The philosophy of patient-centred care has become widely embraced but its implementation is dependent on interrelated factors. A factor that has received limited attention is the role of policy tools. In Ontario, one method government can use to promote healthcare priorities is through health regulatory colleges, which set the standard of practice for health professionals. The degree to which government policy in support of patient-centered care has influenced the direction provided by health regulatory colleges to their members, and (...) ultimately impacted actual patient care, remains unclear. This study investigates the extent to which Ontario’s health regulatory colleges have provided explicit written guidance to members related to the importance of patient-centred care. It also explores applied and theoretical explanations that may further our understanding of why patient-centred care has not been more fully embraced. Findings reveal that guidance provided by Ontario’s health regulatory colleges varies widely. Institutional barriers and the choice of policy tools for disseminating government preferences may hinder full implementation of the principles of patient-centred care. More fully understanding the role health regulatory colleges’ play in facilitating the implementation of health policy will contribute positively to dialogue and to efforts to achieve positive health system reforms. (shrink)

Background:Emergency care providers are frequently faces with situations in which they have to make decisions quickly in stressful situations. They face barriers to ethical decision-making and recognizing and finding solutions to these barriers helps them to make ethical decision.Objectives:The purpose of this study was to identify barriers of ethical decision-making in Iranian Emergency Medical Service personnel.Methods:In this qualitative research, the participants (n = 15) were selected using the purposive sampling method, and the data were collected by deep and semi-structured (...) interviews. Finally, the data are analyzed using the content analysis approach.Ethical considerations:Permission to conduct the study was obtained from the Ethics Committee of the Shahid Beheshti University of Medical Sciences. The objectives of the study were explained to the participants and written consent was received from them. Also, participants were assured that necessary measures were taken to protect their anonymity and confidentiality.Findings:The results of the analysis are classified in five main categories. It encompasses the following areas: perception of situation, patient-related factors, input and output imbalance, uncoordinated health system, and paradoxes.Conclusion:Emergency Medical Service personnel make ethical decisions every day. It is important that prehospital personnel know how to manage those decisions properly so that clients’ moral rights are respected. Hence, by identifying the dimensions and obstacles of ethical decision-making in Emergency Medical Service personnel, it is possible to enhance the moral judgment and ethical accountability of the personnel and develop the strategies necessary for ethical decision-making in them. (shrink)

AimsThis study aimed to investigate barriers in the observation of professional ethics during clinical care from a nursing viewpoint. Also, it examined the association between these barriers and nurse demographic variables.MethodsA descriptive-analytic design was carried out on 207 nurses working in selected hospitals within an urban area of Iran in 2019. Data were collected using a standard questionnaire containing 33 questions that measured barriers to observation of professional ethics. The questionnaire measures three domains of management, environment and individual (...) class='Hi'>care.ResultsIn the management dimension, the most important barrier preventing observation of professional ethics was the shortage of personnel. For the environmental dimension, biological changes due to working on the nightshift, and for the individual care dimension, a lack of time were the most important barriers preventing observation of clinical ethics. Findings additionally highlighted a significantly inverse association between barriers to observing professional ethics and the male gender, participating in the ethics workshop and high work-level experiences.ConclusionsIt is suggested that nursing managers in hospitals correct and remove obstacles with careful planning and emphasis on principles and standards of care including environmental and managerial factors and training professional ethics to nurses. (shrink)

Dementia is an ever-growing public health concern with significant impact on the quality of life of older adults and their families (Aranda et al. 2021). Research continues to investigate treatment...

This paper claims that palliative care is a suitable approach for offering comprehensive support to patients with life-threatening illness and unavoidable asthenia, to enhance their quality of life in aging and chronic illness. There are however some conceptual barriers to accessing that care on the Chinese Mainland: Death-denying culture and society; Misguidance and malpractice derived from the biomedical model; Prejudice against PC and certain deviant understandings of filial piety culture. To counter these obstacles, the study introduces the philosophy (...) of Chinese Taoist Chuang-tze to enlighten the public from ignorance and remove some illusions about death and dying; inspire people to face and accept illness and death calmly, and keep harmony and inner peace of mind to alleviate suffering, with the aim of providing wisdom and a shift of attitude toward life and death. Chuang-tze’s thoughts are consistent with the provision of palliative care, and to a certain degree, can promote its acceptability and delivery, and the conception of good death in practice. (shrink)

