This paper aims to pursue two goals: first, it will explore the encounter and dialogue between Martin Heidegger’s thinking toward medicine, and in particular, psychiatry. Second, it will look toward understanding how this encounter can illuminate clinical practices and provide significant contributions within the fields of medical education and healthcare. The broader horizon of this paper is to underline how embracing a different approach to health can be of interest to both a medical and philosophical audience, inviting the former to (...) progress in their scientific skills and de-personalize texts toward a more genuine and humanistic encounter with patients, while also engendering the latter to leave the dark and dusty halls of metaphysical thinking to move into the greener pastures of the social dimension. (shrink)

Do doctors fix patients? Or do they heal them? For all of modern medicine’s many successes, discontent with the quality of patient care has combined with a host of new developments, from aging populations to the resurgence of infectious diseases, which challenge medicine’s overreliance on narrowly mechanistic and technical methods of explanation and intervention, or “fixing’ patients. The need for a better balance, for more humane “healing” rationales and practices that attend to the social and environmental aspects of health (...) and illness and the experiencing person, is more urgent than ever. Yet, in public health and bioethics, the fields best positioned to offer countervailing values and orientations, the dominant approaches largely extend and reinforce the reductionism and individualism of biomedicine. The collected essays in To Fix or To Heal do more than document the persistence of reductionist approaches and the attendant extension of medicalization to more and more aspects of our lives. The contributors also shed valuable light on why reductionism has persisted and why more holistic models, incorporating social and environmental factors, have gained so little traction. The contributors examine the moral appeal of reductionism, the larger rationalist dream of technological mastery, the growing valuation of health, and the enshrining of individual responsibility as the seemingly non-coercive means of intervention and control. This paradigm-challenging volume advances new lines of criticism of our dominant medical regime, even while proposing ways of bringing medical practice, bioethics, and public health more closely into line with their original goals. Precisely because of the centrality of the biomedical approach to our society, the contributors argue, challenging the reductionist model and its ever-widening effects is perhaps the best way to press for a much-needed renewal of our ethical and political discourse. (shrink)

For many children with complex medical conditions, decisions regarding their goals of care lie in the zone of parental discretion. That is, clinicians appropriately recognize that in many cases whether to prioritize quantity of life or quality of life is a deeply personal, values-laden decision best made by those who are most deeply invested in the outcome. Once a family has committed to a goal, however, there may be new or ongoing conflict between parents and clinicians regarding the specific (...) interventions provided or not provided in support of that goal. To what extent is it ethically permissible for a seriously ill child’s surrogate decision makers to reject individual interventions that support their desired goal of care? This question might be best described thus: is pediatric healthcare “prix fixe,” in which clinicians help parents decide the best of one or more set combinations (“menus”) of interventions, or is it “à la carte,” in which parents are free to accept or reject each individual intervention? We argue that the concept of a “prix fixe” approach should be discussed with families early in the development of the clinical relationship, as an essential facet of shared decision making. (shrink)

There is no agreed minimum standard with regard to what is considered safe, competent nursing care. Limited resources and organizational constraints make it challenging to develop a minimum standard. As part of their everyday practice, nurses have to ration nursing care and prioritize what care to postpone, leave out, and/or omit. In developed countries where public healthcare is tax-funded, a minimum level of healthcare is a patient right; however, what this entails in a given patient’s actual situation (...) is unclear. Thus, both patients and nurses would benefit from the development of a minimum standard of nursing care. Clarity on this matter is also of ethical and legal concern. In this article, we explore the case for developing a minimum standard to ensure safe and competent nursing care services. Any such standard must encompass knowledge of basic principles of clinical nursing and preservation of moral values, as well as managerial issues, such as manpower planning, skill-mix, and time to care. In order for such standards to aid in providing safe and competent nursing care, they should be in compliance with accepted evidence-based nursing knowledge, based on patients’ needs and legal rights to healthcare and on nurses’ codes of ethics. That is, a minimum standard must uphold a satisfactory level of quality in terms of both professionalism and ethics. Rather than being fixed, the minimum standard should be adjusted according to patients’ needs in different settings and may thus be different in different contexts and countries. (shrink)

Since at least the 1960s, science and technology studies scholars have distinguished between technological and social fixes. The author introduces a new concept for the STS theoretical tool kit—the cultural fix—and illustrates this concept using examples from her own research on pregnancy loss and neonatal intensive care, as well as that of anthropologists Katherine Newman and Sherry Ortner on downward mobility and unemployment in the United States. It is argued that the cultural fix represents a distinctive anthropological contribution (...) to the field. (shrink)

The ethics of care and Confucian care ethics are both characterised by relations-based moral reasoning and decision-making. Acknowledging this similarity, this article compares and contrasts these two ethics, highlighting Western and Eastern moral concerns. One of the main differences between the two ethical theories is their different focus on vulnerability and inequality as factors in achieving equality in the ethics of care; another is the reciprocity, rather than equality, dimension in Confucian ethics. Both theories enshrine the view (...) that the characteristics of care offer scope for developing the capacity for judgement. However, a fundamental difference is revealed when considering that Confucian ethics emphasises care as a virtue in the cultivation of one's moral agency, whereas the ethics of care sees care as both a disposition and practice, and the caring relationship to be a primary means of moral evaluation. For the care ethicists, the practice of care embraces communicative morality, within fluid, dynamic interpersonal relationships - in sharp contrast to Confucian care practices, which are constructed within formal standards and fixed, role-based relationships. (shrink)

