Will my patients get their residence permit? A critical analysis of the ethical dilemmas involved in writing medical certificates for residence permits in France.

BACKGROUND: France has long been a country of immigration and in some respects may be seen to have a generous policy with respect to asylum seekers and access to health care for migrants. The French state notably provides healthcare access for undocumented migrants, through state medical aid and since 1998 has had a humanitarian policy for granting temporary residence permits for medical reason (TRPMR) to migrants. Within a context of political debate, reform and tightening immigration control we will examine this latter policy focusing especially on the dilemmas that arise for physicians of migrant patients when they are requested to write medical certificates as part of a TRPMR application. In a 2017 reform the key role of making recommendations on the granting or not of permits was handed over to Ministry of the Interior health inspectors. Recommendations are made after perusal of medical certificates established by the migrant's physician and complementary evidence. MAIN BODY: The writing of medical certificates by a physician would seem straightforward. This is far from the case since it raises a number of ethical dilemmas. These occur within a physician-patient relationship embedded within a social contract between the State, the physician and the migrant patient. To clarify the ethical issues arising 3 vignettes based on practice within an infectious disease unit at a large Paris hospital have been developed. The vignettes highlight ethical dilemmas in the care for migrants with tuberculosis (dilemma in defining health and disease), chronic hepatitis (dilemma between beneficence and do not harm), and HIV / AIDS (issue of deservingness). We will go on to reflect on issues of social justice and responsibility for the health of migrants within a globalized world. CONCLUSIONS: Criteria for residence permit delivery appear less than clear-cut and are interpreted in a restrictive way. Neither are the consequences of refusing a residence permit taken into account. We call for an empirical transnational ethics study involving countries implementing similar TRPMR policies. We also call for inclusion of lobbying competences into the medical undergraduate curricula, in order to breed future generations of physicians skilled in defending social justice.

Dentists' perspectives on barriers to providing oral health care in French psychiatric hospitals with on-site dental clinics.

OBJECTIVES: Psychiatric inpatients suffer from poorer oral health than the general population, and difficulties in accessing necessary dental treatment remain even when a dedicated dental service is available within the psychiatric hospital. The aim of this study was to identify barriers to access dental care from the point of view of dentists working within French psychiatric hospitals. METHODS: The relatively small number of dentists working in psychiatric hospitals necessitated a qualitative approach. Semi-structured interviews were conducted, recorded, transcribed and coded in a conventional content analysis approach. RESULTS: Eight interviews were conducted. Six of the dentists interviewed were men, and two were women. Three of them worked full-time in a psychiatric facility, while the other five worked partly in the hospital and partly in private practice. The average duration for interviews was 54 minutes (minimum 24 min, maximum 89 min). The interviews highlighted three dimensions of barriers to access to dental care. The first dimension was directly related to the patient. This may be linked to the patient's psychiatric disorder but not necessarily. This also encompasses refusal of care. A second dimension regrouped events related to the organization of the hospital (locally), such as communication issues between staff members within the dental office, and with other staff members from the psychiatric ward. A third dimension included difficulties related to the overall organization of the healthcare system, including financial issues and deinstitutionalization. CONCLUSIONS: In-site dental consultations appear as an interesting tool to enhance access to oral care for psychiatric inpatients. However, difficulties remain from the dentists' perspective.

Policy Makers', NGO, and Healthcare Workers' Accounts of Migrants' and Refugees' Healthcare Access Across Europe-Human Rights and Citizenship Based Claims.

Freely available healthcare, universally accessible to the population of citizens, is a key ideal for European welfare systems. As labor migration of the twentieth century gave way to the globalized streams of the twenty-first century, new challenges to fulfilling these ideals have emerged. The principle of freedom of movement, together with large-scale forced migration have led to large scale movements of people, making new demands on European healthcare systems which had previously been largely focused on meeting sedentary local populations' needs. Drawing on interviews with service providers working for NGOs and public healthcare systems and with policy makers across 10 European countries, this paper considers how forced migrants' healthcare needs are addressed by national health systems, with factors hindering access at organizational and individual level in particular focus. The ways in which refugees' and migrants' healthcare access is prevented are considered in terms of claims based on citizenship and on the human right to health and healthcare. Where claims based on citizenship are denied and there is no means of asserting the human right to health, migrants are caught in a new form of inequality.

Autism and the right to education in the EU: Policy mapping and scoping review of the United Kingdom, France, Poland and Spain.

INTRODUCTION: Autistic people may have different educational needs that need to be met to allow them to develop their full potential. Education and disability policies remain within the competence of EU Member States, with current educational standards and provisions for autistic people implemented locally. This scoping review aims to map EU and national special education policies with the goal of scoping the level of fulfilment of the right to education of autistic people. METHODS: Four EU countries (United Kingdom, France, Poland and Spain) were included in this scoping review study. Governmental policies in the field of education, special education needs and disability law were included. Path dependency framework was used for data analysis; a net of inter-dependencies between international, EU and national policies was created. RESULTS AND DISCUSSION: Each country created policies where the right to free education without discrimination is provided. Poland does not have an autism specific strategy, whereas the United Kingdom, France and Spain have policies specifically designed for autistic individuals. Within the United Kingdom, all countries created different autism plans, nevertheless all aim to reach the same goal-inclusive education for autistic children that leads to the development of their full potential. CONCLUSION: Policy-making across Europe in the field of education has been changing through the years in favour of autistic people. Today their rights are noticed and considered, but there is still room for improvement. Results showed that approaches and policies vastly differ between countries, more Member States should be analysed in a similar manner to gain a broader and clearer view with a special focus on disability rights in Central and Eastern Europe.

