Ethical analysis of health care reform: implications for diverse communities

The values driving nursing's political actions and the ethics underlying proposed health system change have not yet been thoroughly examined. This article attempts to (a) clarify ethical issues surrounding the health care debate in the United States, (b) describe the conflicts surrounding proposed reform especially the effects on disadvantaged communities and (c) earnestly entreat a critical discussion of nursing's humanistic position on health care reform. The interaction between the nursing literature and the various proposals on health care reform suggest various themes that reflect ethical issues due to conflicts in values. Our analysis is based on the belief that, in addition to political action and lobbying, the nursing community must confront critical questions about the values driving its policy making.     

The cutaneous microcirculation: ultrastructure and microanatomical organization

Nowadays hospitals are facing their responsibilities with necessitous patients care, in terms of social protection issues, adequate practice behaviours and professional challenges. The humanitarian aid new wave and innovative social interventions partially explain the success of some militant professionals. An historical approach ambulatory care facilities for deprived people and biographical interviews of health and social professionals show three logics: humanistic motivation, ethical responsibility and media-political charism. In spite of differences in careers promotion, field actors are volunteers to develop together new socially oriented strategies.     

Social capital and health: implications for public health and epidemiology

Public health and its "basic science", epidemiology, have become colonised by the individualistic ethic of medicine and economics. Despite a history in public health dating back to John Snow that underlined the importance of social systems for health, an imbalance has developed in the attention given to generating "social capital" compared to such things as modification of individual's risk factors. In an illustrative analysis comparing the potential of six progressively less individualised and more community-focused interventions to prevent deaths from heart disease, social support and measures to increase social cohesion faired well against more individual medical care approaches. In the face of such evidence public health professionals and epidemiologists have an ethical and strategic decision concerning the relative effort they give to increasing social cohesion in communities vs expanding access for individuals to traditional public health programs. Practitioners' relative efforts will be influenced by the kind of research that is being produced by epidemiologists and by the political climate of acceptability for voluntary individual "treatment" approaches vs universal policies to build "social capital". For epidemiologists to further our emerging understanding of the link between social capital and health they must confront issues in measurement, study design and analysis. For public health advocates to sensitise the political environment to the potential dividend from building social capital, they must confront the values that focus on individual-level causal models rather than models of social structure (dis)integration. The evolution of explanations for inequalities in health is used to illustrate the nature of the change in values.     

Running for political office: If at first you don't succeed….

Psychologists are serving in several state legislatures and gaining firsthand experience as political candidates. This article chronicles a psychologist's 1994 campaign for the Washington State House of Representatives. Campaign vignettes, political strategies, and the candidate's personal perceptions illuminate the value (even necessity) of psychologists entering politics. Psychologists bring to legislative deliberations a strong fund of knowledge about critical social issues such as health care, violence, and children's needs. Psychologists also possess effective interpersonal and group dynamic skills that can be real assets in developing public policy. A commitment to advocacy for mental health services and a community service ethic provide motivation for seeking office; indeed, entering politics can be viewed more as a logical extension of psychological work than as a deviation from it. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ethical, social and legal issues in Huntington disease: the nurse's role

The nurse's role will be discussed in relation to the issues which may present as the result of our ability to use predictive tests for neurodegenerative disease. Huntington disease is an autosomal dominant inherited disease, characterised by emotional problems, abnormalities of movement and dementia. The disease is slowly progressive leading to a severely debilitated state and finally death in ten to twenty years. In 1983, DNA testing became available for persons at risk for Huntington disease and for confirmation of diagnosis for those showing symptoms. The availability of testing presents many ethical, social and legal issues for persons at risk, health care professionals and other segments of society. This paper will briefly review the genetic transmission and profession of Huntington disease. It will outline some of the benefits as well as some of the risks and problems DNA testing presents.     

Ethics in the intensive care unit. Creating an ethical environment

This article discusses ethical issues that exist each and every day in interactions with patients, families, and fellow workers in the ICU, even in the absence of overt conflict or controversy. The creation of an ethical working environment in the ICU is a necessary precondition for dealing with the ethical issues raised by specific issues such as cardiopulmonary resuscitation, the limitation or withdrawal of life-sustaining treatment, the special care of children with disabilities, brain death, and organ procurement, and triage. The creation of an ethical working environment requires developing a collaborative relationship with patients, families, staff, and other health care professionals.     