Cuneo and Shafer-Landau have argued that there are moral conceptual truths that are substantive and non-vacuous in content, what they called ‘moral fixed points’. If the moral proposition ‘torturing kids for fun is pro tanto wrong’ is such a conceptual truth, it is because the essence of ‘wrong’ necessarily satisfies and applies to the substantive content of ‘torturing kids for fun’. In critique, Killoren :165–173, 2016) has revisited the old skeptical ‘why be moral?’ question and argued that the moral fixed (...) points give us no reason to care about morality and, therefore, they are normatively irrelevant. He concluded that this is a counterintuitive implication that undermines the proposal. In this paper, I develop a rejoinder to Killoren’s argument that explains why, at least from the perspective of the moral fixed points framework, if the moral fixed points exist, they are necessarily normatively relevant for rational agents. I supplement this explanation with an explanation of why it might prima facie appear that moral fixed points are not normatively relevant, although ultima facie they are relevant. The supplementary explanation explains prima facie normative irrelevance as the upshot of failures of rational agency. I conclude that the moral fixed points, can, in principle, offer an interesting response to the skeptical ‘why be moral?’ question’. (shrink)

SARGENT A. Nursing Inquiry 2012; 19: 134–143 [Epub ahead of print]Reframing caring as discursive practice: a critical review of conceptual analyses of caring in nursingThis study critically examines the way in which the concept of caring is presented in the nursing literature through conceptual analytic approaches. A critical reflection on the potential consequences of representing a concept of caring as vague and ambiguous, yet central to ontology and epistemology in professional nursing is presented drawing on comparisons between the conceptual analyses (...) of caring, and of structuralist perspectives of language, and how this potentially limits scholarship in this area. A search of the literature revealed nine conceptual papers. These papers highlight the self‐referential characteristics of the concept of caring, and of analytical methods in general. It is proposed that this is the result of a systematic adherence to a rigid, structuralist view of language, whereby stable relationships between words and their meanings are assumed. An alternative perspective is offered by viewing caring as a discursive practice rather than a fixed conceptual entity, calling into question the role that the concept plays in nursing practice. A poststructuralist perspective requires caring to be perceived as a discourse of nursing that is fluid and contingent, rather than a central and guiding concept, opening up a new orientation for nursing scholarship in caring research. (shrink)

A novel fatalistic argument that combines elements of modal, temporal, and epistemic logic to prove that the fixed past is not compatible with the open future has recently been presented by Lampert (Analysis 82(3):426–434, 2022). By the construction of a countermodel, it is shown that his line of reasoning is defective. However, it is also explained how Lampert’s argument could be corrected if it were supported with an extra premise regarding the temporal status of a priori knowledge. This additional assumption—which (...) was tacit in the original presentation—is shown to be the weakest link, and it is argued that, despite Lampert’s assurance, it can be plausibly rejected in a roughly Ockhamist framework. Thus, it is concluded that the fixed past poses no threat to the open future; however, a few different lessons about knowledge, necessity, and time are drawn from careful reflection on this novel argument. (shrink)

Managed Care Organizations (MCOs) are frequently criticized for their marketing mistakes. Often that criticism is leveled against an implicit benchmark of an ideal competitive market or an ideal system of government provision. But any accurate assessment in the choice of health care organizations always requires a comparative measure of error rates. These are high in the provision of health care, given the inherent uncertainties in both the cost and effectiveness of treatment. But the continuous and rapid evolution (...) of private health care mechanisms is, in the absence of regulation, more likely to secure access and contain costs than any system of government regulation. State regulation is subject to the risk of capture and to the sluggish and acquisitive behavior of state run monopolies. The proposed fixes for the MCOs (rights to specialists, access to physicians outside the network, guaranteed emergency room access) are likely, when imposed from without, to cost more than they are worth. The long-term risk is that markets will fail under regulation, paving the way for greater losses from massive government control of the health care delivery system. (shrink)

There are various grounds on which one may wish to distinguish a right to health care from a right to health. In this article, I review some old grounds before introducing some new grounds. But my central task is to argue that separating a right to health care from a right to health has objectionable consequences. I offer two main objections. The domestic objection is that separating the two rights prevents the state from fulfilling its duty to maximise (...) the health it provides each citizen from its fixed health budget. The international objection is that separating a human right to health care fails the moral requirement that, for any given moral human right, the substance to which any two right-holders are entitled be of an equal standard. (shrink)

