Health Care Analysis最新文献

The article examines the patient-doctor relationship, relying on Michel Foucault's concept of the clinical gaze. We argue that during the last decades, a profound transformation of the social nature of medicine took place, one that Foucault's understanding of the clinical gaze cannot adequately account for. First, the article offers an elaboration of the three-node network of clinical gaze, the clinic, and nosology to explain the positioning of the doctor and the patient within the specific social ontology generated by the rise of medicine. We then discuss intensive but irresolute developments brought by technological advancements, especially the X-ray tube. Finally, we argue that in the contemporary clinic, equipped with a plethora of sophisticated devices, the position of the doctor endured the most radical transformation in comparison with Foucault's proponent of the clinical gaze at the dawn of modern medicine.

How can we draw the line between health and disease? This crucial question of demarcation has immense practical implications and has troubled scholars for ages. The question will be addressed in three steps. First, I will present an important contribution by Rogers and Walker who argue forcefully that no line can be drawn between health and disease. However, a closer analysis of their argument reveals that a line-drawing problem for disease-related features does not necessarily imply a line-drawing problem for disease as such. The second step analyzes some alternative approaches to drawing the line between health and disease. While these approaches do not provide full answers to the question, they indicate that the line-drawing question should not be dismissed too hastily. The third step investigates whether the line-drawing problem can find its solution in the concept of suffering. In particular, I investigate whether returning to the origin of medicine, with the primary and ultimate goal of reducing suffering, may provide sources of demarcation between health and disease. In fact, the reason why we pay attention to particular phenomena as characteristics of disease, consider certain processes to be relevant, and specific functions are classified as dys-functions, is that they are related to suffering. Accordingly, using suffering as a criterion of demarcation between health and disease may hinder a wide range of challenges with modern medicine, such as unwarranted expansion of disease, overdiagnosis, overtreatment, and medicalization.

In a time marked by the development of innovative treatments in healthcare and the need for health professionals to deal with resulting ethical dilemmas in clinical practice, this study was developed to determine the influence of the bioethics teaching on the moral competence of medical and nursing students. The authors conduct a longitudinal study using the Moral Competence Test extended version before and after attending the ethics curricular unit, in three nursing schools and three medical schools of Portugal. In this questionnaire the participant is confronted with three ethical dilemmas (related to theft, euthanasia and the torture of a terrorist) and asked to evaluate arguments for and against the attitude of the main character (Worker, doctor and judge). For both nursing and medical students, C-score was lower after the attendance of the ethics curricular units, with a statistically significant decrease in the total score (from 21 to 19.5 on average; p = 0.046) for nursing students and a decrease not statistically significant for medical students (from 23.2 to 22 on average; p = 0.358). A multivariate analysis did not find any association between this decrease and gender, course, or age. The phenomenon of moral segmentation was observed, with better performance in the worker and judge dilemma, than in the doctor dilemma. These results highlight the need to reflect on the curricular strategies that can be implemented for health professionals to better develop moral competence and decision-making, allowing for the provision of humanized health care.

Persons with profound intellectual and multiple disabilities (PIMD) cannot speak about their Quality of Life (QoL), which makes it necessary to involve others. In current approaches, these 'others' are seen as assessors trying to describe QoL as objectively as possible, which involves a reduction of their experiences, through which they develop knowledge on the QoL of the person with PIMD. The objective of this paper is to give caregivers' knowledge on the QoL of a person with PIMD a theoretical basis that values these experiences. We will argue that caregivers should be seen as witnesses, not assessors, and their statements on QoL as testimonies, not assessments. Audiences judge the trustworthiness of these witnesses intersubjectively, which implies a relationship characterized by trust and suspicion. Trust supports the witness to tell in her own words about the QoL of the person with PIMD; it demands receptivity, indicating that both the witness and the audience are willing to reconsider their perspective on QoL. Suspicion is necessary too, which helps the witness to critically approach her own interpretations and supports her to create more trustworthy testimonies. We conclude that the concept of witnessing helps to acknowledge caregivers' experiential knowledge of QoL of a person with PIMD, which may also apply to other persons who cannot speak about their own QoL. We hope that our study will empower caregivers to give testimonies on QoL of a person with PIMD, which is crucial when complex decisions about the life of this person have to be made.