The philosophy of patient-centred care has become widely embraced but its implementation is dependent on interrelated factors. A factor that has received limited attention is the role of policy tools. In Ontario, one method government can use to promote healthcare priorities is through health regulatory colleges, which set the standard of practice for health professionals. The degree to which government policy in support of patient-centered care has influenced the direction provided by health regulatory colleges to their members, and (...) ultimately impacted actual patient care, remains unclear. This study investigates the extent to which Ontario’s health regulatory colleges have provided explicit written guidance to members related to the importance of patient-centred care. It also explores applied and theoretical explanations that may further our understanding of why patient-centred care has not been more fully embraced. Findings reveal that guidance provided by Ontario’s health regulatory colleges varies widely. Institutional barriers and the choice of policy tools for disseminating government preferences may hinder full implementation of the principles of patient-centred care. More fully understanding the role health regulatory colleges’ play in facilitating the implementation of health policy will contribute positively to dialogue and to efforts to achieve positive health system reforms. (shrink)

In Japan, most residents with Hansen’s disease live in dedicated sanatoria because of an established quarantine policy, even after being cured of the primary disease. They suffer from secondary diseases and are advancing in age, and advance care planning is increasingly crucial for them to live their lives with dignity in a sanatorium. In this study, we have three aims: to understand how to promote communication about their wishes for medical treatment, care, and recuperation; to identify required assistance; (...) and to explore how to promote ACP in a sanatorium. This study is a qualitative research conducted through semi-structured interviews. The study included 57 ex-Hansen’s disease patients and 66 staff from 10 facilities. Ex-Hansen’s disease patients were expected to consider ACP, but this was in the context of uncertainty about whether a sanatorium would close and whether there would be doctors to manage their needs. They reported being confused when staff rushed to confirm their advance directives, feeling that they were not provided with enough information before being approached. Barriers to promoting ACP were found to be insufficient of team-based care and information sharing, ex-Hansen’s disease patients’ weak interest in their end of life, and their conservative thoughts. We believe that ACP can be achieved by listening to the wishes of recovered patients through regular home care visits by nurses and everyday support by care workers. Furthermore, multidisciplinary coordination is urgently needed for promoting ACP. (shrink)

Mental health problems start early in life. However, the majority of adolescents fulfilling the criteria for mental health disorders do not receive treatment, and half of those who do get treatment drop out. This begs the question of what differentiates helpful from unhelpful treatment processes from the perspective of young clients. In this study, we interviewed 12 young people who entered mental health care reluctantly at the initiative of others before the age of 18. Their journeys through mental health (...) care varied significantly despite sharing the same starting point. Our analyses resulted in a model of three trajectories. We describe relational and structural facilitators and obstacles within each trajectory and have formulated narratives highlighting core experiences differentiating them. Trajectory 1 was characterized by a rapid loss of hope, leading the adolescents to conclude that mental health care was not worth the investment. Trajectory 2 was characterized by a lingering hope that never materialized into a constructive therapeutic process despite prevailing efforts by both therapists and adolescents. Trajectory 3 was characterized by genuine meetings, allowing the therapist to transform from an unsafe stranger into a safe, competent, and benevolent adult. We discuss how our results have implications for understanding agency displayed by adolescent clients in therapy, therapist flexibility and authenticity, service organization, and attributional processes influencing clinical judgment and therapeutic processes when adolescent psychotherapy has a difficult starting point. (shrink)

Patients with end-stage renal disease experience significant mortality and morbidity, including cognitive decline. Advance care planning has been emphasized as a responsibility and priority of physicians caring for patients with chronic kidney disease in order to align with patient values before decision-making capacity is lost and to avoid suffering. This emphasis has proven ineffective, as illustrated in the case of a patient treated in our hospital. Is this ineffectiveness a consequence of failure in the courtroom or the clinic? Through (...) our own experience we affirm what has been written before: that legal precedent favors intensive treatment in virtually all cases without ‘clear and convincing evidence’ of a patient’s previously declared wishes to the contrary. Equally clear is that more than 20 years of support in the clinical literature suggesting advance care planning early in the course of disease can address challenges in the legal system for those lacking capacity. However, many physicians fail t... (shrink)

Those giving birth within modern maternity systems are recognised as facing a number of barriers to person-centred care. In this paper, I argue that in order to best facilitate the conditions for positive change, work needs to be done to provide a more granular articulation of the specific barriers. I then offer a nuanced and contextually aware articulation of one key component of the overall failure to ensure person-centred care: medical authority and the expectation of conformity. Articulating these (...) barriers with increased specificity is valuable, as it creates a stronger foundation from which to challenge existing problems which serve to constrain the autonomy of birthing individuals. The analysis offered in this paper also underscores the need for change at an institutional, rather than individual, level. (shrink)