Seeking mental health care from private health practitioners among individuals with alcohol dependence/abuse; results from a study in the French general population.

INTRODUCTION: Better knowledge of the factors that have an impact on pathways to mental health care may contribute greatly to organizing optimum health-care delivery. However, surveillance systems concerning alcohol problems in the French general population are suboptimal. The objectives of this study were to investigate: 1) the prevalence of mental health-care seeking in individuals with alcohol abuse/dependence in France, 2) which category of medical practitioner was consulted, and 3) psychological and socio-environmental factors associated with mental health-care seeking. METHODS: A total sample of 22,138 individuals was interviewed in a telephone survey. Individual data on alcohol dependence/abuse and other mental health disorders were collected using the Composite International Diagnosis Interview - short form. Mental health-care seeking was assessed, together with data on living conditions, deprivation, and self-reported drinking problems. Only respondents meeting criteria for alcohol dependence/abuse were included in analyses. RESULTS: Less than half of the 722 respondents with alcohol abuse/dependence had sought mental health care in the preceding 12 months, of whom 90.5% consulted their general practitioner (GP) (56.1%), or both a general practitioner and a psychiatrist (34.4%). Mental health-care seeking was associated with female sex, previous alcohol discussion with a doctor, and the presence of psychiatric comorbidities arising in the preceding 12 months. Living environment, socio-economic status, or self-reported drinking problems had no influence. DISCUSSION: A minority of people with alcohol abuse/dependence sought mental health care, mainly in relation to psychiatric comorbidities. In addition, most people consulting a GP were not referred to a psychiatrist. However, social deprivation and living in rural areas did not hinder mental health-care seeking among respondents. Adequate protocols to treat alcohol disorders could be implemented among private health-care providers to improve management of alcohol problems in France.

[Ebola, a matter of trust]. / Ebola, question de confiance.

An outbreak of Ebola occurred in 2014-2015 in Guinea, Liberia and Sierra Leone. Two opposing hypotheses may be put forward to explain its decline in these countries. The first of which attributes this decline to authoritarian emergency action imposed on the populations. This comprised the opening of specialized centres to fight the epidemic, directing people suspected of being contaminated to travel to such centres, and taking charge of cremating the remains of the deceased victims of Ebola. This process was founded on the supposed weaknesses of the health systems in question and sought to offer a substitute for them. The second hypothesis suggests that the reduction of the number of Ebola cases in West Africa was due to the combined efforts of civil society and the local health services facing up to this new challenge. This explanation is based on the experience of the Democratic Republic of the Congo which has confronted seven epidemics of Ebola since 1976 and which privileged the mobilization of local capacities involving both the health services and the community. This last hypothesis is built on the appreciation of local strengths and strives to mobilize and facilitate such assets. What was the impact of such radically different approaches to managing the outbreak?

Teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes.

BACKGROUND: Teaching ethics in public health programmes is not routine everywhere - at least not in most schools of public health in the European region. Yet empirical evidence shows that schools of public health are more and more interested in the integration of ethics in their curricula, since public health professionals often have to face difficult ethical decisions. DISCUSSION: The authors have developed and practiced an approach to how ethics can be taught even in crowded curricula, requiring five to eight hours of teaching and learning contact time. In this way, if programme curricula do not allow more time for ethics, students of public health can at least be sensitised to ethics and ethical argumentation. This approach - focusing on the application of seven mid-level principles to cases (non-maleficence, beneficence, health maximisation, efficiency, respect for autonomy, justice, proportionality) - is presented in this paper. Easy to use 'tools' applying ethics to public health are presented. SUMMARY: The crowded nature of the public health curriculum, and the nature of students participating in it, required us to devise and develop a short course, and to use techniques that were likely to provide a relatively efficient introduction to the processes, content and methods involved in the field of ethics.

Why the French did not choose to panic: a dynamic analysis of the public response to the influenza pandemic.

To understand the French public's response to the 2009 pandemic A/H1N1 influenza health threat a sequence analysis framework has been employed mobilising different theoretical strands such as innovations diffusion theory, surprise theory and social representation theory. These tend to suggest that disease episodes, public health policy and the public's response should be considered within a larger socio-cognitive frame incorporating representations anchored by prior disease episodes and campaigns. It is suggested in this article that the public's response was greatly influenced by the pervasive anchoring of the social representations of the pandemic threat to the 1918 Spanish flu in the lay and scientific media. These representations were eventually seen not to match the reality of the disease and consequently the French public did not panic during the 2009 pandemic. This hypothesis has been tested empirically by examining retrospective media, bibliographical data and an analysis of risk perception carried out through three cross-sectional studies prior to and during the pandemic episode and one month after the launch of the vaccination campaign. These findings suggest that alarmist framings of health threats may be counterproductive since they may reduce the capacity of public health organisations to mobilise the public in the case of more serious emerging disease.