The factors impeding health system reform in Iraqi Kurdistan region.

The relatively poor health outcomes in Iraq have been attributed to the inability to address the shortfalls in the public health model. Calls for health system reform in Iraqi Kurdistan Region started in 2004; however, few, if any, significant changes have been achieved since then. This research examines the factors impeding public health system reform in the Iraqi Kurdistan Region, as perceived by the health policy makers, through 11 in-depth, unstructured interviews. Participants attributed the delay in reform to 16 impeding factors that can be categorized into 5 major themes: historical, ethical, cultural, political and institutional. The intricate network of these inter-dependent factors provides a possible explanation for the failure or unsustainability of reform efforts. Reform initiatives might have a better chance of success if they take into consideration the well-established and unique background and social construct in Iraq, as well as the impact of decades of conflict and insecurity, both of which influence the individual and institutional reasoning and behaviour across the entire health system.

Against proportional shortfall as a priority-setting principle.

As the demand for healthcare rises, so does the need for priority setting in healthcare. In this paper, I consider a prominent priority-setting principle: proportional shortfall. My purpose is to argue that proportional shortfall, as a principle, should not be adopted. My key criticism is that proportional shortfall fails to consider past health.Proportional shortfall is justified as it supposedly balances concern for prospective health while still accounting for lifetime health, even though past health is deemed irrelevant. Accounting for this lifetime perspective means that the principle may indirectly consider past health by accounting for how far an individual is from achieving a complete, healthy life. I argue that proportional shortfall does not account for this lifetime perspective as it fails to incorporate the fair innings argument as originally claimed, undermining its purported justification.I go on to demonstrate that the case for ignoring past health is weak, and argue that past health is at least sometimes relevant for priority-setting decisions. Specifically, when an individual's past health has a direct impact on current or future health, and when one individual has enjoyed significantly more healthy life years than another.Finally, I demonstrate that by ignoring past illnesses, even those entirely unrelated to their current illness, proportional shortfall can lead to instances of double jeopardy, a highly problematic implication. These arguments give us reason to reject proportional shortfall.

Salve Lucrum: The Existential Threat of Greed in US Health Care.

In this Viewpoint, Donald Berwick explores the pursuit of profit in US health care across sectors­such as pharmaceutical companies, insurers, hospitals, and physician practices­and its harms to patients, and then offers potential solutions.

The evolution of public health ethics frameworks: systematic review of moral values and norms in public health policy.

Given the evolution of the public health (PH) and the changes from the phenomenon of globalization, this area has encountered new ethical challenges. In order to find a coherent approach to address ethical issues in PH policy, this study aimed to identify the evolution of public health ethics (PHE) frameworks and the main moral values and norms in PH practice and policy. According to the research questions, a systematic search of the literature, in English, with no time limit was performed using the main keywords in databases Web of Science (ISI) and PubMed. Finally, the full text of 56 papers was analyzed. Most of the frameworks have common underpinning assumptions and beliefs, and the need to balance PH moral obligation to prevent harm and health promotion with respect for individual autonomy has been specified. As such, a clear shift from liberal values in biomedical ethics is seen toward the community's collective values in PHE. The main moral norms in PH practice and policy included protecting the population against harm and improving PH benefits, utility and evidenced-based effectiveness, distributive justice and fairness, respect for all, privacy and confidentiality, solidarity, social responsibility, community empowerment and participation, transparency, accountability and trust. Systematic review of PHE frameworks indicates utilization of the aforementioned moral norms through an practical framework as an ethical guide for action in the PH policy. The validity of this process requires a systematic approach including procedural conditions.

Liberty in Health Care: A Comparative Study Between Hong Kong and Mainland China.