The Affordable Care Act (ACA) transforms the U.S.'s public and private health care financing systems into vehicles for promoting public health by making evidence-based preventive services available nationwide through individual and group health plans, Medicare, and Medicaid. The ACA accomplishes this transformation by breaking down two barriers: (1) the public health-health care divide, which led to a dominance of curative medicine over preventive health measures and (2) ERISA preemption, which created an obstacle to the provision of a (...) uniform set of evidence-based preventive services that could be made available to the U.S. population through individual and group health plans. As a result, prevention measures with proven effectiveness will now be provided on a national and uniform basis to a majority of Americans, with the potential to improve health outcomes and reduce costs. (shrink)

As costs decline and technology inevitably improves, current trends suggest that artificial intelligence (AI) and a variety of "carebots" will increasingly be adopted in medical care. Medical ethicists have long expressed concerns that such technologies remove the human element from medicine, resulting in dehumanization and depersonalized care. However, we argue that where shame presents a barrier to medical care, it is sometimes ethically permissible and even desirable to deploy AI/carebots because (i) dehumanization in medicine is not (...) always morally wrong, and (ii) dehumanization can sometimes better promote and protect important medical values. Shame is often a consequence of the human-to-human element of medical care and can prevent patients from seeking treatment and from disclosing important information to their healthcare provider. Conditions and treatments that are shame-inducing offer opportunities for introducing AI/carebots in a manner that removes the human element of medicine but does so ethically. We outline numerous examples of shame-inducing interactions and how they are overcome by implementing existing and expected developments of AI/carebot technology that remove the human element from care. (shrink)

The most prominent — and certainly the most controversial — feature of the Patient Protection and Affordable Care Act is the so-called “individual mandate,” which attempts to address the problem of 50 million uninsured by requiring nearly all Americans, beginning in 2014, to obtain health insurance. While expanded access to health insurance has been both the cornerstone and the lightening rod of the ACA, the Act also contains significant public health provisions focusing on, among other things, promoting the availability (...) of prevention and wellness services. Although these public health provisions have been greeted with mixed reviews, there has been very little discussion of what may be the ACA’s most significant public health feature: the preventive services mandate. In a bold stroke, the ACA changes the way evidence-based preventive services will be provided and paid for by private health insurance plans, Medicare, and Medicaid. By requiring these health plans to provide evidence-based preventive services with no out-of-pocket costs, the ACA transforms the U.S.’s public and private health care financing systems into vehicles for promoting public health. (shrink)

The Physician Orders for Life-Sustaining Treatment Paradigm is designed to improve end-of-life care by converting patients' treatment preferences into medical orders that are transferable throughout the health care system. It was initially developed in Oregon, but is now implemented in multiple states with many others considering its use. An observational study was conducted in order to identify potential legal barriers to the implementation of a POLST Paradigm. Information was obtained from experts at state emergency medical services and long-term (...) care organizations/agencies in combination with a review of relevant state law. (shrink)

The Physician Orders for Life-Sustaining Treatment Paradigm is designed to improve end-of-life care by converting patients’ treatment preferences into medical orders that are transferable throughout the health care system. It was initially developed in Oregon, but is now implemented in multiple states with many others considering its use. Accordingly, an observational study was conducted in order to identify potential legal barriers to the implementation of a POLST Paradigm. Information was obtained from experts at state emergency medical services and (...) long-term care organizations/agencies in combination with a review of relevant state law. Legal analysis of survey responses and existing laws identified several potential state legal barriers to a POLST Paradigm implementation. The most potentially problematic barriers are detailed statutory specifications for out-of-hospital DNR protocols. Other potential barriers include limitations on the authority to consent to forgo life-sustaining treatments, medical preconditions, and witnessing requirements for out-of-hospital DNR protocols. (shrink)

