The Missing Chapter: The Education of Surgery and Anesthesiology Trainees as Civic Advocates.

The SARS-CoV-2 pandemic has highlighted existing systemic inequities that adversely affect a variety of communities in the United States. These inequities have a direct and adverse impact on the healthcare of our patient population. While civic engagement has not been cultivated in surgical and anesthesia training, we maintain that it is inherent to the core role of the role of a physician. This is supported by moral imperative, professional responsibility, and a legal obligation. We propose that such civic engagement and social justice activism is a neglected, but necessary aspect of physician training. We propose the implementation of a civic advocacy education agenda across department, community and national platforms. Surgical and anesthesiology residency training needs to evolve to the meet these increasing demands.

Ethical Advocacy Across the Autism Spectrum: Beyond Partial Representation.

Recent debates within the autism advocacy community have raised difficult questions about who can credibly act as a representative of a particular population and what responsibilities that role entails. We attempt to answer these questions by defending a set of evaluative criteria that can be used to assess the legitimacy of advocacy organizations and other nonelectoral representatives. With these criteria in hand, we identify a form of misrepresentation common but not unique to autism advocacy, which we refer to as partial representation. Partial representation occurs when an actor claims to represent a particular group of people but appropriately engages with only a subset of that group. After highlighting symbolic and substantive harms associated with partial representation, we propose several strategies for overcoming it.

The Moral Agency of Physician Organizations: Meeting Obligations to Advocate for Patients and the Public.

The close of the American College of Physician's (ACP) centennial year is an opportune time to reflect on the organization's important role in professional development and advocating for sound health policy. Organized medicine provides a professional home where members can participate in scholarly activities and access guidance that will help them to be better doctors. Professional organizations also serve patients by improving physicians' knowledge and skill, being a public repository of health-related information, and advocating for improvement of public health. High-functioning medical professional organizations, such as ACP, also function intentionally as moral agents through well-designed efforts to advocate for patients and the public.

Conscientious objection to abortion and reproductive healthcare: a review of recent literature and implications for adolescents.

PURPOSE OF REVIEW: Conscientious objection to reproductive healthcare (refusal to perform abortion, assisted reproductive technologies, prenatal diagnosis, contraception, including emergency contraception and sterilization, etc.) has become a widespread global phenomenon and constitutes a barrier to these services for many women. Adolescents are a particularly vulnerable group because some providers object to specific aspects of their reproductive healthcare because of their status as minors. RECENT FINDINGS: Recent peer-reviewed publications concerning conscientious objection address provider attitudes to abortion and emergency contraception, ethical arguments against conscientious objection, calls for clarification of the current laws regarding conscientious objection, legal case commentaries, and descriptions of the country-specific impact of policies in Russia and Italy. SUMMARY: Conscientious objection is understudied, complicated, and appears to constitute a barrier to care, especially for certain subgroups, although the degree to which conscientious objection has compromised sexual and reproductive healthcare for adolescents is unknown. Physicians are well positioned to support individual conscience while honoring their obligations to patients and to medical evidence.

Rawlsian Justice and Palliative Care.

Palliative care serves both as an integrated part of treatment and as a last effort to care for those we cannot cure. The extent to which palliative care should be provided and our reasons for doing so have been curiously overlooked in the debate about distributive justice in health and healthcare. We argue that one prominent approach, the Rawlsian approach developed by Norman Daniels, is unable to provide such reasons and such care. This is because of a central feature in Daniels' account, namely that care should be provided to restore people's opportunities. Daniels' view is both unable to provide pain relief to those who need it as a supplement to treatment and, without justice-based reasons to provide palliative care to those whose opportunities cannot be restored. We conclude that this makes Daniels' framework much less attractive.

Patient advocacy: Japanese psychiatric nurses recognizing necessity for intervention.

