Feeding difficulties in older patients who are suffering from dementia present problems with balancing conflicting ethical principles. They have been considered by several writers in recent years, and the views of nursing and care staff have been studied in different contexts. The present study used focus groups to explore the way in which nursing and care staff in a National Health Service trust deal with conflict between ethical principles in this area. Three focus groups were convened, one each from the (...) staff of three wards caring for patients with dementia. Case histories were discussed and transcripts analysed. It emerged that staff were aware of making fine judgements of utility concerning the spectrum of feeding methods available. Informants gave some weight to the principle of autonomy, but sought to balance that against their commitment to care. In explaining their perspectives, informants gave more weight to personal attitudes and trust culture than to professional ethics. (shrink)

This paper considers the social justice initiative of the Canadian Nurses Association (CNA). It focuses mainly on the two editions of the CNA's discussion document on social justice, and particularly on its emphasis on the principle of equity. The paper considers whether a coherent justification can be made for the CNA's espousal of equity, and the discussion focuses in turn on the principle of equity itself and on the CNA's position in relation to equity. A body of arguments supporting an (...) active moral role for professions, generally known as civic professionalism, provides a framework for exploring the CNA's role in this respect. Justifications for equity are explored in relation to the liberal‐contextualist spectrum, and civic professional arguments are subjected to the same structure of analysis. This is in turn related to evidence from the literature concerning nursing perceptions of equity. The paper concludes that contextualist justifications of equity and civic professionalism support one another more robustly than liberal justifications in relation to the CNA's initiative; and that they also sit more comfortably with the realities of the CNA's role in relation to nursing, and to the Canadian health care system. (shrink)

The question of corporate moral responsibility – of whether it makes sense to hold an organisation corporately morally responsible for its actions,rather than holding responsible the individuals who contributed to that action – has been debated over a number of years in the business ethics literature. However, it has had little attention in the world of health care ethics. Health care in the United Kingdom(UK) is becoming an increasingly corporate responsibility, so the issue is increasingly relevant in the health care (...) context, and it is worth considering whether the specific nature of health care raises special questions around corporate moral responsibility. For instance, corporate responsibility has usually been considered in the context of private corporations, and the organisations of health care in the UK are mainly state bodies. However, there is enough similarity in relevant respects between state organisations and private corporations, for the question of corporate responsibility to be equally applicable. Also, health care is characterised by professions with their own systems of ethical regulation. However, this feature does not seriously diminish the importance of the corporate responsibility issue, and the importance of the latter is enhanced by recent developments. But there is one major area of difference. Health care, as an activity with an intrinsically moral goal, differs importantly from commercial activities that are essentially a moral, in that it narrows the range of opportunities for corporate wrongdoing, and also makes such organisations more difficult to punish. (shrink)

The UK government is setting up a new kind of organisation as part of the National Health Service, the foundation trust. Foundation trusts will be more distanced from government than existing NHS bodies, and will have closer community links. In this paper I identify the importance of legitimacy in health care and explore the potential situation of foundation trusts in terms of the bases of their legitimacy as organisations. Relationships with community, stakeholders and government are all considered as sources of (...) legitimacy for foundation hospitals, and comparisons are made with other organisations, state, voluntary and private. I conclude that the blueprint of the foundation hospital creates a set of relationships which are incoherent and mutually conflicting, and conceals a crucial relationship with the state. I argue that these problems are likely to weaken the legitimacy of the foundation trust. (shrink)

In this paper I explore the relationship between the Canadian state and Canada’s First Nations, in the context of the Canadian health care system. I argue that Canada’s provision of health care to its citizens can be best understood morally in terms of a covenant, but that the covenant fails to meet the needs of indigenous peoples. I consider three ways of changing the relationship and obligations linking Canada’s First Nations and the Canadian state, with regard to health care- assimilation, (...) accommodation and separation. I argue that all of these options create problems, and at present there is a good argument for working with the status quo, accepting that First Nations are outside the covenant, and securing the state’s commitment to their health care on the basis of their citizenship and the liberal principle of equal treatment of citizens by the state. (shrink)

