How the logics of the market, bureaucracy, professionalism and care are reconciled in practice: an empirical ethics approach.

BACKGROUND: In the Netherlands, the for-profit sector has gained a substantial share of nursing home care within just a few years. The ethical question that arises from the growth of for-profit care is whether the market logic can be reconciled with the provision of healthcare. This question relates to the debate on the Moral Limits of Markets (MLM) and commodification of care. METHODS: The contribution of this study is twofold. Firstly, we construct a theoretical framework from existing literature; this theoretical framework differentiates four logics: the market, bureaucracy, professionalism, and care. Secondly, we follow an empirical ethics approach; we used three for-profit nursing homes as case studies and conducted qualitative interviews with various stakeholders. RESULTS: Four main insights emerge from our empirical study. Firstly, there are many aspects of the care relationship (e.g. care environment, personal relationships, management) and every aspect of the relationship should be considered because the four logics are reconciled differently for each aspect. The environment and conditions of for-profit nursing homes are especially commodified. Secondly, for-profit nursing homes pursue a different professional logic from the traditional, non-profit sector - one which is inspired by the logic of care and which contrasts with bureaucratic logic. However, insofar as professionals in for-profit homes are primarily responsive to residents' wishes, the market logic also prevails. Thirdly, a multilevel approach is necessary to study the MLM in the care sector since the degree of commodification differs by level. Lastly, it is difficult for the market to engineer social cohesion among the residents of nursing homes. CONCLUSIONS: The for-profit nursing home sector does embrace the logic of the market but reconciles it with other logics (i.e. logic of care and logic of professionalism). Importantly, for-profit nursing homes have created an environment in which care professionals can provide person-oriented care, thereby reconciling the logic of the market with the logic of care.

[PERSONALIZED MEDICINE AND EBM: ETHICAL ASPECTS]. / LA MÉDECINE PERSONNALISÉE FACE À LA MÉDECINE FACTUELLE : ASPECTS ÉTHIQUES.

More patients are actually treated due to the incredible improvements of medical care, especially in the field of pharmacotherapy. Medical guidelines are based on the results of controlled trials. This kind of medicine, also called Evidence Based Medicine (EBM), is actually the cornerstone of good clinical practice. Nevertheless, it remains a lot of patients disappointed by the fact that they have no medical gain of their treatment. The reason is that each patient has his/her own metabolic characteristics. Better is, the characterization of such patients, better will be the treatment targeting them. It is what is called the personalized medicine. To reach this challenge, pharmacogenetic advances would be helpful. From an antagonism between EBM and personalized medicine, this new medical paradigm has to consider these approaches as partners. To reach this goal, medical doctors, legal authorities and pharmaceutical companies have to be responsible in front of these new ethical challenges.

Contracts to devolve health services in fragile states and developing countries: do ethics matter?

Fragile states and developing countries increasingly contract out health services to non-state providers (NSPs) (such as non-governmental organisations, voluntary sector and private sector). The paper identifies ethical issues when contracts involve devolution of health services to NSPs and proposes procedures to prevent or resolve these ethical dilemmas. Ethical issues were identified by examining processes of contracting out. Health needs could be used to select areas to be contracted out and to identify service needs. Health needs comprise "disease-burden-related needs", "health-service needs", and "urgency of health-service needs". The mix of services should include an analysis of cost-effectiveness. NSPs should be selected fairly, without bias, and conflicts of interest during their work must be avoided. The population's views must be respected and accountability structures established. Devolved health services should ensure equity of access to healthcare. The services ought to be sustainable and evaluated objectively. Of these issues, conflicts of interest among NSPs and sustainability of health services have not attracted attention in the literature on ethics of health policy. Fair procedures could address these ethical issues-for example, public consultation on issues; decisions based on the public consultation and made on evidence; principles of decisions stated and reasonable; decisions given adequate publicity; a mechanism established to challenge decisions; assurance that mechanisms meet the above conditions; and regular review of the policies. These procedures are complemented by improving self-governance of NSPs, countries' development of guidelines for devolving health services, and measures to educate the public of the client countries on these issues.

[Biopiracy: about its legal meanings]. / Biopiratería: Notas en torno a sus significados jurídicos.

This article explores the legal meanings of biopiracy concept, linked to subjects such as intellectual property rights on genetic resources, bioprospecting contracts, right to food, and food security. It overcomes the critical function of biopiracy concept related to world-wide extended tendencies: privatization and technification. Likewise, protectionism shows the opportunity that biopiracy concept represents for the enrichment of the legal interpretation related to the bioethical statue of biotech developments.

Private cord blood banking: experiences and views of pediatric hematopoietic cell transplantation physicians.

OBJECTIVE: Private cord blood banks are for-profit companies that facilitate storage of umbilical cord blood for personal or family use. Pediatric hematopoietic cell transplantation physicians are currently best situated to use cord blood therapeutically. We sought to describe the experiences and views of these physicians regarding private cord blood banking. PARTICIPANTS AND METHODS: We e-mailed a cross-sectional survey to pediatric hematopoietic cell transplantation physicians in the United States and Canada; 93 of 152 potentially eligible physicians (93 of 130 confirmed survey recipients) from 57 centers responded. Questions addressed the number of transplants performed by using privately banked cord blood, willingness to use banked autologous cord blood in specific clinical settings, and recommendations to parents regarding private cord blood banking. RESULTS: Respondents reported having performed 9 autologous and 41 allogeneic transplants using privately banked cord blood. In 36 of 40 allogeneic cases for which data were available, the cord blood had been collected because of a known indication in the recipient. Few respondents would choose autologous cord blood over alternative stem cell sources for treatment of acute lymphoblastic leukemia in second remission. In contrast, 55% would choose autologous cord blood to treat high-risk neuroblastoma, or to treat severe aplastic anemia in the absence of an available sibling donor. No respondent would recommend private cord blood banking for a newborn with 1 healthy sibling when both parents were of northern European descent; 11% would recommend banking when parents were of different minority ethnicities. CONCLUSIONS: Few transplants have been performed by using cord blood stored in the absence of a known indication in the recipient. Willingness to use banked autologous cord blood varies depending on disease and availability of alternative stem cell sources. Few pediatric hematopoietic cell transplantation physicians endorse private cord blood banking in the absence of an identified recipient, even for mixed-ethnicity children for whom finding a suitably matched unrelated donor may be difficult.

The politics of underdevelopment: metered to death-how a water experiment caused riots and a cholera epidemic.

Water privatization programs in South Africa, part of a government policy aimed at making people pay for the full cost of running water ("total cost recovery"), was developed by private water companies and the World Bank to finance improved water supplies and build the country's economy. Instead the programs are causing more misery than development. Millions of poor people have had their water supply cut off because of inability to pay, forcing them to get their water from polluted rivers and lakes and leading to South Africa's worst cholera outbreak--which the government paid millions of dollars to control. Residents in some townships are rebelling, and many of the private multinational water companies are reassessing their involvement in South Africa.