Of the many factors contributing to the relative under-development across sub-Saharan Africa over the past five decades, one cause that is currently gaining more attention from both scholars and development practitioners is the lack of a transparent and accountable national budget process in most African countries. Although most African constitutions provide for a number of mechanisms of accountability within the budget process that are tasked with monitoring and sanctioning the misuse of public funds by the executive, various legal, capacity and (...) political constraints greatly hinder these mechanisms from playing an effective oversight role. This article examines the various challenges faced by four key mechanisms of accountability-parliamentary budget committees, supreme audit institutions, citizen budget monitoring and advocacy groups and elections-in holding leaders to account through the various stages of the budget process. However, despite these challenges, the article concludes by examining some recent progress and successes in the budget accountability arena. (shrink)
The use of the Quality Adjusted Life-Year (QALY) as a measure of the benefit obtained from health care expenditure has been attacked on the ground that it gives a lower value to preserving the lives of people with a permanent disability or illness than to preserving the lives of those who are healthy and not disabled. The reason for this is that the quality of life of those with illness or disability is ranked, on the QALY scale, below that of (...) someone without a disability or illness. Hence we can, other things being equal, gain more QALYs by saving the lives of those without a permanent disability or illness than by saving the lives of those who are disadvantaged in these ways. But to do so puts these disadvantaged people under a kind of double jeopardy. Not only do they suffer from the disability or illness, but because of it, a low priority is given to forms of health care that can preserve their lives. This, so the objection runs, is unjust or unfair. This article assesses this objection to the use of QALYs as a basis for allocating health care resources. It seeks to determine what is sound in the double jeopardy objection, and then to show that the defender of QALYs has an adequate response to it. (shrink)
Most countries appear to believe that their health system is in a state of semi-crisis with expenditures rising rapidly, with the benefits of many services unknown and with pressure from the public to ensure access to a comprehensive range of services. But whose values should inform decision-making in the health area, and should the influence of different groups vary with the level of decision-making? These questions were put to 54 members of the public and health professionals in eight focus groups. (...) Adopting a different perspective from other studies, participants were not asked if particular groups should be involved in decisions but rather through deliberation and discussion nominated their own potential decision makers. This delivered a clear message that participants saw a legitimate role for a broad range of stakeholders in priority-setting decisions so as to incorporate a diversity of expertise and opinion. Companion themes were the acknowledgment that decisions involve ethical judgments and are not purely technical, that the power of special interest groups (such as clinicians) should be kept in check, and that the process by which decisions are reached is important. The results suggest that qualitative methods of investigation have the potential to improve the legitimacy of policy decisions by contributing to a better understanding of the values of the public and health professionals, and by expanding the range of options available for further research. (shrink)
The recent interest in wisdom in professional health care practice is explored in this article. Key features of wisdom are identified via consideration of certain classical, ancient and modern sources. Common themes are discussed in terms of their contribution to ‘clinical wisdom’ itself and this is reviewed against the nature of contemporary nursing education. The distinctive features of wisdom (recognition of contextual factors, the place of the person and timeliness) may enable their significance for practice to be promoted in more (...) coherent ways in nursing education. Wisdom as practical knowledge (phronesis) is offered as a complementary perspective within the educational preparation and practice of students of nursing. Certain limitations within contemporary UK nursing education are identified that may inhibit development of clinical wisdom. These are: the modularization of programmes in higher education institutions, the division of pastoral and academic support and the relationship between theory and practice. (shrink)
Harris argues that if QALYs are used only 50% of the population will be eligible for survival, whereas if random methods of allocation are used 100% will be eligible. We argue that this involves an equivocation in the use of "eligible", and provides no support for the random method. There is no advantage in having a 100% chance of being "eligible" for survival behind a veil of ignorance if you still only have a 50% chance of survival once the veil (...) is lifted. A 100% chance of a 50% chance is still only a 50% chance. We also argue that Harris provides no plausible way of dealing with the criticism that his random method of allocation may result in the squandering of resources. (shrink)
The events of the Holocaust of European Jews (and others) by the Nazi state between 1939 and 1945 deserve to be remembered and studied by the nursing profession. By approaching literary texts written by Holocaust ‘survivors’ from an interpersonal dimension, a reading of such works can develop an ‘ethic of responsibility’. By focusing on such themes as rationality, duty, witness and the virtues, potential lessons for nurses working with people in a variety of settings can be drawn. Implications for the (...) teaching of nursing ethics are made in the areas of the virtues, relationships, professional ethics and the moral community of nursing. (shrink)
