"Don't fuss at our staff": A moral economy of volunteerism in South Carolina safety net clinics.

In South Carolina, a state that has foregone Medicaid expansion, working poor residents often rely on safety net clinics for medical care. This care often occurs far from major hospitals, in different, inferior, spaces where limited services are provided in lesser circumstances. The temporary and conditional aid provided in these clinics is meant as a last resort, but often serves as the only source of care for many working poor patients, who must manage the effects of sustained precarity and protracted immiseration with conditional aid provided by volunteers. Here I explore the function that volunteering plays in regulating patients' utilization, and ability to contest, the quality of safety net care. Using ethnographic examples and interview data I show how the needs of patients-referred to in the clinics as "clients"-are managed and contained by a moral economy of volunteer care. These reciprocal obligations of debt and duty preclude working poor patients from making demands of, or lodging complaints against, the free clinics' staff, due to their capacity as volunteers, and leaves the state's safety net effectively unassailable to accusations of inefficacy or neglect. Consequently, patients must defer care, ignore episodes of maltreatment, and ration and share prescription medications, lest they be considered recusant or deemed not sufficiently appreciative of the volunteer staff dedicating their time to them. As a result of this moral economy, the plight of the state's uninsured working poor residents goes under-recognized as the safety net absorbs their cases, hiding the attritional nature of the ostensibly free care they receive and ration.

An empirical ethics study of the coherence of NICE technology appraisal policy and its implications for moral justification.

BACKGROUND: As the UK's main healthcare priority-setter, the National Institute for Health and Care Excellence (NICE) has good reason to want to demonstrate that its decisions are morally justified. In doing so, it has tended to rely on the moral plausibility of its principle of cost-effectiveness and the assertion that it has adopted a fair procedure. But neither approach provides wholly satisfactory grounds for morally defending NICE's decisions. In this study we adopt a complementary approach, based on the proposition that a priority-setter's claim to moral justification can be assessed, in part, based on the coherence of its approach and that the reliability of any such claim is undermined by the presence of dissonance within its moral system. This study is the first to empirically assess the coherence of NICE's formal approach and in doing so to generate evidence-based conclusions about the extent to which this approach is morally justified. METHODS: The study is grounded in the theory, methods and standards of empirical bioethics. Twenty NICE policy documents were coded to identify and classify the normative commitments contained within NICE technology appraisal policy as of 31 December 2021. Coherence was systematically assessed by attempting to bring these commitments into narrow reflective equilibrium (NRE) and by identifying sources of dissonance. FINDINGS: Much of NICE policy rests on coherent values that provide a strong foundation for morally justified decision-making. However, NICE's formal approach also contains several instances of dissonance which undermine coherence and prevent NRE from being fully established. Dissonance arises primarily from four sources: i) NICE's specification of the principle of cost-effectiveness; ii) its approach to prioritising the needs of particular groups; iii) its conception of reasonableness in the context of uncertainty, and iv) its concern for innovation as an independent value. CONCLUSION: At the time of analysis, the level of coherence across NICE policy provides reason to question the extent to which its formal approach to technology appraisal is morally justified. Some thoughts are offered on why, given these findings, NICE has been able to maintain its legitimacy as a healthcare priority-setter and on what could be done to enhance coherence.

A critical view on using "life not worth living" in the bioethics of assisted reproduction.

This paper critically engages with how life not worth living (LNWL) and cognate concepts are used in the field of beginning-of-life bioethics as the basis of arguments for morally requiring the application of preimplantation genetic diagnosis (PGD) and/or germline genome editing (GGE). It is argued that an objective conceptualization of LNWL is largely too unreliable in beginning-of-life cases for deriving decisive normative reasons that would constitute a moral duty on the part of intending parents. Subjective frameworks are found to be more suitable to determine LNWL, but they are not accessible in beginning-of-life cases because there is no subject yet. Conceptual and sociopolitical problems are additionally pointed out regarding the common usage of clear case exemplars. The paper concludes that a moral requirement for the usage of PGD and GGE cannot be derived from the conceptual base of LNWL, as strong reasons that can be reliably determined are required to limit reproductive freedom on moral grounds. Educated predictions on prospective well-being might still be useful regarding the determination of moral permissibility of PGD and/or GGE. It is suggested that due to the high significance of subjective experience in the normativity of beginning-of-life bioethics, the discipline is called to more actively realize the inclusion of people with disabilities. This regards for instance research design, citation practices, and language choices to increase the accessibility of societal debates on the reproductive ethics of genetic technologies.

