, transportation and public accommodations. Since it prohibits discrimination on the basis of disability in both public and private services and programs, in health care “it applies to programs provided by (...) the government, benefits provided by employers, and services pro- ”2 vided by physicians.Moreover, the ADA defines disability broadly to include “any.. (shrink)

Calling on the methodology of psychology, the authors explore the way illness alters the self-image of the sick person, and the way the experience changes the person who is ill. The reader is taken through the psychological impacts of the first clinical moment when the patient realizes he or she is in the altered state of illness, as well as the subsequent effects of pain, hospitalization, being bed-ridden, fatigued or disabled. The central thesis is that an integral picture of medicine (...) must include social-cultural aspects, the institutionalization of health care, and an attempt to provide patient-centered care. The approach taken is the empirically based psychosocial reflection of the disturbances to a person's self-image caused by various kinds of illness. Focusing on the world of the patient, the authors relate to problems concerning self-image, pain, exhaustion, isolation, handicaps, aging, dying and death. The relationships between patients and medical personnel are also examined. Concluding the work is an excellent bibliography keyed to the chapters of the text. (shrink)

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

This paper firstly distinguishes between principles of “global justice” that apply the same anywhere and everywhere – Tännsjö’s utilitarianism, egalitarianism, prioritarianism and such like – and principles of “local justice” that apply within the specific sphere of health-care. Sometimes the latter might just be a special case of the former – but not always. Secondly, it discusses reasons, many psychological in nature, why physicians might devote excessive resources to prolonging life pointlessly, showing once again that those reasons might (...) themselves be morally significant. (shrink)

Edited by four leading members of the new generation of medical and healthcare ethicists working in the UK, respected worldwide for their work in medical ethics, Principles of Health Care Ethics, Second Edition_is a standard resource for students, professionals, and academics wishing to understand current and future issues in healthcare ethics. With a distinguished international panel of contributors working at the leading edge of academia, this volume presents a comprehensive guide to the field, with state of the art (...) introductions to the wide range of topics in modern healthcare ethics, from consent to human rights, from utilitarianism to feminism, from the doctor-patient relationship to xenotransplantation. This volume is the Second Edition of the highly successful work edited by Professor Raanan Gillon, Emeritus Professor of Medical Ethics at Imperial College London and former editor of the Journal of Medical Ethics, the leading journal in this field. Developments from the First Edition include:_ The focus on ‘Four Principles Method’ is relaxed to cover more different methods in health care ethics. More material on new medical technologies is included, the coverage of issues on the doctor/patient relationship is expanded, and material on ethics and public health is brought together into a new section. (shrink)

This essay focuses on the challenge European states have imposed on themselves, namely, to provide state-of-the-art health care equally to all and for less than market price. Continued endorsement of that challenge in these states hinges on their character as media democracies: the public is moved by a supposed morally warranted expectation that all should receive adequate health care at no significant personal cost. The structural and economic constraints that hamper such forms of healthcare delivery result (...) in systems that are financially inefficient and fail to provide the quality of treatment patients are led to expect. This essay examines the tension between secular moral claims to social solidarity and the actual limits of accessibility to healthcare services. Its critical focus addresses both the difficulties that result from politicians invoking high moral ideals while framing their decisions around short-term political advantage, and the transformation of the Enlightenment’s secular aspirations into a political ideology that distorts such moral ideals. This essay concludes that the commitments to very particular notions of equality and human dignity, which frame contemporary Europe’s provision of publicly subsidized health care, have given rise to a governance that is morally incoherent and unsustainable. This failure of public health care in Europe can thus be read as one more belated manifestation of the epistemological and moral failure of the Enlightenment’s secularizing project, a failure which should invite contemporary Europeans to honestly face the moral challenge of postmodernity. (shrink)

There are four basic models for health care systems: the private market insurance model, the national single-payer model, the national health service model, and the social insurance model. The social justice debate over health care usually focuses on the comparative efficiency and quality of competitive private market insurance and the universal coverage and equity of national health care systems. It is a mistake, however, to think that a universal right to health (...) class='Hi'>care services requires a single-payer, government-run, national health care system. The social insurance model of Germany, France, Japan, and many other countries, deserves more attention, as it incorporates the strengths of both market models and national health care models. (shrink)

This is a short reply to Professor Reichlin’s comment on my book Setting Health-Care Priorities. What Ethical Theories Tell Us. The version of prioritarianism I rely on in the book is defended as the most plausible one. The general claim that there is convergence between all plausible theories on distributive justice is also defended with regard to assisted reproduction, disability, and enhancement.