Suicidality in nursing home residents: Part II. Special issues.

Professional psychologists working with suicidal nursing home residents often deal with a host of special issues that may not be relevant to other populations. This review article (Part 2 of a series) was written to acquaint professionals with the concept of indirect self-destructive behavior and dealing with ethical concerns. This article also summarizes health care systems issues, including how to involve staff and family members in assessment and management, as well as understanding Medicare/Medicaid related concerns and public policy regarding long-term care. The article concludes with information about training and continuing education offerings for psychologists who need more information about working in nursing home settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The difference between withholding and withdrawing life-sustaining treatment

OBJECTIVES: First, to present the position on the distinction between withholding and withdrawing life-sustaining treatment as expressed in guidelines and examine its relation to the attitudes of health care professionals. Second, to examine the possible ethical justification of this distinction. DESIGN, SETTING, AND PARTICIPANTS: Critical analysis of guidelines on life-sustaining treatment and questionnaire administered to 148 health care professionals--physicians and nurses at the intensive care unit (ICU), University Hospital MAS, Malm?, Sweden. RESULTS: In contrast to the guidelines, which emphasize that there is no ethical difference between withholding and withdrawing life-sustaining treatment, not less than 50 per cent of the professionals in the ICU were of the opinion that there is an ethical difference. All attempts to justify this difference with reference to an inherent distinction between withholding and withdrawing seem to be controversial. CONCLUSIONS: We recommend a change in emphasis in professional guidelines. Such guidelines should avoid the controversial issue about the possible inherent ethical difference between withholding and withdrawing life-sustaining treatment. What should be underlined is that the particular situation and the consequences of withholding as well as withdrawing life-sustaining treatment should always be taken into account.     

Determination of selenium in the human brain by graphite furnace atomic absorption spectrometry

Financial issues are encroaching upon health care decisions at a rapid pace in today's managed care arena. An examination of the parallel historical perspectives of bioethics, health care reimbursement, and quality improvement reveals that, by integrating an ethical framework with the quality improvement process, health care professionals can preserve patient-centered care. The article demonstrates the strength of this combined approach using restraints as an example.     

Culturally competent health care: a challenge for nurses in Saudi Arabia

An emerging global reality is the presence of a culturally diverse workforce in health care environments. Not only are nurses delivering care to culturally diverse clients, the nurses themselves may come from different cultural and educational backgrounds. In order to provide culturally competent health care, such diversity must be molded into professional collaboration and respect. To date, health care to the citizens of Saudi Arabia has been provided largely by a foreign labor force, the vast majority of whom are non-Arabic speaking. This paper explores a number of strategies aimed at educating expatriate non-Saudi health professionals in the provision of culturally competent and culturally congruent health care. Leininger's transcultural health care theory is identified as the framework for achieving this goal. The theory has proved to be of great relevance in a hospital setting where some 40 different nationalities are represented among the work force. In such a setting, the potential for cultural conflict and stress is very real. Health professionals new to the Kingdom are introduced to the cultural dimensions of health care as it relates to patient care modes, as well as living and working together in a transcultural environment. Transcultural nursing is a major component of a professional nurse practice model which provides a visionary perspective for nursing care. Within the practice model, transcultural care principles are used to guide education, clinical practice and nursing research. Furthermore, Leininger's theory serves to grasp a comprehensive view of generic (folk) and professional health systems and to identify ethical issues confronted by nurses in the transcultural setting.     

Bioethics and Canadian dentistry

Formal ethical reflection and analysis have become expected components of clinical decision making for all health professionals. The implicit acceptance of professional ethics as the sole determinant of "the right and the good" has been replaced by an expectation for more broadly-based understanding of ethical issues. Dentists, like physicians, must be clear about professional ethics and competent in interdisciplinary and interprofessional discussions of the right and good. Modern bioethics is providing approaches to these issues to help practitioners make ethical clinical decisions. These approaches may not be appropriate for dentistry, especially as practised in Canada. Clearly, there are fundamental questions concerning dentistry as a profession, patient-dentist interactions and dental health that must be addressed to form a basis for an ethic relevant to professional practice. The answers to these questions have profound implications for the initial and continuing education of Canadian dentists and for dentistry itself. Some possible starting points for a truly Canadian ethic for dentistry are suggested from a non-dentist, physician ethicist.     

