Empirical Investigation of Ethical Challenges Related to the Use of Biological Therapies.

The aim of this study was to investigate the ethical dilemma of prioritising financial resources to expensive biological therapies. For this purpose, the four principles of biomedical ethics formulated by ethicists Tom Beauchamp and James Childress were used as a theoretical framework. Based on arguments of justice, Beauchamp and Childress advocate for a health care system organised in line with the Danish system. Notably, our study was carried out in a Danish setting.

Communities as 'renewable energy' for healthcare services? a multimethods study into the form, scale and role of voluntary support for community hospitals in England.

OBJECTIVE: To examine the forms, scale and role of community and voluntary support for community hospitals in England. DESIGN: A multimethods study. Quantitative analysis of Charity Commission data on levels of volunteering and voluntary income for charities supporting community hospitals. Nine qualitative case studies of community hospitals and their surrounding communities, including interviews and focus groups. SETTING: Community hospitals in England and their surrounding communities. PARTICIPANTS: Charity Commission data for 245 community hospital Leagues of Friends. Interviews with staff (89), patients (60), carers (28), volunteers (35), community representatives (20), managers and commissioners (9). Focus groups with multidisciplinary teams (8 groups across nine sites, involving 43 respondents), volunteers (6 groups, 33 respondents) and community stakeholders (8 groups, 54 respondents). RESULTS: Communities support community hospitals through: human resources (average=24 volunteers a year per hospital); financial resources (median voluntary income = £15 632); practical resources through services and activities provided by voluntary and community groups; and intellectual resources (eg, consultation and coproduction). Communities provide valuable supplementary resources to the National Health Service, enhancing community hospital services, patient experience, staff morale and volunteer well-being. Such resources, however, vary in level and form from hospital to hospital and over time: voluntary income is on the decline, as is membership of League of Friends, and it can be hard to recruit regular, active volunteers. CONCLUSIONS: Communities can be a significant resource for healthcare services, in ways which can enhance patient experience and service quality. Harnessing that resource, however, is not straight forward and there is a perception that it might be becoming more difficult questioning the extent to which it can be considered sustainable or 'renewable'.

Challenges in the delivery of surgical care for head and neck cancer patients in the Hong Kong Special Administrative Region and China.

PURPOSE OF REVIEW: This article aims to explore the ethical dilemmas faced by head and neck surgeons in the Hong Kong Special Administrative Region (HKSAR) and China in the provision of safe, oncological sound and timely care for head and neck cancer patients. RECENT FINDINGS: There is no literature, in particular, in relation to the treatment of head and neck cancer patients and priority setting in head and neck surgery. However, through examining the healthcare provision and sociocultural backgrounds of the HKSAR and China, certain aspects, such as traditional Chinese medicine and medical guan xi (Seeking medical care for personal connections) have been shown to significantly influence the provision of care in China. Medical guan xi facilitates inequity and is problematic in developing a system based on justice, equity, nonmalfeasance and beneficence. In the HKSAR, resource limitations are related to the maldistribution of healthcare between the public and private sectors, resulting in significant time constraints for surgery and oncology care of patients. There is informal application of ethical frameworks for priority setting, however, these have neither been formally supported nor enforced from an administrative level that needs to be addressed. SUMMARY: In the HKSAR, there needs to be a strengthening of an ethical framework for priority setting to adhere to justice for our patients and healthcare providers in treating head and neck cancer patients. In China, priority setting is largely set by sociocultural practices that are endemic, in particular, medical guan xi that is inequitable and needs to be addressed to improve the doctor-patient relationship.

Appeal to the Rule of Rescue in health care: discriminating and not benevolent?

Thirty years of debate have passed since the term "Rule of Rescue" has been introduced into medical ethics. Its main focus was on whether or why medical treatment for acute conditions should have priority over preventive measures irrespective of opportunity costs. Recent contributions, taking account of the widespread reluctance to accept purely efficiency-oriented prioritization approaches, advance another objection: Prioritizing treatment, they hold, discriminates against statistical lives. The reference to opportunity costs has also been renewed in a distinctly ethical fashion: It has been stipulated that favoring help for identifiable lives amounts to a lack of benevolence for one's fellow creatures. The present article argues against both objections. It suggests that the debate's focus on consequences (deaths or severe ill health) should be reoriented by asking which aspects of such states of affairs are actually attributable to a decision maker who judges within a specific situation of choice.

Cultural, ethical, and spiritual implications of natural disasters from the survivors' perspective.