The prevailing “segregated model” for understanding clinical research sharply separates it from clinical care and subjects it to extensive regulations and guidelines. This approach is based on the fact that clinical research relies on procedures and methods—research biopsies, blinding, randomization, fixed treatment protocols, placebos—that pose risks and burdens to participants in order to collect data that might benefit all patients. Reliance on these methods raises the potential for exploitation and unfairness, and thus points to the need for independent ethical (...) review and more extensive informed consent. In contrast, it is widely assumed that clinical care does not raise these ethical concerns because it is designed to promote the best interests of individual patients. The segregation of clinical research from clinical care has been largely effective at protecting research participants. At the same time, this approach ignores the fact that several aspects of standard clinical care, such as clinician training and scheduling, also pose some risks and burdens to present patients for the benefit of all patients. We argue that recently proposed learning health care systems offer a way to address this concern, and better protect patients, by developing integrated review and consent procedures. Specifically, current approaches base the need for independent ethical review and more extensive informed consent on whether an activity is categorized as clinical research or clinical care. An ethically sounder approach, which could be incorporated into learning health care systems, would be to base the need for independent ethical review and more extensive informed consent on the extent to which an activity poses risks to present patients for the benefit of all patients. (shrink)

Rationing in healthcare remains very much a taboo topic. Before COVID-19, it rarely received public attention, even when it occurred in everyday practices, mainly in the form of implicit rationing, as it continues to do today. There are different definitions, types and levels of healthcare rationing, according to different perspectives. With the aim of contributing to a more coherent debate on such a highly emotional healthcare issue as rationing, here are provided a number of reflections from a patient advocate perspective (...) which are specifically focused on bedside rationing, the most troublesome level, both for patients and clinicians, particularly in regard to cancer care. Oncology, with its numerous expensive therapies and increasing number of patients, is undeniably one of the main areas contributing to the increase in healthcare costs. However, the fixed budgets of today's publicly financed health systems cannot allow unlimited access to the potentially beneficial treatments to all patients. Bedside rationing constitutes the last phase of many decision-making processes occurring at different interrelated levels (macro-levels), both inside and outside healthcare systems, which implicitly and inevitably result in a bottleneck determined by the upstream decisions themselves. Shifting from implicit to explicit bedside rationing essentially means moving from a paternalistic to a citizen-before-patient approach; this implies, first of all, a cultural change. Practical bedside rationing is an ethically complex topic, but one that needs to be urgently addressed in a transparent and open debate. In this scenario, the oncological community – patients, patient advocates and clinicians – can and should play an important role. (shrink)

Since at least the 1960s, science and technology studies scholars have distinguished between technological and social fixes. The author introduces a new concept for the STS theoretical tool kit—the cultural fix—and illustrates this concept using examples from her own research on pregnancy loss and neonatal intensive care, as well as that of anthropologists Katherine Newman and Sherry Ortner on downward mobility and unemployment in the United States. It is argued that the cultural fix represents a distinctive anthropological contribution (...) to the field. (shrink)

IntroductionBorderline personality disorder patients are often subjected to inpatient compulsory care due to suicidal behaviour. However, inpatient care is usually advised against as it can have detrimental effects, including increased suicidality.AimTo investigate what motives psychiatrists have for treating borderline personality disorder patients under compulsory care.Materials and MethodsA questionnaire survey was distributed to all psychiatrists and registrars in psychiatry working at mental health emergency units or inpatient wards in Sweden. The questionnaire contained questions with fixed response alternatives, with (...) room for comments, about the respondents’ motives for practising compulsory care of borderline personality disorder patients. The responses were analysed quantitatively with descriptive statistics, and comments were analysed with qualitative descriptive content analysis.ResultsThe psychiatrists’ views were divided on when it was justified to treat borderline personality disorder patients under compulsory care, as were their views on borderline personality disorder patients’ decision competence. When there was an assessed risk of harm, 53% were positive to compulsory care of decision-competent borderline personality disorder patients and another 31% because they considered the patients to be decision incompetent in such situations. Adding the risk of harm caused many respondents to alter their assessment of the patient from decision competent to decision incompetent.ConclusionThe large variations in doctors’ opinions indicate that the care of borderline personality disorder patients is arbitrary. Further, the assessed risk of harm increases the use of compulsory care, even though such care is advised against in clinical guidelines, has questionable legal support, and could lead to an increased suicide risk over time. (shrink)

The paper offers an analysis of Plato’s conception of the care of the self in his Gorgias. There are two components of the self-care: self-knowledge and self-control. The first part deals with self-knowledge. The second part asks the question, wether there can be a fixed model of the individual soul’s order. The third part of the paper deals with Plato’s conception of self-control. The last part is concerned with the problem of a self-control training.

