Research on justifications has shown their significance in advice-giving, decision-making and children disputes. However, the majority of studies gloss over practical functions of justifications in patient-physician interactions as they are often expected and pursued by patients and in turn, are adopted by physicians to support their stance and authority. This study, through conversation analysis (CA), aims to explore a) what are pragmatic functions of justifications in patient-physician interaction? b) how and when do physicians unfold their justifications for treatment recommendations? c) (...) how do physicians deal with different responses based on their epistemic and deontic domains?. A total of 32 video-recordings between postpartum women and physicians are collected and studied. Four pragmatic functions of justifications drawn upon by physicians are explored: justifications as face-saving, reassurance, risk discussion and clarification-seeking. Despite physicians’ attempts to justify their positions as less challenged by patients, this is not the entire picture as they demonstrate their desire to resolve patients’ concerns and coordinate their viewpoints to achieve the best practice that facilitates patients’ well-being. (shrink)

Deemed consent legislation for deceased organ donation was introduced in England in 2020, and is considered a vital part of the new UK NHS Blood and Transplant’s 10-year strategy to increase consent for organ donation. Despite the legislation containing safeguards to protect the public, the introduction of deemed consent creates ethical, psychological and social un/certainties for healthcare professionals in their practice. In this paper, we offer insights into healthcare professionals’ perspectives on deemed consent, drawn from interview data with 24 healthcare (...) professionals in an NHS Trust in England, prior to the introduction of the legislation. Whilst participants supported deemed consent in principle, they were concerned that it would present a threat to the nature of donation as a ‘gift’; the notion of informed consent (or non-consent); and the autonomy of donors, their relatives, and their own roles as health professionals, posing dilemmas for practice. We argue that healthcare professionals present themselves as guardians of potential (non)donors and thus as having ethics and integrity in their own practice. We draw conclusions around the values and principles that matter to healthcare professionals when contemplating consent in deceased donation which will be useful for organ donation committees and ethics forums. (shrink)

Based on a qualitative study, this paper explores how United States public health professionals view and think about the existing U.S. healthcare system, while also allowing these study participants to imagine new ways of structuring and practicing public health. Using semi-structured qualitative interviews, I show how public health professionals engage with the concept of “the social” and their personal experiences with public health to question the status quo. By giving public health professionals space in which to imagine changes and different (...) ways of practicing public health, I demonstrate the effectiveness of imagination as a capacity that public health professionals possess to take the lead in creating the changes they hope for. (shrink)

Clinical decision-making in old-age care is a complex and ethically sensitive process. Despite its importance, research addressing the challenges of clinical decision-making in old-age care within this cultural context is limited. This study aimed to explore the challenges and ethical concerns in clinical decision-making in old-age care in Ethiopia. This qualitative study employed an inductive approach with data collected via semi-structured interviews with 20 older patients and 26 health professionals recruited from healthcare facilities in Ethiopia. Data were analysed using reflexive (...) thematic analysis. Our analysis identified three key themes. First, participants highlighted perceptions that older patients’ religious beliefs interfere with the clinical decisions both older patients and health professionals make. Second, older patients often receive limited information from health professionals about their diagnosis and treatment. Third, families of older patients appear to strongly influence clinical decisions made by older patients or health professionals. This research enhances the understanding of clinical decision-making in old-age care within Ethiopia, a context where such research is scarce. As a result, this study contributes towards advancing the deliberation of ethical dilemmas that health professionals who work with older patients in Ethiopia might face. A key implication of the study is that there is a need for more ethics and cultural competence training for health professionals working with older patients in Ethiopia. (shrink)

Environmental pollution and greenhouse gas emissions that contribute to climate change have adverse impacts on global health. Somewhat paradoxically, health care systems that aim to prevent and cure disease are themselves major emitters and polluters. In this paper we develop a justification for the claim that solidaristic health care systems should include sustainability as one of the criteria for determining which health interventions are made available or reimbursed – and which not. There is however a complication: most adverse health effects (...) due to climate change do occur elsewhere in the world. If solidarity would commit us to take care of everyone’s health, worldwide, it might imply that solidaristic health system cannot justifiably restrict universal access to their own national populations. In response we explain health solidarity is to be considered as a moral ideal. Such an ideal does not specify what societies owe to whom, but it does have moral implications. We argue that ignoring sustainability in political decision making about what health care is to be offered, would amount to betrayal of the ideal of solidarity. (shrink)

Providers are essential to the delivery of abortion care. Yet, they often occupy an ambiguous space in political discourse around abortion. The introduction of a new abortion service in Ireland invites us to look afresh at providers. Since the Health (Regulation of Termination of Pregnancy) Act 2018 came into force, by far the most common form of abortion care has been early medical abortion (EMA). This is typically provided by General Practitioners (GPs), with approximately 10% of GPs having chosen to (...) provide EMA. This article draws on an empirical study of providers to investigate their motivations for, and experiences of, provision and their views on colleagues who have not chosen to provide. The study shows that for many providers, the choice to provide was grounded in a moral commitment to protecting women’s rights to autonomy and health and ensuring that the harms of the past were not repeated. The article argues that notwithstanding increased normalisation of EMA in Ireland, conscience still has a role to play in abortion care provision and it is important to reflect on the various aspects of this role. (shrink)