In recent years there have been several calls in professional and academic journals for healthcare personnel in Canada to raise the profile of postcolonial theory as a theoretical and explanatory framework for their practice with Indigenous people. In this paper I explore some of the challenges that are likely to confront those healthcare personnel in engaging with postcolonial theory in a training context. I consider these challenges in relation to three areas of conflict. First I consider conflicts around paradigms of (...) knowledge, wherein postcolonial theory operates from a different base from most professional knowledge in health care. Second I consider conflicts of ideology, wherein postcolonial theory is largely at odds with Canada’s political and popular cultures. And finally I consider issues around the question of Canada’s legitimacy, which postcolonial theory puts in doubt. I suggest ways in which these conflicts might be addressed and managed in the training context, and also identify potential positive outcomes that would be enabling for healthcare personnel, and might also contribute to an improvement in Canada’s relationship with its indigenous peoples. (shrink)

The question of corporate moral responsibility – whether corporate bodies can be held morally responsible for their actions – has been debated by a number of writers since the 1970s. This discussion is intended to add to that debate, and focuses for that purpose on our understanding of the organisation. Though the integrity of the organisation has been called into question by the postmodern view of organisations, that view does not necessarily rule out the attribution of corporate agency, any more (...) than the postmodern view of the person rules out the attribution of individual agency. The postmodern view is opposed to a reifying, metaphysical view of corporate agency, but a semantic view of corporate agency would seem to sit more comfortably with it. A bigger problem for the idea of corporate moral responsibility arises from the fact that in Kantian terms organisations are not ends in themselves. In that sense they are not like persons, and this must limit their autonomy, and their responsibility. This aspect of organisations also limits their punishability. For these reasons corporate moral responsibility must be seen as more limited than the responsibility of persons. (shrink)

The National Institute for Health and Clinical Excellence (hereafter NICE) was created in 1998 to give guidance on which treatments should be provided by the British National Health Service, and to whom. So it has a crucial role as an agent of distributive justice. In this paper I argue that it is failing to adequately explain and justify its decisions in the public arena, particularly in terms of distributive justice; and that this weakens its legitimacy, to the detriment of the (...) National Health Service as a whole. I argue that this failure arises from the fact that NICE works within the frameworks of positivist science and liberal ethics, largely to the exclusion of other perspectives. This narrowness of view prevents NICE from properly connecting with the range of moral concerns represented in the population. I argue for NICE’s deliberations to become more inclusive, both in terms of epistemology, and also in terms of ethical perspectives. And I suggest a range of perspectives that could usefully be included. Finally I offer a framework of structures, philosophies and discussion process that will enable competing perspectives to be debated fairly and productively in this process. (shrink)

In this paper I put forward an ethical argument for the provision of extensive patient choice by the British National Health Service. I base this argument on traditional liberal rights to freedom of choice, on a welfare right to health care, and on a view of health as values-based. I argue that choice, to be ethically sustainable on this basis, must be values-based and rational. I also consider whether the British taxpayer may be persuadable with regard to the moral acceptability (...) of patient choice, making use of Rawls’ theory of political liberalism in this context. I identify issues that present problems in terms of public acceptance of choice, and also identify a boundary issue with regard to public health choices as against individual choices. (shrink)

In recent years UK government policy has been drawing private companies into the operation of the British National Health Service as providers of health care. Hitherto the National Health Service has been the main employer of health care practitioners, but this may change as a result of this development. There is an issue as to whether professional health care practitioners owe the same moral commitment to an employer in the private sector as they would owe to an employer that is (...) part of the state-run National Health Service. I explore some arguments around this issue, focusing on ways of identifying organisational commitment to good health care. With regard to the practitioners commitment to the organisation I consider two strengths of commitment, normative and calculative. I then undertake an analysis of performance, regulatory regimes, and organisational obligations for both sectors. I conclude that while performance and regulatory regimes show little difference between sectors, there is a reasonably compelling argument in favour of a stronger moral commitment to state bodies based on organisational obligations. (shrink)

In this paper I outline an approach to the distribution of resources between psychotherapy modalities in the context of the UK’s health care system, using recent discussions of Cognitive Behavioural Psychotherapy as a way of highlighting resourcing issues. My main goal is to offer an approach that is just, and that accommodates the diversity of different schools of psychotherapy. In order to do this I draw extensively on the theories of Justice and of Political Liberalism developed by the late John (...) Rawls, and adapt these to the particular requirements of psychotherapy resourcing. I explore some of the implications of this particular analysis, and consider how the principles of Rawlsian justice might translate into ground rules for deliberation and decision-making. (shrink)