Introduction Compulsory care is controversial, since respect for the patient’s autonomy is a standard requirement in health care. Many psychiatrists have experienced that patients with borderline personality syndrome sometimes demand compulsory care for themselves in order not to exert self-harm—like Ulysses contracts. The aim of this study was to examine the possible existence and extent of borderline personality syndrome-patient demands for Ulysses contracts regarding compulsory care in acute psychiatry, and how external influences and demands could affect (...) the caregivers’ decisions about compulsory care. Method An anonymous questionnaire, with three questions with fixed answers, was distributed to 42 licensed medical doctors on call at the psychiatric emergency unit in the city of Stockholm. Thirty-three questionnaires were answered, giving a response rate of 79%. Results Ninety-four percent of the respondents recognized the phenomenon of borderline personality syndrome patients requesting compulsory care, 21% stated that this request had affected their clinical decision, and 55% had used compulsory care for other reasons than the patient’s best interest. Discussion The results indicate that compulsory care is sometimes given in the form of Ulysses contracts for borderline personality syndrome patients. Also, compulsory care is sometimes used for other reasons than the borderline personality syndrome patient’s best interest. Psychological mechanisms affect the decisions of both patients and caregivers. More research should be done concerning to whom, why, and with what consequences compulsory care is prescribed. (shrink)

The study discusses a new approach to parental agency in pediatric palliative care based on an active form of caregiving. It also explores the possibility of a positive conceptualization of parental agency in its relational context. The paper begins with an illustrative case study based on a clinical situation. This is followed by an analysis of various aspects of parental agency based on empirical studies that disclose the insufficiencies of the traditional approach to parental agency. In the next step, (...) parental agency is analyzed from a reality‐based perspective as an activity focused on relationships and the cognitive capacity of parents vis‐a‐vis their seriously ill children. The paper also considers the importance of the cultural and social contexts in which parental agency and decision‐making take place. This agency is addressed not as individualistic in form, and nor is it exercised in terms of fixed choices. Rather, the focus is on its dynamic and future‐oriented aspects. Consequently, parental agency should be comprehended not only as a form of proxy agency representing the child's best interests but also as a complex decision‐making process in which the parents learn from their child how to become good, compassionate caregivers and at the same time good parents. (shrink)

Joseph Hooker first learned that Charles Darwin believed in the transmutation of species in 1844. For the next 14 years, Hooker remained a "nonconsenter" to Darwin's views, resolving to keep the question of species origin "subservient to Botany instead of Botany to it, as must be the true relation." Hooker placed particular emphasis on the need for any theory of species origin to support the broad taxonomic delimitation of species, a highly contentious issue. His always provisional support for special creation (...) waned during the 1850s as he lost faith in its expediency for coordinating the study of plant geography, systematics and physiology. In 1858, Hooker embraced Darwin's "considerable revolution in natural history," but only after Darwin had carefully molded his transmutationism to meet Hooker's exacting specifications. (shrink)

The creation of pharmacotherapies, such as Selective Serotonin Reuptake Inhibitors (SSRIs), for the treatment of depression was hailed as a great breakthrough in mental health care. However, since that time, serious questions have arisen as to their safety and the way they are prescribed without full information being provided to patients about a range of important issues, including the possible aetiologies of depression, and the efficacy and potential side-effects of medication. These issues have been especially important in the (...) class='Hi'>care and treatment of young people, as there is evidence that SSRIs may be implicated in increased suicidal behaviour. In this article, we examine the experiences of five individuals who were prescribed an SSRI in their late teens or early twenties, and discuss some of the ethical issues that arise from their accounts. (shrink)

This paper offers a critical commentary on the essentialist concept of ethnicity, which, it is argued, underpins the discourse of transcultural health‐care. Following a consideration of the difficulties that ensue from the way in which ethnicity has been theorised within transcultural nursing in particular, the paper turns to a consideration of alternative ways of thinking about ethnicity, which have emerged from more recent social anthropology and postmodernism. It addresses the question of how to therorise ethnicity in a way that (...) does not entail its reification as a set of fixed cultural properties, and makes some tentative suggestions for the possibility of a critical culturalist approach to difference and healthcare practice, which must include a consideration of racisms. (shrink)

A word, first, about the religious sensibility that I have found helpful to describe the care professionals owe to dying patients, particularly patients with advanced dementia.That word is covenant. It is a biblical term; but, today, it covers such dubious devices as real estate covenants. A real estate covenant often operates below the moral level of a contract to wall some people out of a neighborhood. Classically understood, however, the word covenant helps probe the obligations of doctors to their (...) patients more deeply than the notion of a contract. Covenants of the sort I have in mind and contracts appear to be first cousins; they both include an agreement and an exchange between parties. But, in spirit, contracts and covenants differ markedly. Contracts are external; covenants are internal to the parties involved. We sign contracts in order to discharge them expediently. Contracts are limited and time-bound — whether a contract to fix plumbing or to charge such and such for a medical procedure. (shrink)

This paper applies crip theory (McRuer, 2006, 2018) as well as other key conceptual tools from disabled childhood studies (Runswick-Cole et al., 2018) and disability studies in education (Cousik & Maconochie, 2017) as a tactic intended to question and resist the story of overcoming as it manifests itself within the discourses and practices of self-regulation in early learning classrooms. This paper offers a brief overview of the range of self-regulation strategies enacted within educational settings in Ontario, Canada, that purport to (...) support young children in overcoming themselves on their way to normalcy. This paper also engages in crip theory as a strategy to both question and disrupt the taken for granted assumption that self-regulation entails a return towards or a sustaining of the efficient and productive neoliberal individual in school systems. Finally, this paper considers how we might not only invite but embrace the disruptions that occur when embodied differences refuse to be overcome by demands to self-regulate. Ultimately, a key aim of this paper is to resist how discourses and practices of self-regulation in Early Childhood Education and Care (ECEC) establish the overcoming narrative as a means to cure, fix or exclude embodied differences while contemplating the vibrant possibilities embedded within learning with and from disabled childhoods. (shrink)