Trusting young children to help causes them to cheat less.

Trust and honesty are essential for human interactions. Philosophers since antiquity have long posited that they are causally linked. Evidence shows that honesty elicits trust from others, but little is known about the reverse: does trust lead to honesty? Here we experimentally investigated whether trusting young children to help can cause them to become more honest (total N = 328 across five studies; 168 boys; mean age, 5.94 years; s.d., 0.28 years). We observed kindergarten children's cheating behaviour after they had been entrusted by an adult to help her with a task. Children who were trusted cheated less than children who were not trusted. Our study provides clear evidence for the causal effect of trust on honesty and contributes to understanding how social factors influence morality. This finding also points to the potential of using adult trust as an effective method to promote honesty in children.

Designing and psychometric assessment of the moral intelligence scale for healthcare professionals.

The moral intelligence of healthcare professionals in the cardiac operating room is one of the most important aspects of professional competence. However, moral intelligence is an abstract and multidimensional concept that needs to be clarified and described based on organizational culture and environment. Therefore, there is a need to design a specific scale for measuring the moral intelligence of healthcare professionals in the cardiac operating room. This study aims to design and assess the psychometric properties of a moral intelligence scale for healthcare professionals in the cardiac operating room. The present study was a mixed method study with a sequential exploratory approach. The research was conducted in 2023-2024 in Iran. The first phase data were collected from 20 healthcare professionals and were analyzed by conventional content analysis method. In the second phase, the validity and reliability of the instrument were evaluated by involving 300 healthcare professionals in the cardiac operating room. The moral intelligence of health care professionals in the cardiac operating room was defined as moral sensitivity combined with moral commitment and moral courage for the provision of quality care that respects the principles of medical ethics. After deducing the conceptual framework, the moral intelligence scale for healthcare professionals in the cardiac operating room was developed with three dimensions: "moral sensitivity," "moral commitment," and "moral courage." 11 items were removed during testing to ensure content validity. Face validity was confirmed with impact scores > 1.5 for all items. A scale was developed through factor analysis with three factors that accounted for 73.04% of the observed variance. The instrument's reliability using Cronbach's alpha coefficient calculation was reported as 0.94 for the entire instrument. The testretest showed no statistically significant difference between the pre and post-test scores of moral intelligence (p = 0.51). The moral intelligence scale demonstrated acceptable psychometric properties. The moral intelligence scale for health care professionals in the cardiac operating room demonstrated acceptable psychometric properties. This instrument may serve to assess the moral intelligence of healthcare professionals and determine the need for educational interventions to reduce the ethical challenges and improve the moral intelligence of this healthcare.

The Diversity Compass: a clinical ethics support instrument for dialogues on diversity in healthcare organizations.

BACKGROUND: Increasing social pluralism adds to the already existing variety of heterogeneous moral perspectives on good care, health, and quality of life. Pluralism in social identities is also connected to health and care disparities for minoritized patient (i.e. care receiver) populations, and to specific diversity-related moral challenges of healthcare professionals and organizations that aim to deliver diversity-responsive care in an inclusive work environment. Clinical ethics support (CES) services and instruments may help with adequately responding to these diversity-related moral challenges. However, although various CES instruments exist to support healthcare professionals with dealing well with morally challenging situations in healthcare, current tools do not address challenges specifically related to moral pluralism and intersectional aspects of diversity and social justice issues. This article describes the content and developmental process of a novel CES instrument called the Diversity Compass. This instrument was designed with and for healthcare professionals to dialogically address and reflect on moral challenges related to intersectional aspects of diversity and social justice issues that they experience in daily practice. METHODS: We used a participatory development design to develop the Diversity Compass at a large long-term care organization in a major city in the Netherlands. Over a period of thirteen months, we conducted seven focus groups with healthcare professionals and peer-experts, carried out five expert interviews, and facilitated four meetings with a community of practice consisting of various healthcare professionals who developed and tested preliminary versions of the instrument throughout three cycles of iterative co-creation. RESULTS: The Diversity Compass is a practical, dialogical CES instrument that is designed as a small booklet and includes an eight-step deliberation method, as well as a guideline with seven recommendations to support professionals with engaging in dialogue when they are confronted with diversity-related moral challenges. The seven recommendations are key components in working toward creating an inclusive and safe space for dialogue to occur. CONCLUSIONS: The Diversity Compass seeks to support healthcare professionals and organizations in their efforts to facilitate awareness, moral learning and joint reflection on moral challenges related to diversity and social justice issues. It is the first dialogical CES instrument that specifically acknowledges the role of social location in shaping moral perspectives or experiences with systemic injustices. However, to make healthcare more just, an instrument like the Diversity Compass is not enough on its own. In addition to the Diversity Compass, a systemic and structural approach to social justice issues in healthcare organizations is needed in order to foster a more inclusive, safe and diversity-responsive care and work environment in health care organizations.