Contemporary realities of global population movement increasingly bring to the fore the challenge of quality and equitable health provision across language barriers. While this linguistic challenge is not unique to immigration contexts and is likewise shared by health systems responding to the needs of aboriginal peoples and other historical linguistic minorities, the expanding multilingual landscape of receiving societies renders this challenge even more critical, owing to limited or even non‐existing familiarity of modern and often monolingual health systems with the particular (...) needs of new linguistic minorities. The centrality of language to health beliefs, attitudes, practices, cultural scripts, and conceptual frameworks emphasizes its pivotal role in the healthcare process, and consequently in the adverse effects of treatment that is language‐insensitive and unaware. Such an attitude on the part of medical authorities risks considerable epistemic injustice in the form of a (mis)judgement of patients’ intelligence, credibility, and rationality based on the language that they speak and the manner in which they speak it, consequently impacting the quality and equity of care provided. This danger, I argue, may be effectively countered by fostering among the participants in the healthcare process a sense of epistemic humility through greater metalinguistic awareness. Outlining a range of operative steps that can be used to facilitate this. I argue that the reality of language barriers in the healthcare process, while not entirely eliminable, may nevertheless be successfully addressed, in order to mitigate the challenge of quality and equitable healthcare provision in multilingual societies. (shrink)

The complex regulatory framework governing the U.S. health care system can be an obstacle to programming that address health-related social needs. In particular, health care fraud and abuse law is a pernicious barrier as health care organizations may minimize or forego programming altogether out of real and perceived concern for compliance. And because health care organizations have varying resources to navigate and resolve compliance concerns, as well as different levels of risk tolerance, fears related to (...) the legal landscape may further entrench inequities in access to meaningful programs that improve health outcomes. This article uses food and nutrition programming as a case study to explore the complexities presented by this area of law and to highlight pathways forward. (shrink)

La cura della salute è un fenomeno originario e insieme una necessità fondamentale, dinamica e non trascurabile della vita, dell’esistenza e dell’esperienza personale e comunitaria di ogni essere umano. La primarietà ontologica della cura, evidenziata anche negli studi filosofici più recenti dedicati alle pratiche dell’aver cura, richiama infatti, attraverso la dimensione co-esistentiva dell’essere insieme nel mondo l’uno con l’altro e l’uno per l’altro, alla stessa primarietà etica e al contempo politica della cura nel naturale e positivo sviluppo della struttura relazionale (...) personale e dell’esistenza condivisa. Si tratta di un processo di rilevazione e conseguente impegno nel favorire oggi concretamente percorsi di cura e umanizzazione della pratica medica e sanitaria, sia quotidiana che straordinaria, nonostante molteplici limiti e complessità rintracciabili nelle stesse pratiche contemporanee dell’aver cura, esemplificativamente ricercati e identificati in alcuni recenti lavori internazionali dal carattere necessariamente interdisciplinare. È significativo, infatti, che in alcuni rilevanti documenti circa gli sviluppi di una delle principali frontiere contemporanee dell’aver cura, come quella costituita dal processo di realizzazione, sviluppo, diffusione e promozione locale, nazionale e internazionale delle reti di cure palliative, vengano ad essere centralmente ricercati, identificati e positivamente ri-evidenziati i principali limiti, gli ostacoli e le barriere attualmente riscontrabili nello sviluppo delle reti di cure palliative; oltre alla messa in evidenza di una sempre positiva e necessaria opportunità di gettare lo sguardo verso il futuro e gli orizzonti di sviluppo della presa in carico globale della persona sofferente nelle varie fasi della malattia e in condizioni di estrema vulnerabilità percepita e vissuta. (shrink)

Overweight and obesity among children and adolescents are global problems of our time. Due to their authority and role modeling, parents play an essential part in the efficacy of prevention and intervention programs. This study assessed the barriers that parents of overweight/obese children face in preventive and interventional health care utilization. Sixteen parents were qualitatively interviewed. A content analysis was performed, and barriers to change were allocated to their stage of change according to the transtheoretical model. Among the main (...) barriers is the underestimation of health risks caused by overweight/obesity in association with diminished problem awareness. Parents seem not necessarily in need of theoretical knowledge for prevention and interventions. They do however need support in evaluating the weight status of their child and the knowledge of whom to turn to for help as well as specific and hands-on possibilities for change. The results extend past studies by adding specific barriers to change that parents commonly experience. Possibilities to address these barriers, e.g., through trainings at the pediatric practice or adoption of conversation techniques, are discussed. Future studies might identify subgroups experiencing specific barriers and thus be able to address these in an individualized way. (shrink)