Many writers suggest that managed care had a brief life and that we are now in a post-managed care era. Yet managed care has had a long history and continues to thrive. Writers also often assume that managed care is a fixed entity, or focus on its tools, rather than the context in which it operates and the functions it performs. They overlook that managed care has evolved and neglect to examine the role that it (...) plays in the health system.This article argues that private actors and the state have used managed care tools to promote diverse goals. These include the following: increasing access to medical care; restricting physician entrepreneurialism; challenging professional control over the medical economy; curbing medical spending; managing medical practice and markets; furthering the growth of medical markets and private insurance; promoting for-profit medical facilities and insurers; earning bounties for reducing medical expenditures; and reducing governmental responsibility for, and oversight of, medical care. Struggles over these competing goals spurred the metamorphosis of managed care internationally. (shrink)

Health care in prison and particularly the health care of older prisoners are increasingly important topics due to the growth of the ageing prisoner population. The aim of this paper is to gain insight into the approaches used in the provision of equivalent health care to ageing prisoners and to confront the intuitive definition of equivalent care and the practical and ethical challenges that have been experienced by individuals working in this field. Forty interviews took place (...) with experts working in the prison setting from three Western European countries to discover their views on prison health care. Experts indicated that the provision of equivalent care in prison is difficult mostly due to four factors: variability of care in different prisons, gatekeeper systems, lack of personnel, and delays in providing access. This lack of equivalence can be fixed by allocating adequate budgets and developing standards for health care in prison. (shrink)

The conventional wisdom is that managed care's brief life is over and we are now in a post-managed care era. In fact, managed care has a long history and continues to thrive. Writers also often assume that managed care is a fixed thing. They overlook that managed care has evolved and neglect to examine the role that it plays in the health system. Furthermore, private actors and the state have used managed care tools to (...) promote diverse goals. These include the following: increasing access to medical care; restricting physician entrepreneurialism; challenging professional control over the medical economy; curbing medical spending; managing medical practice and markets; furthering the growth of medical markets and private insurance; promoting for-profit medical facilities and insurers; earning bounties for reducing medical expenditures: and reducing governmental responsibility for, and oversight of, medical care. Struggles over these competing goals spurred the metamorphosis of managed care. This article explores how managed care transformed physicians' conflicts of interests and responses to them. It also examines how managed care altered the opportunities for patients/medical consumers to use exit and voice to spur change. (shrink)

Fixing Frege is one of the most important investigations to date of Fregean approaches to the foundations of mathematics. In addition to providing an unrivalled survey of the technical program to which Frege's writings have given rise, the book makes a large number of improvements and clarifications. Anyone with an interest in the philosophy of mathematics will enjoy and benefit from the careful and well-informed overview provided by the first of its three chapters. Specialists will find the book an indispensable (...) reference and an invaluable source of insights and new results. Although Frege is widely regarded as the father of analytic philosophy, his work on the foundations of mathematics was for a long time rather peripheral to ongoing research. The main reason for this is no doubt Russell's discovery in 1901 that the paradox now bearing his name can be derived in Frege's logical system. But recent decades have seen a huge surge of interest in Fregean approaches to the foundations of mathematics. A variety of consistent theories have been discovered that can be salvaged from Frege's inconsistent system, and foundational and philosophical claims have been made on behalf of many of these theories. Burgess claims quite plausibly that the significance of any such modified Fregean theory will in large part depend on how much of ordinary mathematics it enables us to develop. His book is accordingly 'a survey of various modified Fregean systems, attempting to determine the scope and limits of each'. The book's agenda is thus predominantly technical, and its spirit open-minded and experimental. (shrink)

It is important and urgent to question therelationship between evidence-based medicineand power shifts in health care systems.Although definitions of EBM are phrased as ascientific approach to medicine, EBM is anormative concept: it aims to improve medicineand health care. Both proponents and opponentsuse a normative concept. More particularly,they provide particular views on positions,responsibilities, possibilities, norms andrelationships between professionals, patientgroups, governments and other parties in healthcare and society. From this perspective, wewant to analyse the role of EBM in modernwestern societies. (...) By using citizenshiptheory, we will argue that the role of EBM isnot fixed but depends on the relation betweenstate and society. We will first analyse thefundamental change in western societies duringthe past decades, from modern to post-modernsocieties. Then, we will elaborate a fourfoldmodel of possible relationships between stateand society, and discuss the issue of how EBM mayfit in, by giving some examples of the practiceof EBM in different European countries. On thisbasis, we conclude to consider EBM as a publicforum where proponents and opponents of EBMdiscuss diverse and possibly conflicting waysof changing medicine, health care, and healthpolicy. This requires the incorporation of theperspective of citizens and their socialnetworks, professionals with practical andtacit knowledge, and diverse public views onwhat is regarded as `a good life'. Inasmuch asEBM is expected to be practically relevant, itought to be tied to rather than separated fromthe normative world of emancipated patients anddiverse health care practices. Proponents andopponents of EBM should be prepared to defendthe normative claims and power effects that areinherently tied to any presentation ofevidence. (shrink)