Cultural barriers to health care reform

The rate of proliferation of health care reform proposals makes it impossible to consider them all adequately; whatever plan is finally legislated, there will be many who are not satisfied with it, and clamor for change is likely to be a prominent feature of health care politics for a long time. This article takes a brief look at the health care reform process in the United States, including some of the impediments to development of a plan that would address both contemporary and future issues. Some traditional ethical viewpoints and cultural values, having to do with concepts of justice, are seen as inimical to long-range program development. The need for alteration of traditional views is regarded as urgent, to facilitate cultural movement in directions that will not only permit development of workable health care programs, but will extend broadly to address other compelling societal issues. The impetus for advantageous cultural movement originates among perceptive individuals who are regarded by society as legitimately influential. Many physicians still are accorded this sort of recognition, and the considered input of medical professionals is essential.     

Use of advance directives: facilitating health care decisions by adults with mental retardation and their families

As increasing numbers of adults with mental retardation survive into adulthood and old age, they may face decisions about their health care and end-of-life treatment. Advance directives may serve as a tool for communicating one's preferences about future medical treatment. Information about the types, extent of use, and ethical context of advanced directives is provided and four critical issues regarding use of advanced directives by adults with mental retardation and their families are examined: assessment of decision-making capacity, standards for surrogate decision-making, family involvement in advanced directives planning, and constraints on the use of advanced directives. Implications for professionals are discussed, including ways to facilitate advance care planning.     

Trauma, change, and psychological health in the 21st century.

The impact of stressful life events on health has been the object of inquiry for decades. Health care professionals have studied how stressful life events may precipitate or contribute to the onset of illness. Traumatic events and experiences can profoundly affect physical and psychological well-being, which in turn may predispose an individual to greater resilience or greater vulnerability to life stresses. Examined herein is the relationship between life stresses--including social stressors, political stressors, and environmental stressors--and the critical health related issues that psychologists need to prepare for in both the science and the practice of psychology over the next decade and during the 21st century. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Growth screening and urban deprivation

OBJECTIVES: To assess the effect of urban deprivation on childhood growth in a modern British society by analysing data from a regional growth survey, the Tayside growth study. SETTING: The Tayside Region in Scotland, which has three districts with distinct socioeconomic status: Dundee (D, urban city), Angus (A, rural), and Perth (P, rural and county town). SUBJECTS AND METHODS: Height and weight of 23,046 children (> 90% of the regional childhood population) were measured as part of a child health surveillance programme, by community health care workers at 3, 5, 7, 9, 11, and 14 years. Height standard deviation score (calculated against Tanner) and body mass index (BMI-weight (kg)/height (m)2) were calculated for each child by a central computer program; mean height standard deviation score and BMI standard deviation score were calculated for each measuring centre (school, health clinic). A deprivation score for each centre was calculated from the prevalence of single parent families; families with more than three children; unemployment rate; the number of social class V individuals; the percentage of council houses. RESULTS: Mean height standard deviation score for Tayside was 0.11. An intraregional difference was demonstrated: mean height standard deviation score (SD) D = 0.04 (1.0); A = 0.14 (1.1); P = 0.21 (1.1); P < 0.002. There was a positive association between short stature and increasing social deprivation seen throughout Tayside (P < 0.05), with a strong association in Dundee primary school children (r = 0.6; P < 0.001). Analysis by district showed that the association was significant only above the age of 8 (P < 0.004). There was no relation between BMI and social deprivation. CONCLUSIONS: In an industrialised developed society, urban deprivation appears to influence height mostly in late childhood, and this association should be taken into consideration in the clinical management of short stature. Height seems to be a better physical indicator of urban deprivation, and hence an index of childhood health, than BMI.     