In Canada, all institutions that conduct publicly funded, animal-based research are expected to comply with the standards of the Canadian Council on Animal Care (CCAC). The CCAC promotes the use of animal alternatives, and uses the “3Rs” principles of Replacement, Reduction, and Refinement as a guiding ethical framework. To ensure these standards are strictly enforced, internal ethics committees at each institution are tasked with creating “Animal Use Protocol” (AUP) forms to be filled out by researchers and evaluated by the (...) committees. In this paper, we assess AUP forms from Canada’s top research universities to identify the extent to which they conform to, or advance, the 3Rs framework. Our results show various deficiencies that call into question the quality of information elicited by these forms. To remedy this, we recommend that the CCAC assume responsibility for creating a standardized 3Rs section to be used on all AUP forms. In addition, proposal forms and experimental results for all research at CCAC-certified institutions should be digitized and uploaded into a national database. We argue that this would offer higher quality information for researchers at the experimental design stage, while strengthening the CCAC’s mandate to be accountable to the Canadian public. (shrink)

Background Coping with end-of-life issues is a major challenge for governments and health systems. Despite progress in legislation, many barriers exist to its full implementation. This study is aimed at identifying these end-of-life barriers in relation to Israel. Methods Qualitative in-depth interviews using professionals and decision makers in the health-care and related systems were carried out, along with two focus groups based on brainstorming techniques consisting of nurses and social workers. Data was managed and analyzed using Naralyzer software. Results (...) Qualitative analysis showed identification of six primary barriers: 1) law, procedures, and forms; 2) clinical aspects; 3) human aspects; 4) knowledge and skills of medical teams; 5) communication; and 6) resource allocation. These were further divided into 44 sub area barriers. Conclusions This study highlights the role of the family doctor in end-of-life by training physicians in decision-making workshops and increasing their knowledge in the field of palliative medicine. Effectively channeling resources, knowledge, and support for medical teams, by accounting for the structure and response of the units for home treatment will improve patient’s access to information on and support for end-of-life laws, as well as reduce legislative barriers in other countries that face the same issues. (shrink)

This article describes, analyzes, and advocates for management of clinical healthcare conflict by a process commonly referred to as bioethics mediation. Section I provides a brief introduction to classical mediation outside the realm of clinical healthcare. Section II highlights certain distinguishing characteristics of bioethics mediation. Section III chronicles the history of bioethics mediation and references a number of seminal writings on the subject. Finally, Section IV analyzes barriers that have, thus far, limited the widespread implementation of bioethics mediation.

Pratt and de Vries1 pose an important and uncomfortable question to all stakeholders in the global bioethics space. If global bioethics as they define it is ‘the ethics of public health and healthcare problems that are characterised by a global level effect or that require action beyond individual countries, and the ethics of research related to such problems’, one would expect justice and inclusivity to be among the ethical priorities. Yet, Pratt and de Vries carefully demonstrate how different forms of (...) epistemic injustice and coloniality are embedded in the structure, generation of knowledge and praxis of global bioethics. They do this by unpicking three layers at which coloniality and epistemic injustice operate; knowledge-producer, knowledge-applied and knowledge-solicited. The authors also offer a three-pronged incremental approach to how individual and institutional actors in global bioethics can contribute to epistemic justice in the field. Pratt and de Vries present their work as ‘a first step towards reorienting the field’ of global health bioethics away from epistemic injustice. Indeed, theirs is a mapping, problem statement and recommendations piece …. (shrink)

GPs usually care for their patients for an extended period of time, therefore, requests to not only discontinue a patient’s treatment but to assist a patient in a suicide are likely to create intensely stressful situations for physicians. However, in order to ensure the best patient care possible, the competent communication about the option of physician assisted suicide as well as the assessment of the origin and sincerity of the request are very important. This is especially true, since (...) patients’ requests for PAS can also be an indicator for unmet needs or concerns. Twenty-three qualitative semi-structured interviews were conducted to in-depth explore this multifaceted, complex topic while enabling GPs to express possible difficulties when being asked for assistance. The analysis of the gathered data shows three main themes why GPs may find it difficult to professionally communicate about PAS: concerns for their own psychological well-being, conflicting personal values or their understanding of their professional role. In the discussion part of this paper we re-assess these different themes in order to ethically discuss and analyse how potential barriers to professional communication concerning PAS could be overcome. (shrink)