Evidence shows that during birth women frequently experience unconsented care, coercion, and a loss of autonomy. For many countries, this contradicts both the law and medical ethics guidelines, which emphasize that competent and fully informed women’s autonomy must always be respected. To better understand this discordance, we empirically describe perinatal maternity care providers’ and women’s moral deliberation surrounding coercive measures during birth. Data were obtained from 1-on-1 interviews with providers (N = 15) and women (N = 14), and a survey (...) of women (N = 118). Analyses focused on an in-depth exploration of responses to a question on the permissibility of coercion in birth whose wording was borrowed from a Swiss medical-ethical guideline. Reasons for and against a principle permissibility of coercive measures in birth were grouped into clusters of reasons to build a coherent explanatory framework. Factors considered morally relevant when deliberating on coercion included women’s decisional capacity, beneficence/non-maleficence, authority through knowledge on the part of providers, flaws of the medical system, or the imperative to protect the most vulnerable. Also, we identified various misconceptions, such as the conviction that a pathological birth can justify coercion or that fetal rights can justifiably infringe on women’s autonomy. Information and education on the issue of coercion in birth are urgently needed to enable women to fully exercise their reproductive autonomy, to prevent long-term adverse health outcomes of women and children, and to reconcile the medical vigilance which has lead to a reduction of perinatal morbidity and mortality with women’s enfranchisement in their own care. (shrink)

It is perhaps most useful to approach the Doctor-Patient relationship (DPR) by admitting that it’s complicated. We review some of the strategies that have been employed to mitigate this complexity, zeroing in on one that promises to capture the main features of the DPR without eliminating some of its more important, existential components; pieces of the puzzle that must be retained if we are to avoid oversimplification and the errors that can arise by ignoring important foundational properties. We believe that (...) a useful way to look at the DPR and to capture essential features that must be balanced in the process is provided by Partnership Theory and its definition in terms of the so-called domination and partnership systems. We apply this theory to the DPR and investigate the implications of this application to health care. We see that in the absence of mitigating circumstances, adoption of the patient-as-partner model serves healthcare well and is flexible enough to accommodate circumstances that dictate modifications. (shrink)

The case of Charlie Gard sparked an ongoing public and academic debate whether in court decisions about medical treatment for children in England & Wales the best interests test should be replaced by a harm threshold. However, the literature has scantly considered (1) what the impact of such a replacement would be on future litigation and (2) how a harm threshold should be introduced: for triage or as standard for decision-making. This article directly addresses these gaps, by first analysing reported (...) cases in England & Wales about medical treatment in the context of a S31 order, thus using a harm threshold for triage and second comparing court decisions about medical treatment for children in England & Wales based on the best interest test with Dutch and German case law using a harm threshold. The investigation found that whilst no substantial increase of parental discretion can be expected an introduction of a harm threshold for triage would change litigation. In particular, cases in which harm is limited, currently only heard when there are concerns about parental decision-making, may be denied a court hearing as might cases in which the child has lost their capacity to suffer. Applying a harm threshold for triage in decisions about withholding or withdrawing life-sustaining treatment might lead to a continuation of medical treatment that could be considered futile. (shrink)

This study examined variation in medical practitioners’ practice-based conceptions of what it means to be a doctor, based on interviews with 30 clinicians who were also medical educators. Participants included general practitioners, surgeons and physicians (non-surgical specialists). Participants were asked to draw a concept map of ‘being a doctor’, followed by semi-structured interviews using a phenomenographic research design. Three conceptions were identified, varyingly focused on (1) treating patients’ medical problems; (2) maximising patients’ well-being; and (3) maximising community health. Each conception (...) was distinguished by variation in awareness of six underlying dimensions of being a doctor: (1) doctors’ actions; (2) treatment success; (3) patients’ actions; (4) patients’ well-being; (5) community needs; and (6) social justice. Whilst all participants included dimensions 1 and 2 in their described practice, numerous participants did not include dimensions 3 and 4, i.e. did not take the patients’ role and the impact of patients’ psychosocial context into account in their practice. This is concerning, especially amongst medical educators, given the widely acknowledged importance of patient-centred care in medical practice. Similarly, only some of the participants considered community health needs and felt a broader social responsibility beyond their responsibility to individual patients. These findings highlight aspects of the medical profession that need to be further emphasised in medical training and continuing professional development. (shrink)