Cultural, ethical, and spiritual implications of disaster depend on various factors. The impact of a disaster on a particular culture depends on the people in that culture and the strength and resilience of the culture. Disasters may slow cultural development; however, typically the customs, beliefs, and value systems remain the same even if the outward expressions of culture change. Critical to survivors is the implication of aid that is culturally sensitive. Ethical questions and dilemmas associated with disasters and their management are profound. Adhering to ethical principles does not solve all of the issues related to disaster management, but awareness of their utility is important. People affected by a disaster may not be capable of responding to human rights violations, so it is the first responders who must be cognizant of their responsibility to protect the victims' dignity and rights. Ethical treatment of survivors entails a crucial blend of knowledge about ethnic culture, religious beliefs, and human rights. A strong awareness of ethical principles is merely a beginning step to well-informed decision making in disaster situations. The literature also suggests that during a crisis, spirituality helps victims to cope. Important to any catastrophic event is the understanding that every disaster creates unique circumstances that require relief responses tailored to the specific situation.

Priority dilemmas in psoriasis care and visions of a future care in a group of administrators, politicians and professionals in northern Sweden.

During the 1990s priority discussions were actualized in Sweden due to increased demands on health care and limited resources. In the county of Västerbotten in northern Sweden, with large rural areas, the decision makers faced special challenges due to distances and cost. Despite discussions striving for fairness in priorities, decision makers are still dealing with limited resources and difficult priority decisions regarding different diseases and treatments. In this study we aimed at describing views on priorities in public psoriasis care and visions of a future care among politicians, administrators and professionals in the county of Västerbottten in northern Sweden. Qualitative research interviews were performed with 23 key-persons. The findings revealed priority dilemmas about issues on organization, accessibility and ethics. Visions of a future care appeared as ambitions of a more effective care with good accessibility, continued research, information and a holistic approach in priorities. We conclude that dilemmas revealed in this study were a reflection of a gap between intentions and practice. In efforts to reduce these dilemmas we suggest methods with fairness in economic planning and priority setting, with concrete, official statements about the dominating views on which the priorities are based, and public information about these statements.

A strategy to improve priority setting in developing countries.

Because the demand for health services outstrips the available resources, priority setting is one of the most difficult issues faced by health policy makers, particularly those in developing countries. Priority setting in developing countries is fraught with uncertainty due to lack of credible information, weak priority setting institutions, and unclear priority setting processes. Efforts to improve priority setting in these contexts have focused on providing information and tools. In this paper we argue that priority setting is a value laden and political process, and although important, the available information and tools are not sufficient to address the priority setting challenges in developing countries. Additional complementary efforts are required. Hence, a strategy to improve priority setting in developing countries should also include: (i) capturing current priority setting practices, (ii) improving the legitimacy and capacity of institutions that set priorities, and (iii) developing fair priority setting processes.

Evidence, economics and ethics: resource allocation in health services organizations.

Priority setting is a challenge for health services organizations across health systems. Because demand for health services exceeds available resources, health services priorities must be set to ensure resources are used appropriately to meet the community's health needs. Various approaches have been developed to assist decision-makers to set priorities in their organizations. The dominant approaches come from evidence-based medicine, economics and ethics.

Understanding the role of "the hidden curriculum" in resource allocation--the case of the UK NHS.

In this paper we want to briefly illustrate the ways in which technical, ethical and political judgements of various kinds are interwoven in the processes of healthcare decision-making in the UK. Drawing upon the research for the "Choices in Health Care" project we will borrow the notion of the hidden curriculum from education to illuminate the nature of resource allocation decision processes. In particular we will indicate some of the fundamental but largely hidden political factors in play in these processes and the importance of the inchoate and implicit notion of "NHS values" in shaping UK resource allocation policies. We suggest that these more diffuse, holistic and system level value judgements are both central to understanding priority setting and at the same time difficult to reduce or abstract out into lists of single values/principles.

What kind of evidence is it that Evidence-Based Medicine advocates want health care providers and consumers to pay attention to?

BACKGROUND: In 1992, Evidence-Based Medicine advocates proclaimed a "new paradigm", in which evidence from health care research is the best basis for decisions for individual patients and health systems. Hailed in New York Times Magazine in 2001 as one of the most influential ideas of the year, this approach was initially and provocatively pitted against the traditional teaching of medicine, in which the key elements of knowing for clinical purposes are understanding of basic pathophysiologic mechanisms of disease coupled with clinical experience. This paper reviews the origins, aspirations, philosophical limitations, and practical challenges of evidence-based medicine. DISCUSSION: EBM has long since evolved beyond its initial (mis)conception, that EBM might replace traditional medicine. EBM is now attempting to augment rather than replace individual clinical experience and understanding of basic disease mechanisms. EBM must continue to evolve, however, to address a number of issues including scientific underpinnings, moral stance and consequences, and practical matters of dissemination and application. For example, accelerating the transfer of research findings into clinical practice is often based on incomplete evidence from selected groups of people, who experience a marginal benefit from an expensive technology, raising issues of the generalizability of the findings, and increasing problems with how many and who can afford the new innovations in care. SUMMARY: Advocates of evidence-based medicine want clinicians and consumers to pay attention to the best findings from health care research that are both valid and ready for clinical application. Much remains to be done to reach this goal.