The aim of this paper is to summarize key psychoanalytic concepts first developed by Sigmund Freud and apply them to a critical exploration of three terms that are central to nursing's self‐image—empathy, caring, and compassion. Looking to Menzies‐Lyth's work, I suggest that the nurse's strong identification as a carer can be understood as a fantasy of being the one who is cared for; critiques by Freud and others of empathy point to the possibility of it being, in reality, a form (...) of projective identification; reading Lacan and Žižek, I propose that repeated research into caring and repeated complaint about barriers to caring can be understood as manifestations of the death drive first posited by Freud. I conclude that psychoanalytic insights suggest that caring roles can raise profoundly ambivalent issues for those who care but they can also point the way to freedom from painful and self‐destructive symptoms inherent in such work. (shrink)

The omen of the door and the eagle at Iliad 24.314–21 appears to have sparked scant scholarly interest, but deserves careful attention. The omen itself forms part of an analogy, for the eagle is likened in the size of its wingspan to a large, barred door. This simile might seem unremarkable, merely a convenient means of depicting great size, a casual juxtaposition of two ordinary nouns. The omen, on the whole, might be dismissed as nothing more than a conventional expression (...) of divine favor. But closer scrutiny will reveal that there is, in fact, nothing arbitrary or haphazard in the selection of the terms of the analogy. Appreciation of the elegance and subtlety of the simile in turn reveals the full import of the omen. (shrink)

Global firms need to decide on the correspondence between their corporate ethics and the globalization of their activities. When firms go global, they face ethical complexities as they operate in different legal and cultural environments that may impact the admissibility and appropriateness of their approach to institutionalize and implement corporate ethics. Global firms may have good reasons to establish global codes of ethics that are to be obeyed by all employees worldwide. However, developing and implementing such codes can be rather (...) difficult due to various, and partly competing, conditions in the countries of operation. In this article, two legal disputes are analyzed to illustrate some of the difficulties that may emerge when firms globalize their codes of ethics. I argue that these conflicts can be mitigated when firms carefully design their codes and the processes of code implementation. (shrink)

Jones, Kate In Victoria, a complex maze of issues govern the accessibility of appropriate support for people with a severe disability or serious illness, be it financial assistance, or a range of rehabilitative services. This article is a continuation from the previous article printed in the last issue of the Bulletin - Crisis: Young People Living in Aged Care Homes.

Background While most countries that allow abortion on women’s request also grant physicians a right to conscientious objection (CO), this has proven to constitute a potential barrier to abortion access. Conscientious objection is regarded as an understudied phenomenon the effects of which have not yet been examined in Germany. Based on expert interviews, this study aims to exemplarily reconstruct the processes of abortion in a mid-sized city in Germany, and to identify potential effects of conscientious objection. Methods Five semi-structured (...) interviews with experts from all instances involved have been conducted in April 2020. The experts gave an insight into the medical care structures with regard to abortion procedures, the application and manifestations of conscientious objection in medical practice, and its impact on the care of pregnant women. A content analysis of the transcribed interviews was performed. Results Both the procedural processes and the effects of conscientious objection are reported to differ significantly between early abortions performed before the 12th week of pregnancy and late abortions performed at the second and third trimester. Conscientious objection shows structural consequences as it is experienced to further reduce the number of possible providers, especially for early abortions. On the individual level of the doctor-patient relationship, the experts confirmed the neutrality and patient-orientation of the vast majority of doctors. Still, it is especially late abortions that seem to be vulnerable to barriers imposed by conscientious objection in individual medical encounters. Conclusion Our findings indicate that conscientious objection possibly imposes barriers to both early and late abortion provision and especially in the last procedural steps, which from an ethical point of view is especially problematic. To oblige hospitals to partake in abortion provision in Germany has the potential to prevent negative impacts of conscientious objection on women’s rights on an individual as well as on a structural level. (shrink)

Does language limit the moral thoughts we can have? To answer that, I distinguish between two kinds of limits: Boundaries or barriers fence things out. Identification and erection of linguistic barriers, defines, diagnoses, or places restrictions on what language can in principle grasp or be, and often involves abstraction from actual linguistic behavior. This is typically preformed by remarks I call ‘theses’; Contours or outlines give real-life portrayals. Drawing the contours of a linguistic activity involves a certain attention to reality: (...) to detail and particularity, and we typically draw contours by using remarks I call ‘helpers’. I examine the possibility that confusion can be diagnosed in Sabina Lovibond's attempt to apply the idea that moral language has necessary boundaries, and explain the alternative of drawing linguistic contours. I then examine Richard Rorty's position according to which the fact that we can shape our language indicates that the boundaries of language do not encompass all possible sense, and compare Rorty's discussion with Sarah Bachelard's discussion of euthanasia. My claim here is that trying to improve on the language we have might be part of drawing its contours, rather than redefining its boundaries. The discussion reveals a difference between two kinds of contour drawing, and thus between two kinds of helpers: ones that help to draw the contours of the actuality of linguistic activities, and ones that help to draw the contours of their potentiality. Finally, I argue that the value of drawing contours instead of barriers is that the former better reveal the fact that we care about our ways of making sense. (shrink)