BACKGROUND: Advocacy is an important role of psychiatric nurses because their patients are ethically, socially, and legally vulnerable. This study of Japanese expert psychiatric nurses' judgments of interventions for patient advocacy will show effective strategies for ethical nursing practice and their relationship with Japanese culture. OBJECTIVES: This article explores Japanese psychiatric nurses' decision to intervene as a patient advocate and examine their ethical, cultural, and social implications. RESEARCH DESIGN: Using semi-structured interviews verbatim, themes of the problems that required interventions were inductively summarized by a qualitative analysis and their contexts and nursing judgments were examined. PARTICIPANTS AND RESEARCH CONTEXT: The participants were 21 nurses with 5 or more years of experience in psychiatric nursing. ETHICAL CONSIDERATIONS: The research was approved by Institutional Review Board of research site and study facilities. The participants gave written informed consent. FINDINGS: Analysis of 45 cases showed that nurses decided to intervene when (a) surrounding people's opinions impeded patients' safety, (b) healthcare professionals' policies impeded patients' decision-making, (c) own violent behaviors impeded treatment and welfare services for patients, (d) own or families' low acceptance of illness impeded patients' self-actualization, (e) inappropriate treatment or care impeded patients' liberty, and (f) their families abused patients' property. DISCUSSION: To solve conflicts between patients and their surrounding people, the nurses sought reconciliation between them, which is in accordance with Japanese cultural norms respecting harmony. When necessary, however, they protected patients' rights against cultural norms. Therefore, their judgments cannot be explained by cultural norms alone. CONCLUSION: The findings indicate that the nurses' judgments were based on respect for patients' rights apart from cultural norms, and they first sought solutions fitting the cultural norms before other solutions. This seems to be an ethical, effective strategy if advocates know the culture in depth.

The ethical leadership challenge for effective resolution of patient and family complaints and grievances: proven methods and models.

Health care leaders and managers face the ethical leadership challenge in ensuring effective resolution of patient and family complaints and grievances. In today's society of increasing discontent about safety, quality, cost, and satisfaction, patient complaints and grievances are becoming more prevalent. Under the mandates of the Patient Protection and Affordable Care Act for transparency of quality and patient satisfaction scores and to be compliant with the standards from the Centers for Medicare & Medicaid Services and The Joint Commission, it is imperative that leadership ensure an ethical culture for effective resolution of patient and family complaints and grievances. This article addresses this ethical leadership challenge by providing a systematic approach with proven methods and models for effective resolution of complaints and grievances and thereby improving satisfaction, quality, safety, and cost.

Ethical considerations of doll therapy for people with dementia.

The use of doll therapy for people with dementia has been emerging in recent years. Providing a doll to someone with dementia has been associated with a number of benefits which include a reduction in episodes of distress, an increase in general well-being, improved dietary intake and higher levels of engagement with others. It could be argued that doll therapy fulfils the concepts of beneficence (facilitates the promotion of well-being) and respect for autonomy (the person with dementia can exercise their right to engage with dolls if they wish). However, some may believe that doll therapy is inappropriate when applied to the concepts of dignity (people with dementia are encouraged to interact with dolls) and non-maleficence (potential distress this therapy could cause for family members). The absence of rigorous empirical evidence and legislative guidelines render this a therapy that must be approached cautiously owing to the varied subjective interpretations of Kitwood's 'malignant social psychology' and bioethics. This article suggests that by applying a 'rights-based approach', healthcare professionals might be better empowered to resolve any ethical tensions they may have when using doll therapy for people with dementia. In this perspective, the internationally agreed upon principles of the United Nations Convention on the Rights of Persons with Disabilities provide a legal framework that considers the person with dementia as a 'rights holder' and places them at the centre of any ethical dilemma. In addition, those with responsibility towards caring for people with dementia have their capacity built to respect, protect and fulfil dementia patient's rights and needs.

Exploring ethical aspects of elective surgery patients' decision-making experiences.

The practice of respecting patients' autonomy is rooted in the healthcare professionals' empathy for patients' situations, without which appropriate supports to the patients during the informed consent process may be remarkably moderated. The purpose of this study was to explore elective surgery patients' experiences during their decision-making process. This research was conducted using a phenomenological approach, and the data analysis was guided by Colaizzi's method. A total of 17 participants were recruited from a hospital in southern Taiwan. Two major themes emerged from the analyses: (a) a voluntary yet necessary alternative--to undergo a surgery and (b) alternatives compelled by the unalterable decision--the surgery. It was concluded that unless healthcare professionals can empathize with the distressed situation of their patients who are facing elective surgery, the practice of informed consent may become merely a routine. Nurses can be the best advocates for patients and facilitators to enhance communication between patients and healthcare personnel.