The debate regarding the role of conscientious objection in healthcare has been protracted, with increasing demands for curbs on conscientious objection. There is a growing body of evidence that indicates that in some cases, high rates of conscientious objection can affect access to legal medical services such as abortion-a major concern of critics of conscientious objection. Moreover, few solutions have been put forward that aim to satisfy both this concern and that of defenders of conscientious objection-being expected to participate in the provision of services that compromise their moral integrity. Here we attempt to bring some resolution to the debate by proposing a pragmatic, long-term solution offering what we believe to be an acceptable compromise-a quota system for medical trainees in specialties where a conscientious objection can be exercised, and is known to cause conflict. We envisage two main objectives of the quota system we propose. First, as a means to introduce conscientious objection into countries where this is not presently permitted. Second, to minimise or eliminate the effects of high rates of conscientious objection in countries such as Italy, where access to legal abortion provision can be negatively affected.

This paper analyses the ethics of routine measurement for healthcare improvement. Routine measurement is an increasingly central part of healthcare system design and is taken to be necessary for successful healthcare improvement efforts. It is widely recognised that the effectiveness of routine measurement in bringing about improvement is limited-it often produces only modest effects or fails to generate anticipated improvements at all. We seek to show that these concerns do not exhaust the ethics of routine measurement. Even if routine measurement does lead to healthcare improvements, it has associated ethical costs which are not necessarily justified by its benefits. We argue that the practice of routine measurement changes the function of the healthcare system, resulting in an unintended and ethically significant transformation of the sector. It is difficult to determine whether such changes are justified or offset by the benefits of routine measurement because there may be no shared understanding of what is 'good' in healthcare by which to compare the benefits of routine measurement with the goods that are precluded by it. We counsel that the practice of routine measurement should proceed with caution and should be recognised to be an ethically significant choice, rather than an inevitability.

The original version of this article unfortunately contained a mistake. The fourth sentence of third paragraph under section Do Harm Reduction Programs Condone Harm? Should be "One of us (Corvino)" instead of "One of us (name removed for blinded manuscript)".The original article has been corrected.

'Harm reduction' programs are usually justified on the utilitarian grounds that they aim to reduce the net harms of a behavior. In this paper, I contend that (1) the historical genesis of harm reduction programs, and the crucial moral imperative that distinguishes these programs from other interventions and policies, are not utilitarian; (2) the practical implementation of harm reduction programs is not, and probably cannot be, utilitarian; and (3) the continued justification of harm reduction on utilitarian grounds is untenable and may itself cause harm. Promoting harm reduction programs as utilitarian in the public arena disregards their deeper prioritarian impulses. 'Harm reduction' is a misnomer, and the name should be abandoned sooner rather than later.

In this paper, I offer a prolegomenon to the philosophy of harm reduction. I begin with an overview of the philosophical literature on both harm and harm reduction, and a brief summary of harm reduction scholarship outside of philosophy in order to make the case that philosophers have something to contribute to understanding harm reduction, and moreover that engagement with harm reduction would improve philosophical scholarship. I then proceed to survey and assess the nascent and still modest philosophy of harm reduction literature that has begun to emerge. I pay particular attention to two Canadian philosophers who have called for the expansion of harm reduction beyond the realm of so-called "vice" (that is, addiction, intoxicants and sex work). Finally, I sketch some of the most interesting and important philosophical issues that I think the philosophy of harm reduction must grapple with going forward.

Critical literatures, and public discourses, on public health policies and practices often present fixated concerns with paternalism. In this paper, rather than focus on the question of whether and why intended instances of paternalistic policy might be justified, we look to the wider, real-world socio-political contexts against which normative evaluations of public health must take place. We explain how evaluative critiques of public health policy and practice must be sensitive to the nuance and complexity of policy contexts. This includes sensitivity to the 'imperfect' reach and application of policy, leading to collateral effects including collateral paternalism. We argue that theoretical critiques must temper their demandingness to real-world applicability, allowing for the detail of social and policy contexts, including harm reduction: apparent knock-down objections of paternalism cannot hold if they are limited to an abstract or artificially-isolated evaluation of the reach of a public health intervention.