This article examines the barriers to quality health care for transgender, nonbinary, and gender-expansive people (TGE) who become pregnant and give birth, identifying three central themes that emerge from the literature. These insights suggest that significant reform will be necessary to ensure access to safe, appropriate, gender-affirming care for childbearing TGE people. After illustrating the need for systemic changes that untether rigid gender norms from the provision of perinatal care, the article proposes that the Midwives Model of (...) Care offers a set of values and clinical practices that are well-suited to meet the needs of many TGE patients during pregnancy and childbirth and which should be incorporated into the healthcare system more broadly. (shrink)

BackgroundWith the enactment of Bill C-7 in Canada in March 2021, people who are eligible for medical assistance in dying (MAiD), whose death is reasonably foreseeable and are at risk of losing decision-making capacity, may enter into a written agreement with their healthcare provider to waive the final consent requirement at the time of provision. This study explored healthcare providers’ perspectives on honouring eligible patients’ request for MAiD in the absence of a contemporaneous consent following their loss of decision-making capacity. (...) MethodA critical qualitative methodology, using a feminist ethics theoretical lens with its focus on power and relationality, was used to examine how socio-political and environmental contexts influenced healthcare providers' moral agency and perspectives. Semi-structured interviews were conducted with 30 healthcare providers (13 physicians, six nurse practitioners, nine nurses and two social workers) from across Canada who provide MAiD-related care.ResultsThemes identified include; (1) balancing personal values and professional responsibilities, (2) anticipating strengths and limitations of the proposed waiver of final consent amendment, (3) experiencing ethical influences on decisions to enter into written agreements with eligible patients, (4) recognizing barriers to the enactment of MAiD in the absence of a contemporaneous consent and (5) navigating the potential for increased risks and burden.DiscussionTo our knowledge, this is the first study in Canada to explore healthcare providers’ perspectives on waiving the final consent for MAiD using a written agreement. Most participants supported expanding eligible people’s access to MAiD following loss of capacity, as they believed it would improve the patients’ comfort and minimize suffering. However, the lack of patients’ input at the time of provision and related ethical and legal challenges may impact healthcare providers’ moral agency and reduce some patients’ access to MAiD. Providers indicated they would enter into written agreements to waive final consent for MAiD on a case-by-case basis. This study highlights the importance of organizational, legal and professional support, adequate resources, clear policies and guidelines for the safety and wellbeing of healthcare providers and to ensure equitable access to MAiD. (shrink)

Using the conceptual lenses offered by the ideational and cultural path taken in the health care arena, this article attempts to explain the trajectory of recent major health care reforms in Italy and the reasons for their failure, as well as providing some directions for successful intervention. A diachronic analysis of the relatively under-investigated phenomenon of health care reforms in Italy is carried out, drawing on a systematic review of the Italian and international literature combined with the (...) research work carried out by the Author. For all the three major health reforms examined, a significant gap between the authoritative policy choices taken and the overall implementation, in terms of process and system changes, can be observed, determining a growing distance between the theoretical efficiency and the practical effectiveness of the Italian National Health Service (NHS) as well as its detachment from the social system. The main obstacle to effective reform seems to be the cultural hegemony of the administrative-managerial and the biomedical paradigms, which, by reinforcing one another, yielded infertile ground for renewing in a post-modern sense the Italian NHS. The various Reforms have not been conceived to break such a positivistic monopoly in that they did not promote cultural or educational intervention. In this context, intervention that acts at a cultural level, such as reforming university education for physicians and managers or devising immigration policies to attract adequately acculturated people to the Italian NHS, seems to be the most promising. (shrink)