Patients and borders, money and mission: responding to medically needy persons from other countries who lack financial resources.

When financially impoverished persons from resource-poor countries travel to resource-rich countries to seek medical treatment, health-care professionals and hospital administrators must decide how to respond. These financially impoverished "medical travelers" are medically no different from financially impoverished citizens or immigrants, but their national residence and purpose of travel may cause them to be seen as having a lower degree of standing within the communities that hospitals are expected to serve. In responding to such persons, health-care professionals and administrators encounter tension between the mission-driven intention to provide care and a budget-driven intention to protect operating margins. Responses require practical wisdom and a readiness to wrestle with tensions related to objectives (charitable versus financial), role-specific obligations (clinicians versus administrators), and contrasting moral frameworks. There are also challenges of reconciling plural moral values, setting moral priorities, and considering whether national borders should constrain our view of persons as neighbors. Finding a way forward amidst many tensions is hard moral work, but it may be facilitated by granting a moral imperative to physical proximity, respecting role-fidelity among clinicians and administrators, furthering candid moral dialogue, and promoting a presumption to treat whenever it is feasible to do so.

[Promoting "well-treatment" in medical imaging]. / Promotion de la bientraitance en imagerie médicale.

A project to promote "well-treatment" has been initiated in the medical imaging department of a Parisian hospital. With the aim of promoting the well-being of the patient and developing shared values of empathy and respect, the members of this medico-technical team have undertaken to build a culture of "well-treatment" which respects the patient's dignity and rights.

Revisiting the best interest standard: uses and misuses.

The best interest standard is the threshold most frequently employed by physicians and ethics consultants in challenging a parent's refusal to provide consent for a child's medical care. In this article, I will argue that the best interest standard has evolved to serve two different functions, and that these functions differ sufficiently that they require separate standards. While the best interest standard is appropriate for choosing among alternative treatment options for children, making recommendations to parents, and making decisions on behalf of a child when the legal decision makers are either unable to make a decision or are in dispute, a different standard is required for deciding when to seek state interference with parental decision-making authority. I will suggest that the harm principle provides a more appropriate threshold for determining when to seek state intervention than the best interest standard.

Nursing care for the patient with co-existing pain and substance misuse: meeting the patient's needs.

Meeting the needs of the patient with co-existing pain and substance misuse is a complex ethical issue. As advocates for the patient, nurses participate in developing a patient-centered approach to care.

Consent and capacity: a guide for district nurses.

The Mental Capacity Act 2005, which came into force in 2007, sought to provide a statutory framework to facilitate empowerment and provide protection to individuals who lack capacity. District nurses must be aware of the legislation regarding mental capacity (Nursing and Midwifery Council, 2008) and understand how and when they may need to assess decision-making capacity. The article explores the legal and ethical issues surrounding consent, and seeks to inform district nurses as to the guidelines used in assessing a person's capacity to consent, along with best interests policy.

[Promoting the dignity and respect of elderly people in institutions]. / Promouvoir la dignité et le respect de la personne âgée en institution.

How can caregivers avoid the mechanical nature of the repetitive care given to elderly people in institutions? As part of a training programme set up in the long-term care home of Saint-Pierre-le-Moutier, a group of caregivers considered this question. On the basis of an ethical approach, they created tools to offer a form of dignified care which respects both the resident and the caregiver.

[The ethics of the nursing commitment in psychiatry]. / Pour une éthique de l'engagement infirmier en psychiatrie.

The referral nurse represents the care environment, he/she is the guarantor of the care plan and forms a commitment with regard to the patient. This positioning, arising from the empathy he/she has for the patient in a situation of vulnerability, may lead him/her to object to and question a medical decision.

Medical advocacy in the face of Australian immigration practices: A study of medical professionals defending the health rights of detained refugees and asylum seekers.