Joseph Hooker first learned that Charles Darwin believed in the transmutation of species in 1844. For the next 14 years, Hooker remained a "nonconsenter" to Darwin's views, resolving to keep the question of species origin "subservient to Botany instead of Botany to it, as must be the true relation." Hooker placed particular emphasis on the need for any theory of species origin to support the broad taxonomic delimitation of species, a highly contentious issue. His always provisional support for special creation (...) waned during the 1850s as he lost faith in its expediency for coordinating the study of plant geography, systematics and physiology. In 1858, Hooker embraced Darwin's "considerable revolution in natural history," but only after Darwin had carefully molded his transmutationism to meet Hooker's exacting specifications. (shrink)

Patient and public involvement is widely thought to be important in the improvement of health care delivery and in health equity. Purpose: The article examines the role of experiential knowledge in service co-production in order to develop opiate substitution treatment services (OST) for high-risk opioid users. Method: Drawing on social representations theory and the concept of social identity, we explore how experts’ by experience and registered nurses’ understandings of OST contain discourses about the social representations, identity, and citizenship of (...) the participants and the effects these may have on developing or hindering inclusive and bottom-up forms of patient and public involvement. Results: The meeting sessions that potentially offer room for creativity and problem-solving fail to provide any new propositions for fixing the system. The health care professionals primarily identify themselves as regulators who protect the correctness of their actions and show little interest in considering experiential knowledge on opioid addiction. Conclusion: The participation of patients has been one of the prominent reforms implemented in health care. The goal of client-centered thinking is often emphasised; however, the implementation is not simple due to the strongly institutionalised knowledge and related working patterns and practices in health care. (shrink)

The impact of recent changes in public health insurance on community‐based health‐care in the USARecent changes in US government‐funded healthcare insurance are having profound impacts on all types of community‐based health‐care, reducing access to care by vulnerable populations. This article traces the impacts of recent policies on a range of community institutions in which nurses play a critical role, such as health centers, highlighting the effects on access to care and the survival of non‐profit services in (...) less‐advantaged communities. In general, the new policies shifted revenues into fixed payment per client contracts (capitation) paid to for‐profit managed care organizations and away from non‐profit community services. The full impact of this competitive, market‐oriented system of health services has just begun to be felt. The uncertainties and dissatisfactions assure continued activity to change current conditions, including efforts by groups that seek greater access to health services for all populations and security for committed providers and personnel, including nurses. (shrink)

The aim of this study was to get a deeper understanding of student nurses’ experiences of personal caring ethics by reflection on caring encounters with patients in clinical practice, ethical caring ideals, ethical problems, and sources for inner strength that give courage to practice good caring. In all, 24 Scandinavian student nurses participated voluntarily in an interview study. The interviews were analyzed within a phenomenological–hermeneutical approach and revealed three themes. The students found themselves in two different states of vulnerability: one (...) in which they were overwhelmed by their vulnerability and began to suffer themselves and the other where their vulnerability became a source of development with focus on the patient. The students’ ethical caring ideals served as fixed reference points in their ethical development, but their ideals were at risk of decline. The students reflected on the barriers for performing ethical care and nurtured their ethical ideals by providing ethical care in secret. Caring in secret occurred also when student nurses did not experience a shared ethos. (shrink)

Obesity has generated significant worries amongst health policy makers and has obtained increased attention in health care. Obesity is unanimously defined as a disease in the health care and health policy literature. However, there are pragmatic and not principled reasons for this. This warrants an analysis of obesity according to standard conceptions of disease in the literature of philosophy of medicine. According to theories and definitions of disease referring to internal processes, obesity is not a disease. Obesity undoubtedly (...) can result in disease, making it a risk factor for disease, but not a disease per se. According to several social conceptions of disease, however, obesity clearly is a disease. Obesity can conflict with aesthetic, moral, or other social norms. Making obesity a “social disease” may very well be a wise health policy, assuring and improving population health, especially if we address the social determinants of obesity, such as the food supply and marketing system. However, applying biomedical solutions to social problems may also have severe side effects. It can result in medicalization and enhance stigmatization and discrimination of persons based on appearance or behavior. Approaching social problems with biomedical means may also serve commercial and professionals’ interests more than the health and welfare of individuals; it may make quick fix medical solutions halt more sustainable structural solutions. This urges health insurers, health care professionals, and health policy makers to be cautious. Especially if we want to help and respect persons that we classify and treat as obese. (shrink)