Family physicians' moral distress when caring for patients experiencing social inequities: a critical narrative inquiry in primary care.

BACKGROUND: Family physicians (GPs) working with patients experiencing social inequities have witnessed patients' healthcare needs proliferate. Alongside increased workload demands fostered within current remuneration structures, this has generated concerning reports of family physician attrition and possible experiences of moral distress. AIM: To explore stories of moral distress shared by family physicians caring for patients experiencing health needs related to social inequities. DESIGN AND SETTING: A critical narrative inquiry, informed by the analytic lens of moral distress, conducted in Ontario, Canada. METHOD: Twenty family physicians were recruited through purposive and snowball sampling via word of mouth and email mailing lists relevant to addictions and mental health care. Physicians participated in two narrative interviews and had the opportunity to review the interview transcripts. RESULTS: Family physicians' accounts of moral distress were linked to policies governing physician remuneration, scope of practice, and the availability of social welfare programmes. These structural elements left physicians unable to get patients much needed support and resources. CONCLUSION: This study provides evidence that physicians experience moral distress when unable to offer crucial resources to improve the health of patients with complex social needs resulting from structural features of the Canadian health and social welfare system. Further research is needed to critically interrogate how health and social welfare systems around the world can be reformed to improve the health of patients and increase family physicians' professional quality of life, potentially improving retention.

'Not in it for huge profits but because it's right': The contested moral economies of UK-India exports in health worker education and training.

While the growth of global markets in health-related services may have significant consequences for healthcare provisioning and training, it has received relatively little attention from the social sciences. This article examines UK-India, and specifically England-India, exports in health worker education and training as one such global market, drawing on sociological scholarship on moral economies to understand how trading in this field is constructed and legitimated by the individuals and organisations involved, what tensions evolve, and what is at stake in them. We employ a qualitative mixed methods approach using publicly available materials on existing UK-India collaborations and primary data from interviews with key stakeholders in India and the UK, including government departments, arms-length bodies, NHS Trusts, trade associations and private providers. Our analysis illustrates the key discursive strategies used to legitimate engagement in these markets, and the complex and contested moral economies unfolding between and across these stakeholders and contexts. Not least, we demonstrate the conflicting moral sentiments and the boundary work required to realise commodification. Situating cross-border trade in health worker education and training in a moral economy framework thus illuminates the social context and moral worlds in which this evolving trade is embedded.

Efficiency or equality? The utilitarianism-egalitarianism trade-off determines carbon allocation preference.

International carbon allocation confronts the conflict between efficiency and equality. Previous research based on the intergroup bias perspective has attributed carbon allocation preference to the defence of ingroup interests (i.e., national interests) while overlooking the critical role of trade-offs between competing moral values. Integrating the contingency theory of justice and moral philosophical theories of utilitarianism and egalitarianism, we proposed that the moral-values trade-off between utilitarianism and egalitarianism determines carbon allocation preference through justice reasoning. Analysis of large-scale survey datasets (Study 1) revealed that aggregated national endorsement of utilitarianism over egalitarianism predicted greater efficiency preference in total and per capita carbon emission levels. Study 2 demonstrated that experimentally manipulating endorsement of utilitarianism versus egalitarianism boosted efficiency (vs. equality) preference in carbon allocation, and justice reasoning characterized by enhanced efficiency-focused justice and diminished equality-focused justice accounted for these effects. Using a 'manipulation-of-mediator' design, Study 3 further confirmed the causal link in the mediation model. By highlighting the significance of moral trade-offs in shaping carbon allocation preference, this research not only provides a novel moral perspective in understanding debates on international carbon allocation but also has important implications for fostering international carbon abatement cooperation.