Lessons in transferring resources: the system of fees per patient

Dowries can be defined as lump sum payments or continuing grants which health authorities make between themselves and to local authorities or voluntary organisations in respect of people with severe mental disorders to be cared for in the community instead of in hospital. This paper has three aims. First to describe how dowries and other processes were set up to encourage the closure of two psychiatric hospitals in England. The broader financing context for mental health care (prior to the reforms in England engendered by the NHS and Community Care Act, 1990) is also described and shows some similarities to the current arrangements in Québec. Second, we abstract some information from a long-running evaluation of the reprovision programme to look at the type of services used in the community by former long-stay patients of these two hospitals and the comparative costs of hospital and community-based care. After leaving hospital, former patients require considerable inputs from other health and social care services; any development of community care for these patients should at the least mirror the facilities provided on the hospital campus. The final aim of this paper is to examine the extent to which this English system of budget reallocation ("dowries") can be employed in Québec to further reduce long-stay hospital provision. There are many similarities between the health and social care systems of the two countries but there are also organisational and political differences. It is not sensible, therefore, to transfer the English budget reallocation to Québec wholesale, but we suggest that there are important process and implementation issues which can guide the development of financing mechanisms in Québec.     

Ethics of resource allocation in developing countries: the case of Sri Lanka

The issues of prioritization of health care services and allocation of resources have recently received increasing attention and discussion. Several reports have been published by governments in different countries and the issues are discussed in many recent books and papers. In this paper the focus is on the problems faced by a developing country when allocation of health care resources is considered. We consider these issues under three headings and exemplify the situation in a developing country by taking Sri Lanka as an example. Firstly the evidence to formulate an ethical basis for the existing health care system in Sri Lanka is discussed, in particular the problem of defining a minimum quality of health care for the population. Secondly, we consider the issues which arise when we want to formulate the ethical basis for health sector reform. In particular, we examine current World Bank proposals. We shall argue that there are a number of important conceptual and ethical issues that have not been properly addressed in the various policy documents. Finally, we introduce our own alternative ethical framework for policy reform.     

Health promotion and empowerment: reflections on professional practice

Recent reformulations of health promotion focus on empowerment as both a means and an end in health promotion practice. Both concepts, however, are rarely examined for their assumptions about social change processes or the potential of community groups, professionals, and institutions to create healthier living situations. This article attends to some of these assumptions, expressing ideas generated during 6 years of professional training workshops with over 2,500 community health practitioners in Canada, New Zealand, and Australia. The article first argues that health promotion is not a social movement but a professional and bureaucratic response to the new knowledge challenges of social movements. As such, it has both empowering and disempowering aspects. The article analyzes empowerment as a dialectical relation in which power is simultaneously given and taken, and illustrates this in the context of health promotion programs. A model of an empowering professional (institutional) health promotion practice is presented, in which linkages among personal services, small group supports, community organizing, coalition advocacy, and political action are made explicit. Practice examples are provided to illustrate each level of the empowering relation, and the article concludes with a brief discussion of the model's educational and organizational utility.     

Families and children's chronic conditions: knowledge development and methodological considerations

The complexity of studying families has been a deterrent in the development of knowledge about families as the unit of care. When chronicity in childhood is combined with family study, research and theory development is particularly challenging. Although publication in the field of chronic illness in childhood has been quite prolific, there are few comprehensive, recognizably organized ways to think about providing care for the family as a whole. This is profoundly important as increasing responsibility of day-to-day care for children with long-term health conditions shifts to the family and to community-based care. This paper presents a synthesis of what is known about families in health care when one member is a child with a long-term health concern, identifies gaps in knowledge that potentially compromise optimal health care delivery, and suggests methods for expanding and deepening our understanding so that we might improve the quality of our efforts to assist families that live with a child with a chronic condition.     

Restraints and the elderly with mental illness: ethical issues and moral reasoning

The use of restraints to enable the care provided to the elderly has long been a source of contention and fodder for argument among health care professionals. The question of whether to use mechanical restraints to prevent falls in the elderly is an ongoing debate. An ethical framework is presented to assist the decision-making process.