Dementia is highly prevalent and up until now, still incurable. If we may believe the narrative that is currently dominant in dementia research, in the future we will not have to suffer from dementia anymore, as there will be a simple techno-fix solution. It is just a matter of time before we can solve the growing public health problem of dementia. In this paper we take a critical stance towards overly positive narratives of techno-fixes by placing our empirical analysis (...) of dementia research protocols and political statements in a framework of technology assessment. From this perspective, it becomes obvious that a techno-fix is just one of many ways to approach societal problems and more importantly that technologies are way less perfect than they are presented. We will argue that this narrow scope, which focusses on the usual suspects for solving illnesses, reduces dementia to organismic aspects, and may be counterproductive in finding a cure for dementia. We conclude with outlining how the narrow scope can be balanced with other narratives and why we should have a reasonable scepticism towards the usual suspects. (shrink)

Hope is like water, existing in different states, exhibiting different properties.In the solid form, hope is manifest as specific hopes: I hope for this, I hope for that. In these concrete forms, solidified hope can become firm and fixed, for better and for worse. Dogged determination aimed at achieving a fixed hope is a very good characteristic—that is, until the continued pursuit of this specific solid hope becomes foolish, harmful, unwise. At the other end of the spectrum, in the gaseous (...) form, hope is amorphous, a glowing feeling that one has to tune into to detect, akin to optimism. In between these two states, hope is liquid. Flowing. Assuming the shape of whatever holds it. Carving, eroding, even dissolving.. (shrink)

Expanding buprenorphine access in the United States requires evidence-based decision-making that considers both the drug's potential dangers and its potential benefits. Risks associated with buprenorphine misuse and diversion highlight the need for careful, ongoing evaluation during each stage of increased access.

The greatest change, once it is accomplished, is simply the outcome of a vast series of adaptations and responsive accommodations, each to its own particular situation.”1It is in no way controversial to say that the U.S. health care system is failing to serve many of its citizens satisfactorily. While it is certainly true that most U.S. citizens are dissatisfied with our current health care system, creating agreement through open dialogue on what, more precisely, is wrong with the system, (...) as well as on what we should do to fix the system, seems to many to be impossibly optimistic. Leonard Fleck, professor of philosophy and medical ethics at Michigan State University and author of Just Caring: The Ethical .. (shrink)

ABSTRACTThis paper argues that the contemporary international refugee regime is grounded in a paradigm of ‘homesickness’, which puts the refugee in an inferior position of the supplicant, whose subjectivity is framed by the regime of fixed belonging. In order to address this situation, we need to challenge the ontological primacy of homesickness and embrace ‘homelessness’, which offers the possibility of rethinking the positions of both refugees and non-refugees in ethical terms. While the responsibility of the non-refugees lies in cultivating an (...) ethos of hospitality, the refugee can take hold of her subjectivity through the practice of care of the self. This paper first examines Nietzsche’s thought on homelessness and compares it with Foucault’s reading of the role of anakhōrēsis in the Hellenistic practice of care of the self. It then suggests how, by building on the project of universal hospitality, we can interpret the figure of the refugee through the prism of an ethic of freedom, anchored in a posit... (shrink)

This article’s aim is to understand if and how the efforts to accumulate and organize clinical data transformed the regulation of pharmaceutical care. The authors analyze how the employment of databases by collectives of physicians and researchers shape both clinical and policy practice—and thereby reshape the relation between clinical work and policy. Since the late 1990s, Dutch government has supported the development of clinical databases for specific expensive medicines to gain oversight about actual medicine use. To be able to (...) produce evidence for appropriate medicine use, the collectives set regulations in clinical practice. These internal regulations provide a framework for establishing “appropriate medicine use”, steering reimbursement decisions. However, internal regulation and policy rules differ in how quickly they can change. While the employment of databases in clinical practices results in a constant adjustment of the protocols, policy makers require the databases to provide for static moments of “proven appropriate medicine use” in order to account for and define a fixed and closed formulary. Subsequently, the employment of the databases did not deliver on the promise of oversight and control due to different clinical and policy requirements. Nevertheless, the databases did stimulate appropriate medicine use and reimbursement in clinical practice. (shrink)

Economic (mis)management in Australia has understandably been influenced by the experiences of countries such as the UK and the USA with which Australia has traditionally had a close relationship. However, the uncritical acceptance of economic rationalism is an indication of our nation's seduction by the possibility of a ‘quick fix’ for a struggling economy. In accepting economic rationalism there has been a dismissal, or at least a failure to take account of, both past Australian experiences and the overseas experience—including the (...) recent experience of a close neighbour, New Zealand, whose health system is under severe strain.The introduction of economic rationalist programmes into the Australian health sector was an attempt to contain expenditure and at the same time reduce dependence on the public system. This has failed to happen on both counts. Its only real ‘achievement’ has been to produce yet more evidence of the practical inadequacies of economic rationalism in general. (shrink)