This essay contends that individual liberty, understood as the permissibility of making choices about one's own health care in support of one's own good and the good of one's family utilizing private resources, is central to the moral foundations of a health care system. Such individual freedoms are important not only because they often support more efficient and effective health care services, but because they permit individuals to fulfill important moral duties. A comparative study of the health care systems in Hong Kong and mainland China is utilized to illustrate the conceptual and moral concerns at stake. Both regions have implemented two-tier health care systems with a public tier of basic health care services together with a second tier of privately purchased health care. As we document, Hong Kong permits patients and doctors significantly greater opportunities to choose private health care of typically higher medical quality than their mainland counterparts. As a result, individuals are able to obtain higher quality health care while also fulfilling important moral duties for themselves and their families. In this sense, Hong Kong's health care system is morally superior to mainland China's. In each case, Confucianism's concerns regarding equality are partly satisfied through the provision of public health care services on the basic tier, while appropriate use of private resources in support of oneself and one's family is permissibly exercised on the private tier. Although it is true that inequalities in health care access and outcome are inevitable within a system that permits such individual freedoms, we argue that such inequalities are morally justifiable in terms of Confucian ethical thought.

An Ethical Analysis of Performance-Based Supplementary Payment in Turkey's Healthcare System.

In 2003 Turkey introduced the Health Transition Program to develop easily accessible, high-quality, and effective healthcare services for the population. This program, like other health reforms, has three primary goals: to improve health status, to enhance financial protection, and to ensure patients' satisfaction. Although there is considerable literature on the anticipated positive results of such health reforms, little evidence exists on their current effectiveness. One of the main initiatives of this health reform is a performance-based supplementary payment system, an additional payment healthcare professionals receive each month in addition to their regular salaries. This system may cause some ethical problems. Physicians have an ethical duty to provide high-quality care to each patient; however, pay-for-performance and other programs that create strong incentives for high-quality care set up a potential conflict between this duty and the competing interest of complying with a performance measure.

Ethical Study on the Reform and Development of Medical and Health Services in China.

At an early stage of its foundation, new China became clear about the nature of public welfare and quickly developed medical and health services, which was well received by the World Health Organization. The marketization and the reduction of input into medical and health services from the 1980s created severe adverse consequences. After the SARS' outbreak in 2003, China started to give serious consideration to its medical and health system, and to work at developing medical and health services. The new healthcare reform launched in 2009 re-emphasizes fairness and public welfare, and China's achievements have been remarkable. Of course, there are still many problems to be solved in the reform, which also paves the way for increasing the reform in future.

When ethical reform became law: the constitutional concerns raised by recent legislation in Taiwan.

In an effort at ethical reform, Taiwan recently revised the Hospice Palliative Care Law authorising family members or physicians to make surrogate decisions to discontinue life-sustaining treatment if an incompetent terminally ill patient did not express their wishes while still competent. In particular, Article 7 of the new law authorises the palliative care team, namely the physicians, to act as sole decision-makers on behalf of the incompetent terminally ill patient's best interests if no family member is available. However, the law fails to provide guidance as to what constitutes the patient's best interests or what specific procedures the treating physicians should follow, and so has raised constitutional concerns. It may be difficult to translate ethical reform into law but it is not impossible if essential requirements are carefully followed. First, there must be substantial nexus between the purpose of the statute and the measures provided under the statute. Second, advocates need to convince the public that futility or waste has amounted to a public health emergency so as to justify lower procedural requirements. Third, a remedy or compensation should be available if the surrogate decisions have not been appropriately made. Fourth,minimum procedural safeguards are necessary even though the statute is intended to reduce the procedural burdens of making surrogate decisions on behalf of incompetent patients who lack family members and did not express their wishes while still competent.

[Psychiatry with open doors. Part 1: Rational for an open door for acute psychiatry]. / Psychiatrie mit offenen Türen. Teil 1: Rational für Türöffnungen in der Akutpsychiatrie.

Despite the reform efforts of the last decades modern acute psychiatry still stands between conflicting priorities in everyday practice. The protection of patient autonomy might conflict with a regulatory mandate of psychiatry in societal contexts and the necessity of coercive measures and involuntary treatment might become problematic with respect to presumed but contentious interests of the patient. The conflicts particularly concern questions of involuntary commitment, door closing, coercive and isolation measures. Research on the topic of therapeutic effectiveness of these practices is rare. Accordingly, the practice depends on the federal state, hospital and ward and is very heterogeneous. Epidemiological prognosis predicts an increase of psychiatric disorders; however, simultaneously in terms of medical ethics the warranty of patient autonomy, shared decision-making and informed consent in psychiatry become increasingly more important. This challenges structural and practical changes in psychiatry, particularly in situations of self and third party endangerment which are outlined and a rationale for an opening of the doors in acute psychiatric wards is provided.