How does economic inequality shape conspiracy theories? Empirical evidence from China.

Conspiracy theories tend to be prevalent, particularly in societies with high economic inequality. However, few studies have examined the relationship between economic inequality and belief in conspiracy theories. We propose that economic inequality leads people to believe conspiracy theories about economically advantaged groups (i.e., upwards conspiracy theories) and that moral evaluations of those groups mediate this relationship. Study 1 (N = 300) found support for these ideas in a survey among Chinese residents. Study 2 (N = 160) manipulated participants' perceptions of economic inequality in a virtual society. The manipulation shaped moral evaluations of economically advantaged groups, and conspiracy beliefs, in the predicted manner. In Study 3 (N = 191) and Study 4 (N = 210), we experimentally manipulated participants' perceptions of economic inequality in real Chinese society and replicated the results of Study 2. In addition, in Study 4, we find that economic inequality predicts belief in conspiracy theories about economically disadvantaged groups (i.e., downward conspiracy theories), which was mediated by anomie. We conclude that perceived economic inequality predicts conspiracy theories about economically advantaged groups and that moral evaluations account for this effect. Also, upward and downward conspiracy theory beliefs are associated with different psychological processes.

White mock jurors' moral emotional responses to viewing female victim photographs depend on the victim's race.

OBJECTIVE: Jurors often see both premortem photographs of female murder victims before death and postmortem photographs after death. Postmortem photographs are often probative but might prejudicially heighten jurors' other-condemning emotions, such as anger and disgust. Premortem photographs are often not probative and might prejudicially heighten jurors' other-suffering emotions, such as sympathy and empathy. We examined how victim race changes the impact of pre- and postmortem photographs on participants' moral emotions and, in turn, their verdicts. HYPOTHESES: We hypothesized that seeing postmortem (vs. no) photographs would increase convictions through other-condemning emotions for White, but not Latina or Black, victims. We also hypothesized that seeing both pre- and postmortem (vs. only postmortem) photographs would further increase convictions through other-suffering emotions, again for White, but not Latina or Black, female victims. METHOD: White participants (N = 1,261) watched a murder trial video. We manipulated the victim's race (White, Black, or Latina) and whether participants saw no victim photographs, premortem photographs of a female victim, postmortem photographs of a female victim, or both pre- and postmortem photographs. Participants reported the emotions they felt during the trial and chose a verdict. RESULTS: Seeing postmortem (vs. no) victim photographs increased White participants' guilty verdicts through other-condemning emotions when the female victim was White or Latina but not when she was Black. Seeing the combination of pre- and postmortem photographs increased White participants' convictions through other-suffering emotions when the victim was a White woman but not when she was Latina or Black. CONCLUSIONS: Attorneys and judges should consider that jurors' emotional reactions to victim photographs are felt selectively depending on the victim's race and could exacerbate racial biases in jurors' judgments. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A study on the path of governance in health insurance fraud considering moral hazard.

Combating health insurance fraud is of utmost importance to physicians, patients, and health insurers. To delve into the mechanisms of health insurance fraud between doctors and patients, this study employed evolutionary game theory to construct a model that comprehensively considers moral hazard, fraud cost, reward, punishment, bribes from patients, and other factors. Through theoretical analysis and numerical simulation of the model, the study discovered that the evolution of governance behavior in health insurance fraud is closely linked to its initial construction of the payment matrix and the initial selection of parameters for the payment matrix. Additionally, increasing penalties for fraudulent behavior, increasing the cost of fraud for both doctors and patients, and reducing moral hazard for both can effectively drive the final strategy of the system toward a non-fraudulent state. The study aims to provide valuable insights and recommendations to doctors, patients, and medical insurance institutions in establishing a sound governance environment for managing fraud behavior in health insurance.