While medical advocacy is mandated as a core professional commitment in a growing number of ethical codes and medical training programs, medical advocacy and social justice engagement are regularly subordinated to traditional clinical responsibilities. This study aims to provide insight into factors that motivate clinician engagement and perseverance with medical advocacy, so as to inform attempts by policymakers, leaders and educators to promote advocacy practices in medicine. Furthermore, this study aims to provide an analysis of the role of medical advocates in systems where patients' rights are perceived to be infringed and consider how we might best support and protect these medical advocates as a profession, by exploring the experiences and perspectives of Australian clinicians defending the health of detained asylum seekers. In this qualitative study thirty-two medical and health professionals advocating on asylum seeker health in immigration detention were interviewed. Transcripts were coded both inductively and deductively from interview question domains and thematically analysed. Findings suggested that respondents' motivations for advocacy stemmed from deeply intertwined professional and personal ethics. Overall, advocacy responses originated from the union of three integral stimuli: personal ethics, proximity and readiness. We conclude that each of these three integral factors must be addressed in any attempt to foster advocacy within the medical profession. In light of current global trends of increasingly protectionist immigration practices, promoting effective physician advocacy may become essential in ensuring patients' universal right to health.

Public health, the APHA, and urban renewal.

Joint efforts by fields of public health in the last decade have advocated use of the built environment to protect health. Past involvement by public health advocates in urban policy, however, has had mixed results. Although public health has significantly contributed to health improvements, its participation in urban renewal activities was problematic. Health advocates and the American Public Health Association produced guidelines that were widely used to declare inner-city areas blighted and provided a scientific justification for demolishing neighborhoods and displacing mostly poor and minority people. Furthermore, health departments failed to uphold their legal responsibility to ensure that relocated families received safe, affordable housing alternatives. These failures have important implications for future health-related work on the built environment and other core public health activities.

"Asset exchange"-interactions between patient groups and pharmaceutical industry: Australian qualitative study.

OBJECTIVE: To understand and report on the nature of patient group interactions with the pharmaceutical industry from the perspective of patient group representatives by exploring the range of attitudes towards pharmaceutical industry sponsorship and how, why, and when interactions occur. DESIGN: Empirical qualitative interview study informed by ethics theory. SETTING: Australian patient groups. PARTICIPANTS: 27 participants from 23 Australian patient groups that represented diverse levels of financial engagement with the pharmaceutical industry. Groups were focused on general health consumer issues or disease specific topics, and had regional or national jurisdictions. ANALYSIS: Analytic techniques were informed by grounded theory. Interview transcripts were coded into data driven categories. Findings were organised into new conceptual categories to describe and explain the data, and were supported by quotes. RESULTS: A range of attitudes towards pharmaceutical industry sponsorship were identified that are presented as four different types of relationship between patient groups and the pharmaceutical industry. The dominant relationship type was of a successful business partnership, and participants described close working relationships with industry personnel. These participants acknowledged a potential for adverse industry influence, but expressed confidence in existing strategies for avoiding industry influence. Other participants described unsatisfactory or undeveloped relationships, and some participants (all from general health consumer groups) presented their groups' missions as incompatible with the pharmaceutical industry because of fundamentally opposing interests. Participants reported that interactions between their patient group and pharmaceutical companies were more common when companies had new drugs of potential interest to group members. Patient groups that accepted industry funding engaged in exchanges of "assets" with companies. Groups received money, information, and advice in exchange for providing companies with marketing, relationship building opportunities with key opinion leaders, coordinated lobbying with companies about drug access and subsidy, assisting companies with clinical trial recruitment, and enhancing company credibility. CONCLUSIONS: An understanding of the range of views patient groups have about pharmaceutical company sponsorship will be useful for groups that seek to identify and manage any ethical concerns about these relationships. Patient groups that receive pharmaceutical industry money should anticipate they might be asked for specific assets in return. Selective industry funding of groups where active product marketing opportunities exist might skew the patient group sector's activity towards pharmaceutical industry interests and allow industry to exert proxy influence over advocacy and subsequent health policy.

Why Physicians Should Advocate for Undocumented Immigrants' Unimpeded Access to Prenatal Care.

Nearly 7% of US citizens born each year have at least one undocumented parent, but many pregnant undocumented immigrants are ineligible for public insurance covering prenatal care due to their immigration status. This article reviews national-level and state-level policies affecting access to prenatal care for members of this population. This article also considers ethical challenges posed by some policies that create obstacles to patients' accessing health care that is universally recommended by professional guidelines.