[Psychiatry with open doors. Part 2: Therapeutic challenges]. / Psychiatrie mit offenen Türen. Teil 2: Therapeutische Herausforderungen.

In the previous part of the issue we argued that opening the doors of acute psychiatric inpatient wards is actually one of the anchor points on the way to an innovative psychiatry. It focuses on the patient's personality in a sense that this is taken as seriously as the psychiatric disorder itself. Patients and relatives should be enabled to participate in treatment decisions as they should experience that treatment teams are concerned about reliance, liability and security in therapeutic relationships in an empathetic way. The second part of the issue contributes to the therapeutic measures, the different skills and modifications of treatment frameworks in acute psychiatry (e.g. prevention of crowding in acute psychiatric inpatient units, education of staff, assessment of the risks of violence, de-escalation strategies and coping with suicidality). They might be helpful in implementing the outlined confidence about the essence of therapeutic relationships, autonomy and codetermination of patients in treatment. These suggestions might enhance a professional approach particularly with respect to prevention and also concerning acute interventions in situations of endangerment to self and others and of aggression and violence in the units. In this way they help to achieve the goal of open doors in psychiatry.

HUMAN RIGHTS AND NIGERIAN PRISONERS--ARE PRISONERS NOT HUMANS?

In Nigeria, just like in many other parts of the world, one of the most extensively discussed issues on the public agenda today is the increase in prison population. The aims of imprisonment are protection, retribution, deterrence, reformation and vindication. Investigations revealed that the prison services have been,neglected more than any other criminal justice agency in Nigeria. For example, most of the prisons were built during the colonial era for the purpose of accommodating a small number of inmates. Human Rights are the basic guarantees for human beings to be able to achieve happiness and self-respect; consequently, in most jurisdictions, the Human Rights Act confirms that these Rights do not stop at the prison gates. However, most States fail to meet the Human Rights obligations of their prisoners. As regards to health, for example, every prison should have proper health facilities and medical staff to provide dental and psychiatric care among others. This article discusses the Nigerian Prison System and challenges, trends and the related Human Rights and Ethical issues in Nigerian prisons. Some of the unmet needs of Nigerian prisoners which include, inter alia, living in unwholesome cells, delayed trial of inmates, lack of voting rights, access to information, lack of conjugal facilities for married prisoners, poor and inadequate nutrition, poor medical care, torture, inhumane treatment and the need to protect prisoners in a changing world. The present report has policy implications for reforming prison services in Nigeria, and countries that sing from the same song sheet with Nigeria on prison services, to conform to the Fundamental Human Rights of prisoners in the 21St century.

Phase changes in the BRCA policy domain.

The recent US Supreme Court ruling against gene patenting has been accompanied by the passage at the federal level of the Patient Protection and Affordable Care Act, both events representing a thawing or phase change in policies that will now make preventive techniques, such as BRCA genetic testing to predict risk for familial breast and ovarian cancer, more affordable and accessible. Authors including Yun-Han Huang in this journal have noted the judicial ruling is one step--a significant one--in the process of patent system reform. This commentary links such changes with policy formation and action taken by members of diverse religious communities in the aftermath of the Human Genome Project and continuing in today's genome sequencing area. Religious engagement has acted as a catalyzing force for change in the creation and dissemination of genetic developments. Religious perspectives are needed to solve the new ethical dilemmas posed by population screening for BRCA mutations and the rise of direct-to-consumer and provider marketing of such genetic tests, which have far-reaching consequences at the individual, family, and societal levels.

The patient-centered medical home: an ethical analysis of principles and practice.