In the past decade structures and processes for the ethical review of UK health care research have undergone rapid change. Although this has focused users' attention on the functioning of review committees, it remains rare to read a substantive view from the inside. This article presents details of processes and findings resulting from a novel structured reflective exercise undertaken by a newly formed research ethics review panel in a university school of nursing and midwifery. By adopting and adapting some of (...) the knowledge to be found in the art and science of malt whisky tasting, a framework for critical reflection is presented and applied. This enables analysis of the main contemporary issues for a review panel that is primarily concerned with research into nursing education and practice. In addition to structuring the panel's own literary narrative, the framework also generates useful visual representation for further reflection. Both the analysis of issues and the framework itself are presented as of potential value to all nurses, health care professionals and educationalists with an interest in ethical review. (shrink)
Harris levels two main criticisms against our original defence of QALYs (Quality Adjusted Life Years). First, he rejects the assumption implicit in the QALY approach that not all lives are of equal value. Second, he rejects our appeal to Rawls's veil of ignorance test in support of the QALY method. In the present article we defend QALYs against Harris's criticisms. We argue that some of the conclusions Harris draws from our view that resources should be allocated on the basis of (...) potential improvements in quality of life and quantity of life are erroneous, and that others lack the moral implications Harris claims for them. On the other hand, we defend our claim that a rational egoist, behind a veil of ignorance, could consistently choose to allocate life-saving resources in accordance with the QALY method, despite Harris's claim that a rational egoist would allocate randomly if there is no better than a 50% chance of being the recipient. (shrink)
What proportion of available healthcare funds should be allocated to hip replacement operations and what proportion to psychiatric care? What proportion should go to cardiac patients and what to newborns in intensive care? What proportion should go to preventative medicine and what to treating existing conditions? In general, how should limited healthcare resources be distributed If not all demands can be met?
The study examined the question of who should make decisions for a National Health Scheme about the allocation of health resources when the health states of beneficiaries could change because of adaptation. Eight semi-structured small group discussions were conducted. Following focus group theory, interviews commenced with general questions followed by transition questions and ended with a ‘focus’ or ‘key’ question. Participants were presented with several scenarios in which patients adapted to their health states. They were then asked their views about (...) the appropriate role of the public, patients and health professionals in making social judgements of quality of life. After discussion and debate, all groups were asked the key question: ‘In light of adaptation, who should evaluate quality of life for the purpose of setting priorities in the allocation of health care?’ In all groups participants presented strong arguments for and against decision making by patients, the public and health professionals. However, most groups thought a representative body which included a range of perspectives should make the relevant judgements. This is at odds with the recommendations in most national pharmaceutical guidelines. The main conclusion of the paper is that health economists and other researchers should explore the possibility of adopting a deliberative, consensus-based approach to evaluating health-related quality of life when such judgements are to be used to inform priority setting in a public system. (shrink)
This case study outlines a staff seminar programme that used art and literature as vehicles to explore personal and professional dimensions of palliative care. Participating staff found the learning experience interesting and insightful.
It has been argued that we find zeno's paradoxes of motion persuasive because physical time is dense and continuous, While time as we experience it is discrete. But we do not experience time as a succession of distinct, Countable, Consecutively ordered mental "nows." nor is it common to attempt the futile mental task of traversing in thought the infinite number of spatial subintervals in zeno's paradoxes, As has also been suggested. Rather, We find the paradoxes persuasive because there are a (...) number of different conceptual and linguistic problems inherent in them. For instance, Understanding how it is possible for achilles to come to the end of an endless sequence of spatial intervals requires disambiguating different senses of the word "end.". (shrink)
Within the increasingly complex picture which has emerged in recent years of the manuscript tradition of Ovid's Amores the relationship of the two earliest MSS appears to remain firm: cod. P or Puteaneus of the 9th or early 10th century, which begins at Am. 1.2.51, was copied, probably directly, from the second half of the 9th-century cod. R or Regius , whose first half now ends at Am. 1.2.50. This view, which originates in S. Tafel's dissertation of 1910 and lies (...) behind the stemma constructed by E. J. Kenney for his OCT edition of 1961 , has come to be taken by Ovidian scholars to be the truth. My purpose in this first section is to show that this idea is unlikely to be the truth and, in the form in which it has most strongly been put forward, cannot be the truth. In the second section consequences for the manuscript tradition as a whole are explored. First we shall need some details. P, the slightly later manuscript, consists in all of 99 folia, of which 1–54 contain most, but not all, of the Heroides — not all, because they are in a lacunose state, a point to which we shall return in greater detail later. Foll. 55–6 are blank sheets of paper, not parchment, clearly inserted at a much later date during rebinding. (shrink)