Virtues in Competency-Based Assessment Frameworks: A Text Analysis.

Introduction: Official documentation of specialty training provides comprehensive and elaborate criteria to assess residents. These criteria are commonly described in terms of competency roles and entrustable professional activities (EPA's), but they may also implicitly encompass virtues. Virtues are desirable personal qualities that enable a person, in this case, a medical specialist, to make and act on the right decisions. We articulate these virtues and explore the resulting implied ideal of a medical professional. Method: We applied a two-staged virtue ethical content analysis to analyze documents, specific to the Dutch training program of the Ear, Nose, and Throat (ENT) specialty. First, we identified explicit references to virtues. Next, we articulated implicit virtues through interpretation. The results were categorized into cardinal, intellectual, moral, and professional virtues. Results: Thirty virtues were identified in the ENT- training program. Amongst them, practical wisdom, temperance, and commitment. Furthermore, integrity, curiosity, flexibility, attentiveness, trustworthiness and calmness are often implicitly assumed. Notable findings are the emphasis on efficiency and effectiveness. Together, these virtues depict an ideal of a future medical specialist. Conclusion: Our findings suggest that competency-frameworks and EPA's implicitly appeal to virtues and articulate a specific ideal surgeon. Explicit attention for virtue development and discussion of the role and relevance of implied ideal professionals in terms of virtues could further improve specialty training.

Medical assistance in dying for people living with mental disorders: a qualitative thematic review.

BACKGROUND: Medical assistance in dying (MAiD) sparks debate in several countries, some of which allow or plan to allow MAiD where a mental disorder is the sole underlying medical condition (MAiD-MD). Since MAiD-MD is becoming permissible in a growing number of jurisdictions, there is a need to better understand the moral concerns related to this option. Gaining a better understanding of the moral concerns at stake is a first step towards identifying ways of addressing them so that MAiD-MD can be successfully introduced and implemented, where legislations allow it. METHODS: Thus, this article aims (1) to better understand the moral concerns regarding MAiD-MD, and (2) to identify potential solutions to promote stakeholders' well-being. A qualitative thematic review was undertaken, which used systematic keyword-driven search and thematic analysis of content. Seventy-four publications met the inclusion criteria. RESULTS: Various moral concerns and proposed solutions were identified and are related to how MAiD-MD is introduced in 5 contexts: (1) Societal context, (2) Healthcare system, (3) Continuum of care, (4) Discussions on the option of MAiD-MD, (5) MAiD-MD practices. We propose this classification of the identified moral concerns because it helps to better understand the various facets of discomfort experienced with MAiD-MD. In so doing, it also directs the various actions to be taken to alleviate these discomforts and promote the well-being of stakeholders. CONCLUSION: The assessment of MAiD-MD applications, which is part of the context of MAiD-MD practices, emerges as the most widespread source of concern. Addressing the moral concerns arising in the five contexts identified could help ease concerns regarding the assessment of MAiD-MD.

Do moral intuitions influence judges' sentencing decisions? A multilevel study of criminal court sentencing in Pennsylvania.

The influence of judges' personal moral values on their sentencing decisions is of longstanding interest to researchers and the public. Few studies, however, have examined this influence empirically. Using a unique data set that combines a survey of 81 criminal court judges with archival data on their 40,385 criminal sentences over a 2-year period, and drawing on Moral Foundations Theory, we hypothesize that judges with strong care and fairness intuitions will sentence defendants less severely while judges with strong loyalty, authority, and sanctity intuitions will sentence defendants more severely. We further hypothesize that these effects will be heightened when the defendant is from a racial minority group. Results show that sentencing outcomes are largely independent of judges' moral intuitions, except that fairness intuitions tend to increase leniency, especially when the defendant is Black, and sanctity intuitions tend to decrease leniency. Implications for future research on sentencing are discussed.

How the minimalist model of ownership psychology can aid in explaining moral behaviors under resource constraints.

The model of ownership psychology as a cognitive adaptation proposes that people flexibly navigate cognitive systems of cooperation and competition, thus enabling them to justify unethical behavior. We discuss how this model captures previous accounts of unethical behavior and propose that a disengagement heuristic can help us understand recent findings in the interconnection between scarcity psychology and unethical behavior.