As is so often the case in a common law system, the legal protection conferred by one strand of law is undermined by other legal provisions. There is no blanket legal duty which compels health care professionals to undergo HIV/AIDS tests; on the other hand, appropriately drafted contracts of employment, duties imposed by courts on employees and the risk of litigation by patients with pressurise individual workers to submit to testing. Whereas in Italy the law clearly condemned any (...) compulsory testing of health care workeers, but must now be interpreted to support it, in England and Wales each individual worker's case must be examined in order to determine whether testing must be submitted to. (shrink)

There are four basic models for health care systems: the private market insurance model, the national single-payer model, the national health service model, and the social insuranceSocial insurance model. The social justice debate over health care usually focuses on the comparative efficiency and quality of competitive private market insurance and the universal coverage and equity of national health care systems. It is a mistake, however, to think that a universal right to health (...) care services requires a single-payer, government-run, national health care system. The social insurance model of Germany, France, Japan, and many other countries, deserves more attention, as it incorporates the strengths of both market models and national health care models. (shrink)

One widely accepted way of justifying universal access to health care is to argue that access to health care is necessary to ensure health, which is necessary to provide equality of opportunity. But the evidence on the social determinants of health undermines this argument.

This essay attempts to describe contemporary Catholic sponsored health care in the United States and to describe the purpose and structure of these particular Christian charitable organizations within the broader society. As health care has become more complex, critics claim that there is not a need for Catholic sponsored health care any longer. The author attempts to evaluate critically whether Catholic health care has a place in contemporary society. He reviews some salient (...) biblical, ecclesial, and justice teachings of the Church to demonstrate why religious institutional presence is still needed. The author reviews contemporary health care structures to show how this is accomplished. He also uncovers additional issues which need to be addressed in order for these charitable institutions to carry on the ministry of the Church, to shape social structures, and to proclaim the reign of God. (shrink)

Lifestyle diseases constitute an increasing proportion of health problems and this trend is likely to continue. A better understanding of the responsibility argument is important for the assessment of policies aimed at meeting this challenge. Holding individuals accountable for their choices in the context of health care is, however, controversial. There are powerful arguments both for and against such policies. In this article the main arguments for and the traditional arguments against the use of individual responsibility as (...) a criterion for the distribution of scarce health resources will be briefly outlined. It is argued that one of the most prominent contemporary normative traditions, liberal egalitarianism, presents a way of holding individuals accountable for their choices that avoids most of the problems pointed out by the critics. The aim of the article is to propose a plausible interpretation of liberal egalitarianism with respect to responsibility and health care and assess it against reasonable counter-arguments. (shrink)

BackgroundAs hospitals have grown more complex, the ethical concerns they confront have grown correspondingly complicated. Many hospitals have consequently developed health care ethics programs (HCEPs) that include far more than ethics consultation services alone. Yet systematic research on these programs is lacking.MethodsBased on a national, cross-sectional survey of a stratified sample of 600 US hospitals, we report on the prevalence, scope, activities, staffing, workload, financial compensation, and greatest challenges facing HCEPs.ResultsAmong 372 hospitals whose informants responded to an online (...) survey, 97% of hospitals have HCEPs. Their scope includes clinical ethics functions in virtually all hospitals, but includes other functions in far fewer hospitals: ethical leadership (35.7%), regulatory compliance (29.0%), business ethics (26.2%), and research ethics (12.6%). HCEPs are responsible for providing ongoing ethics education to various target audiences including all staff (77.0%), nurses (59.9%), staff physicians (49.0%), hospital leadership (44.2%), medical residents (20.3%) and the community/general public (18.4%). HCEPs staff are most commonly involved in policy work through review of existing policies but are less often involved in development of new policies. HCEPs have an ethics representative in executive leadership in 80.5% of hospitals, have representation on other hospital committees in 40.7%, are actively engaged in community outreach in 22.6%, and lead large-scale ethics quality improvement initiatives in 17.7%. In general, major teaching hospitals and urban hospitals have the most highly integrated ethics programs with the broadest scope and greatest number of activities. Larger hospitals, academically affiliated hospitals, and urban hospitals have significantly more individuals performing HCEP work and significantly more individuals receiving financial compensation specifically for that work. Overall, the most common greatest challenge facing HCEPs is resource shortages, whereas underutilization is the most common greatest challenge for hospitals with fewer than 100 beds. Respondents’ strategies for managing challenges include staff training and additional funds.ConclusionsWhile this study must be cautiously interpreted due to its limitations, the findings may be useful for understanding the characteristics of HCEPs in US hospitals and the factors associated with these characteristics. This information may contribute to exploring ways to strengthen HCEPs. (shrink)

Architecture, like ethics, concerns actual rather than ideal choices. William James's remarks on ethics, at a meeting of the Yale Philosophical Club in 1890, could apply equally well to the built environment:The actual possible in this world is vastly narrower than all that is demanded; and there is always a pinch between the ideal and the actual which can only be got through by leaving part of the ideal behind. There is hardly a good which we can imagine except (...) as competing for the possession of the same bit of space and time with some other imagined good.1Health care facilities are spaces in which certain imagined goods—the care of the sick, the treatment or prevention of disease—meet the actual possible of .. (shrink)