The federal regulations that govern biomedical research, most notably those enshrined in the Common Rule, express a protectionist ethos aimed at safeguarding subjects of human experimentation from the potential harms of research participation. In at least one critical way, however, the regulations have always fallen short of this promise: if a subject suffers a research-related injury, then neither the investigator nor the sponsor has any legal obligation under the regulations to care for or compensate the subject. Because very few (...) subjects with research-related injuries can meet the financial or evidentiary requirements associated with a successful legal claim to recover the costs associated with their injuries, most injured subjects must shoulder the burden of those expenses alone. For 40 years, national advisory panels have concluded that this result is out of step with the Common Rule's otherwise protectionist promise. When the Department of Health and Human Services released an Advance Notice of Proposed Rulemaking (ANPRM) in 2011, suggesting potential changes to the Common Rule, the time seemed ripe to address research-related injuries. The ANPRM, however, makes no mention of compensation for research-related injuries, and the federal government once again seems poised to stop short of addressing what has arguably become the most longstanding, frequent, and consistent plea for regulatory reform of research: protections for injured subjects. This article asks why, despite decades of federal-level panels recommending no-fault compensation for research-related injuries, the United States has so strongly resisted change. I suggest that a central reason for our current impasse is that, despite consensus among federal advisory committees that there is an obligation to compensate injured subjects, the committees have not coalesced around a moral justification for that duty. Although multiple justifications can support and even strengthen a single ethical obligation, the reverse has occurred in this context. I demonstrate that the committees' articulation of multiple ethical principles – including humanitarianism, professional beneficence, and compensatory justice – results in incongruent obligations that favor different kinds of compensation systems. This outcome, which I call “moral gridlock,” makes it extremely difficult to determine what kind of compensation scheme to implement. Recognizing that each moral argument for compensation creates a slightly different trajectory is, however, an important first step in moving toward a more systematic approach to compensating injured research subjects. (shrink)

In this article it is argued that there are barriers to effective and non-discriminatory practice when mentoring overseas nurses within the National Health Service (NHS) and the care home sector. These include a lack of awareness about how cultural differences affect mentoring and learning for overseas nurses during their period of supervised practice prior to registration with the UK Nursing and Midwifery Council. These barriers may demonstrate a lack of effective teaching of ethical practice in the context of cultural (...) diversity in health care. This argument is supported by empirical data from a national study. Interviews were undertaken with 93 overseas nurses and 24 national and 13 local managers and mentors from six research sites involving UK health care employers in the NHS and independent sectors in different regions of the UK. The data collected showed that overseas nurses are discriminated against in their learning by poor mentoring practices; equally, from these data, it appears that mentors are ill-equipped by existing mentor preparation programmes to mentor overseas-trained nurses from culturally diverse backgrounds. Recommendations are made for improving mentoring programmes to address mentors’ ability to facilitate learning in a culturally diverse workplace and thereby improve overseas nurses’ experiences of their supervised practice. (shrink)

Advance care directives for health care have been promoted as a way to improve end-of-life decision making. These documents allow a patient to state, in advance of incapacity, the types of medical treatments they would like to receive, to name a surrogate to make those decisions, or to do both. Although studies have shown that both physicians and patients generally have positive attitudes about the use of these documents, relatively few individuals have actually completed one.What underlies this discrepancy (...) between attitudes and behavior with regard to advance care directives? One obvious explanation is lack of access. Emanuel et al. estimated that approximately 90 percent of the population desire an advance care directive, and they pointed to access as the major barrier. Yet interventions that increase accessibility have typically failed to yield more than a 20 percent completion rate. Thus, it appears that access is not the sole determinant of advance care directive completion. (shrink)

Objectives: After years of public discussion too little is still known about willingness to accept the idea of writing an advance directive among various groups of people in EU countries. We investigated knowledge about and willingness to accept such a directive in cancer patients, healthy controls, physicians, and nursing staff in Germany.Methods: Cancer patients, healthy controls, nursing staff, and physicians were surveyed by means of a structured questionnaire.Results: Only 18% and 19% of the patients and healthy controls respectively, and 10% (...) of the medical staff had written an advance directive. However, 50–81% of those surveyed indicated that they wished to write one. This intention was associated with deteriorating health . Only 29% of the healthy controls and 43% of the patients knew about the possibility of appointing a health care proxy. A majority in all groups believed that advance directives may influence the course of treatment , yet half of those surveyed in all groups fear that patients could be pressurised into writing an advance directive, and 38–65% thought that relatives could abuse such documents.Conclusions: Only a minority of the participants had written an advance directive and knew about the possibility of authorising a health care proxy. Deteriorating health was associated with increasing willingness to make a directive. Despite a majority belief that advance directives may influence treatment at the end of life, other factors limit their employment, such as fear of abuse. (shrink)