The patient-centered medical home (PCMH), with its focus on patient-centered care, holds promise as a way to reinvigorate the primary care of patients and as a necessary component of health care reform. While its tenets have been the subject of review, the ethical dimensions of the PCMH have not been fully explored. Consideration of the ethical foundations for the core principles of the PCMH can and should be part of the debate concerning its merits. The PCMH can align with the principles of medical ethics and potentially strengthen the patient-physician relationship and aspects of health care that patients value. Patient choice and these ethical considerations are central and at least as important as the economic and practical arguments in support of the PCMH, if not more so. Further, the ethical principles that support key concepts of the PCMH have implications for the design and implementation of the PCMH. This paper explores the PCMH in light of core principles of ethics and professionalism, with an emphasis both on how the concept of the PCMH may reinforce core ethical principles of medical practice and on further implications of these principles.

The NHS and market forces in healthcare: the need for organisational ethics.

The NHS in England is an organisation undergoing substantial change. The passage of the Health and Social Care Act 2012, consolidates and builds on previous health policies and introduces further 'market-style' reforms of the NHS. One of the main aspects of these reforms is to encourage private and third sector providers to deliver NHS services. The rationale for this is to foster a more competitive market in healthcare to encourage greater efficiency and innovation. This changing healthcare environment in the English NHS sharpens the need for attention to be paid to the ethical operation of healthcare organisations. All healthcare organisations need to consider the ethical aspects of their operation, whether state or privately run. However, the changes in the type of organisations used to provide healthcare (such as commercial companies) can create new relationships and ethical tensions. This paper will chart the development of organisational ethics as a concern in applied ethics and how it arose in the USA largely owing to changes in the organisation of healthcare financing and provision. It will be argued that an analogous transition is happening in the NHS in England. The paper will conclude with suggestions for the development of organisational ethics programmes to address some of the possible ethical issues raised by this new healthcare environment that incorporates both private and public sector providers.

Radiology's ethical responsibility for healthcare reform: tempering the overutilization of medical imaging and trimming down a heavyweight.

In this review we describe the problem of overutilization of high-cost imaging modalities, especially magnetic resonance imaging (MRI) and computed tomography (CT). The overuse of CT is numerically more dramatic and also carries with it the not insignificant risk of harm to patients, namely, induction of radiation-induced malignancies. We report what is known of these risks in various imaging scenarios. The use of Radiology Business Managers is described as a means adopted to control overuse and the limitations of this strategy. The imperative of appropriate utilization is focused on, with emphasis placed on computer-based medical decision support. Impediments to appropriate use, however, exist, with concerns of medicolegal liability high on the list of these issues. Finally, we recommend that radiologists take the lead in the reform process by implementing strategies such as decision support.

Problems and the potential direction of reforms for the current individual medical savings accounts in the Chinese health care system.

Individual health savings accounts are an important part of the current basic medical insurance system for urban workers in China. Since 1998 when the system of personal medical insurance accounts was first implemented, there has been considerable controversy over its function and significance within different social communities. This paper analyzes the main problems in the practical implementation of individual medical insurance accounts and discusses the social and cultural foundations for the establishment of family health savings accounts from the perspective of Chinese Confucian familism. Accordingly, it addresses the direction of the reform and the development of the current system of individual health insurance accounts in China.

Individuals are inadequate: recognizing the family-centeredness of Chinese bioethics and Chinese health system.

This paper is aimed at a critical assessment of the moral framework of the current Chinese health system from a Confucian perspective, by focusing on the debate between the individual directed approach and the family-oriented approach to a health care system. Concerned with the nature and status of the family in communal life, the paper deals with the following questions: to cope with the frailties of material life (including susceptibility to disease), what good is presupposed by human existence and flourishing; why it is the family that serves as the primary locus of bearing and realizing this unique good; and what kind of society might possess the structures necessary to achieve the good thus conceived. All these questions lead to a revision of the theory of justice required in health care, in favor of family health saving accounts as an important institutional guarantee.

Values and health care: the Confucian dimension in health care reform.

Are values and social priorities universal, or do they vary across geography, culture, and time? This question is very relevant to Asia's emerging economies that are increasingly looking at Western models for answers to their own outmoded health care systems that are in dire need of reform. But is it safe for them to do so without sufficient regard to their own social, political, and philosophical moorings? This article argues that historical and cultural legacies influence prevailing social values with regard to health care financing and resource allocation, and that the Confucian dimension provides a helpful entry point for a deeper understanding of ongoing health care reforms in East Asia--as exemplified by the unique case of Singapore.