In this paper we aim to discuss a theoretical explanation for the positive relationship between patients’ knowledge and their trust in healthcare personnel. Our approach is based on John Dewey’s notion of continuity. This notion entails that the individual’s experiences are interpreted as interrelated to each other, and that knowledge is related to future experience, not merely a record of the past. Furthermore, we apply Niklas Luhmann’s theory on trust as a way of reducing complexity and enabling action. Anthony Giddens’ (...) description and analysis of the high modern society provides a frame for discussing the preconditions for patient-healthcare personnel interaction. High modernity is dominated by expert systems and demands trust in these. We conclude that patient knowledge and trust in healthcare personnel is related because both knowledge and trust are future- and action-oriented concepts. The traits of high modernity provides opportunities and challenges as the personnel can and must perform discretion. This discretion must be made in a context where knowledge is considered uncertain and preliminary. (shrink)

In health care, the provision of pertinent information to patients is not just a moral imperative but also a legal obligation, often articulated through the lens of obtaining informed consent. Codes of medical ethics and many national laws mandate the disclosure of basic information about diagnosis, prognosis, and treatment alternatives. However, within publicly funded health care systems, other kinds of information might also be important to patients, such as insights into the health care priorities that underlie treatment offers made. While (...) conventional perspectives do not take this as an obligatory part of the information to be shared with patients, perhaps through viewing it as clinically “non-actionable,” we advocate for a paradigm shift. Our proposition diverges from the traditional emphasis on actionability. We contend that honoring patients as equal moral agents necessitates, among other principles, a commitment to honesty. Withholding specific categories of information pertinent to patients’ comprehension of their situation is inherently incompatible with this principle. In this article, we advocate for a recalibration of the burden of proof. Rather than requiring special justifications for adding to the standard set of information items, we suggest that physicians should be able to justify excluding relevant facts about the patient’s situation and the underlying considerations shaping health care professionals’ choices. This perspective prioritizes transparency and empowers patients with a comprehensive understanding, aligning with the ethos of respect for the patient as person. (shrink)

The term ‘environment’ is not uniformly defined in the public health sciences, which causes crucial inconsistencies in research, health policy, and practice. As we shall indicate, this is somewhat entangled with diverging pathogenic and salutogenic perspectives (research and policy priorities) concerning environmental health. We emphasise two distinct concepts of environment in use by the World Health Organisation. One significant way these concepts differ concerns whether the social environment is included. Divergence on this matter has profound consequences for the understanding of (...) health and disease, for measures derived from that understanding targeting health promotion and disease prevention, and consequently, for epistemic structures and concept development in scientific practice. We hope to improve the given situation in public health by uncovering these differences and by developing a fruitful way of thinking about environment. Firstly, we side with the salutogenic conception of environment as a _health resource_ (as well as a source of health risks). Secondly, we subdivide the concept of environment into four _health-oriented environmental categories_ (viz., natural, built-material, socio-cultural, and psychosocial) and we link these with other theoretical notions proposed in the health sciences literature. Thirdly, we propose that in public health ‘environment’ should be understood as consisting of all extrinsic factors that influence or are influenced by the health, well-being, and development of an individual. Consequently, none of the four categories should be excluded from the concept of environment. We point out the practical relevance and fruitfulness of the conception of environment as a health source and frame this in causal terms, representing _individual health environments_ as causal networks. Throughout, we side with the view that for the design of human health-promoting settings, increased attention and consideration of environmental resources of salutogenic potential is particularly pressing. (shrink)

The practical goal of preventing premature death seems uncontroversial. But the term ‘premature death’ is vague with several, sometimes conflicting definitions. This ambiguity results in several conceptions with which not all will agree. Moreover, the normative rationale behind the goal of preventing premature deaths is masked by the operational definition of existing measures. In this article, we argue that ‘premature death’ should be recognized as a normative concept. We propose that normative theories should be used to justify measures of premature (...) death to provide them with normative validity and public legitimacy. (shrink)

Abstract‘Social inclusion’ is the leading ideal in services and care for people with intellectual disabilities in most countries in the Global North. ‘Social inclusion’ can refer simply to full equal rights, but more often it is taken to mean something like ‘community participation’. This narrow version of social inclusion has become so ingrained that it virtually goes unchallenged. The presumption appears to be that there is a clear moral consensus that this narrow understanding of social inclusion is good. However, that (...) moral consensus is not clear in the case of people with profound intellectual and/or multiple disabilities (PIMD), who are not able to express their needs and preferences verbally. Moreover, social inclusion has proven to be difficult to conceptualize and implement for people with PIMD. Therefore, it becomes imperative to ask about the ethical rationale of the narrow understanding of social inclusion. For what reasons do we think social inclusion is good? And do those reasons also apply for people with PIMD? This article addresses these questions by providing an ethical analysis of the ideal of social inclusion for people with PIMD. It discusses four ethical arguments for social inclusion and probes their relevance for people with PIMD. The article argues that none of these arguments fully convince of the value of the narrow understanding of social inclusion for people with PIMD. It ends with advocating for an ethical space for imagining a good life for people with PIMD otherwise. (shrink)