"The fixed person for fixed duties, who in older societies was such a godsend, in the future ill be a public danger." Twenty years ago, a single legal metaphor accurately captured the role that American society accorded to physicians. The physician was "c- tain of the ship." Physicians were in charge of the clinic, the Operating room, and the health care team, responsible - and held accountabl- for all that happened within the scope of their supervision. This grant of (...) responsibility carried with it a corresponding grant of authority; like the ship's captain, the physician was answerable to no one regarding the practice of his art. However compelling the metaphor, few would disagree that the mandate accorded to the medical profession by society is changing. As a result of pressures from a number of diverse directions - including technological advances, the development of new health professionals, changes in health care financing and delivery, the recent emphasis on consumer choice and patients' rights - what our society expects phy- cians to do and to be is different now. The purpose of this volume is to examine and evaluate the conceptual foundations and the moral imp- cations of that difference. Each of the twelve essays of this volume assesses the current and future validity of the "captain of the ship" metaphor from a different perspective. The essays are grouped into four sections. In Section I, Russell Maulitz explores the physician's role historically. (shrink)

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s severity criteria (...) in Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda. (shrink)

Ethical rationalism has recently dominated the philosophical landscape, but sentimentalist forms of normative ethics (such as the ethics of caring) and of metaethics (such as Blackburn's projectivism and various ideal–observer and response–dependent views) have also been prominent. But none of this has been systematic in the manner of Hume and Hutcheson. Hume based both ethics and metaethics in his notion of sympathy, but the project sketched here focuses rather on the (related) notion of empathy. I argue that empathy is essential (...) to the development of morally required caring about others and also to deontological limits or restrictions on self–concern and other–concern. But empathy also plays a grounding role in moral judgement. Moral approval and disapproval can be non–circularly understood as empathic reflections of the concern or lack of concern that agents show towards other people; and moral utterances can plausibly be seen not as projections, expressions, or descriptions of sentiment but as “objective” and “non–relative” judgements whose reference and content are fixed by sentiments of approval and disapproval. (shrink)

Summary Our basic intuition seems to suggest that the moral biography of an individual matters in our treatment of the individual. We do keep criminal records on file, and we do care about the moral progress of individuals. At times our desire to fix responsibility seems too strong, and in our zeal we invent a definite, metaphysical character on which to pin crimes. However, some moral philosophers have tried to redirect our attention to affix responsibility in a way that (...) attends to actions, deeds done. Two ways to affix responsibility have been reviewed—the SR and the PRA. In the case of Tom Joad we could arrive at the conviction that Tom was responsible through use of either the SR or the PRA. In the end the difference was not that one method held Tom culpable and one exculpated him. The difference was seen in the way the PRA included the earlier commission of the same crime in its evaluation of responsibility. To include in the evaluation of Tom's murder of George the earlier murder of Herb is to entertain a definite theory about the relation of Herb's murderer to George's murderer. I have suggested one possible candidate for that theory, Derek Parfit's theory of person stages. (shrink)

Disrespect in health care often persists despite firm commitments to respectful service provision. This conceptual paper highlights how the ways in which respect and disrespect are characterised can have practical implications for how well disrespect can be tackled. We stress the need to focus explicitly on disrespect (not only respect) and propose that disrespect can usefully be understood as a failure to relate to people as equals. This characterisation is consonant with some accounts of respect but sometimes obscured by (...) a focus on respecting people’s autonomy and dignity. Emphasising equality is consistent with connections patients draw between being (dis)respected and (in)equality. It readily accommodates microaggressions as forms of disrespect, helping to understand how and why experiences of disrespect may be unintentional and to explain why even small instances of disrespect are wrong. Our view of disrespect with an emphasis on equality strengthens the demand that health systems take disrespect seriously as a problem of social injustice and tackle it at institutional, not just individual levels. It suggests several strategies for practical action. Emphasising relational equality is not an easy or short-term fix for disrespect, but it signals a direction of travel towards an important improvement ambition. (shrink)

We largely agree with Grimwade et al ’s1 conclusion that challenge trial participants may ethically be paid, including for risk. Here, we add further arguments, clarify some points from the perspective of economics and indicate areas where economists can support the development of a framework for ethically justifiable payment. Our arguments apply to carefully constructed and monitored controlled human infection model trials that have been appropriately reviewed and approved. Participants in medical studies perform a service. Outside the domain of research (...) participation, there is nearly universal agreement that workers providing a service should be compensated fairly, and that work involving more discomfort and risk should be compensated more generously. Accordingly, labour regulations impose floors, not caps on compensation. Caps, even if intended to protect against undue inducement, also raise concerns about illegal price-fixing that disadvantages workers. Such limits on payment for egg donors have successfully been challenged in court.i Moreover, caps on compensation may harm everyone at risk of infection, not just potential participants. Insufficient compensation may impede the recruitment of enough suitable subjects, for example, when representativeness of the subject sample is required. Delays in vaccine development not only prolong disruption of social, educational and economic activity but also lead to excess infections and deaths. Unlike paid CHIM participants, individuals exposed to such infection do not accept it voluntarily, are not compensated for it, and are unlikely to receive the level of medical supervision afforded to closely monitored CHIM participants. Payment caps can lead to attempts to circumvent the regulation. For example, many countries …. (shrink)