健康公平--概念、影响因素与政策

长期以来健康不平等和不公平一直是卫生改革与发展所关注的重点,并已经成为了国际卫生政策的主要方向.在国家之间健康不平等和不公平也存在不同的理解.发达国家主要集中在产生疾病和导致死亡率差异的社会经济阶层的形成机制,将健康不平等作为疾病病原学的一个函数,关键措施是加强初级卫生保健;在中低收入国家,人们却趋向于通过提供基本的医疗保健服务来解决这一问题.     

英国福利制度的伦理考量及启示

庇古的"福利经济学"理论、凯恩斯的国家干预主义、贝弗里奇报告是英国福利制度产生的理论依据.不仅其建立本身的立足点是道德的,而且国家对经济生活的干预也是道德的.英国福利制度理论的道德基础在于:英国福利制度追求社会公平,缩小贫富差距,消除贫困,保护弱势群体的价值诉求主要体现在如何对待老人、儿童、残疾人、单身母亲以及失业贫困人员等身上.从积极方面看,英国的福利制度是由国家立法而建立起来的比较完善的社会保障制度,是西方资本主义发展到一定阶段的产物;从消极方面看,其社会福利政策建立的初衷是为了社会公正,但结果却很可能造成新的不公正.尽管英国的福利政策和社会保障制度的实践存在许多问题,但也给我们提供了极为丰富的伦理启示:社会发展应当更加突出对弱势群体的关怀;社会福利制度在注意努力实现公平与效率的动态平衡时应更加注重公平;建立完善的福利制度有助于整个社会的道德进步与和谐.     

论弱势群体的道德底线

弱势群体因为贫困的物质利益状况与不平等的物质利益关系而陷入于生存危机之中。生存危机造成道德主体危机,表现为道德能力贫困和主体被边缘化。生存危机导致生存与道德冲突,产生非道德化生存;建构基于生存平等的社会底线公平是建构弱势群体道德底线的根本途径。     

民国初期的佛教组织与慈善思想

<正>民国肇始,百废待兴。一方面彼时社会生产力水平低下,另一方面由于自然灾害与战乱的影响,造成社会上产生越来越多的弱势群体。蔡勤禹指出:"民国社会弱势群体与传统社会弱势群体有共性,根据这种特点,民国弱势群体可以分为灾民、难民、失业者、残疾者、乞丐、失养儿童、鳏寡老人、不幸妇女等。"[1]这些弱势群体需要得到社会救济,而彼时的社会救济制度并不完善,佛教慈善救济事业在那个     

共情关怀对公平决策的影响——来自ERP的证据

本研究运用事件相关电位技术(event-related potential, ERP)和最后通牒博弈范式(ultimatum game, UG)考察了共情关怀对公平决策的影响。实验采用2 (状态共情关怀: 有共情关怀vs.无共情关怀) × 3 (分配公平性: 公平vs.劣势不公平vs.优势不公平)被试内设计, 共37名被试参与实验, 被试作为响应者选择是否接受提议者的分配提议。行为结果显示劣势不公平条件下, 有共情情境的接受率高于无共情情境; 优势不公平条件下呈现相反的结果。ERP结果显示: 对于他人提出的优势不公平提议, 无共情情境较有共情情境下诱发了更负的前部N1 (anterior N1, AN1), 有共情情境比无共情情境下诱发了更大的P2波幅; 有共情情境下, 他人提出的劣势不公平提议较优势不公平和公平提议诱发了更负的内侧额叶负波(medial frontal negativity, MFN); P3在公平条件下的波幅较劣势不公平条件下更大, 并未受到共情关怀的调节。这些结果表明共情关怀不仅调节了公平决策行为, 还调节了公平加工的早期注意和动机及之后的认知和情绪加工, 但由P3表征的高级认知过程仅受到公平性的调节而不受共情水平的影响。     

医疗保健政策与医患关系

医疗保健政策深刻地影响着医患关系,并左右着医患关系的发展与变化.在实行"以公平为主,兼顾效益"的福利性的医疗保健政策时期,我国的医患关系是和谐的.但自从医疗保健政策向"经济导向型"方向转变之后,国家大幅度减少了对卫生事业的投入,医院必须从病人身上取得卫生发展必要的资金,医药费用上涨是必然的,也失去了公平和公正,并最终导致医患关系的恶化.调整医患关系不能仅从医、患两方面着手,建立符合医学伦理的卫生政策,才是问题的关键.     

德鲁克医院管理思想研究

德鲁克医院管理思想主要有:医院管理与企业管理没有多大差异;医疗保健是21世纪增长最快、最需要管理的部门;医疗服务需要合理组织及团队精神;评价医疗服务质量的标准是"最佳";医院要实施目标管理并不断致力于变革,通过"专业化"提高效率和效益;医院管理者与员工之间是伙伴关系;信息技术对医疗服务有深刻的影响;医院应实行"职业化"管理.     

关于过度医疗服务的思考

过度医疗服务是指医疗行业提供了超出个体和社会医疗保健实际需求的医疗服务。有关资料表明 ,近几年 ,医疗费用的增长速度大大超过同期国家财政收入的增长速度 ,这其中一个重要和普遍的原因是过度医疗服务 ,它给个人和社会带来沉重的经济和精神负担。1　过度医疗服务的行业表现为 :放宽住院及治疗标准 ;过度检查检验 ;过度治疗 ,如选择高档药物 ,扩大手术范围等 ;医用材料过度浪费 ;过度医疗保健等。2　分析过度医疗服务的原因有以下 :(1 )经济利益诱惑 :在市场经济下 ,各医院为了提高经济效益千方百计争夺病源 ,提高门诊量和住院率 ,甚至给…     

社会经济因素相关的农村居民医疗服务利用公平性

农村居民医疗服务利用过程中并存着亲穷人的不公平与亲富人的不公平,但分布规律无趋同迹象.新农合在促进农村居民医疗服务利用整体水平提高的同时没有改善其利用公平性.对农村居民医疗服务利用公平性的研究需要以更大范围的调查数据为基础并运用严谨的数理分析方法,同时应对农村居民医疗服务的利用质量公平问题给予适当关注.     

卫生立法——一个基本的着眼点

公平是法的灵魂。卫生立法的根本着眼点,是为了在现有卫生资源条件下,通过立法的手段更好地满足人民群众卫生保健的需要,在医疗保健服务的多方的利益关系中,找到一个合理结合度。     

The Limitations of “Vulnerability” as a Protection for Human Research Participants

Vulnerability is one of the least examined concepts in research ethics. Vulnerability was linked in the Belmont Report to questions of justice in the selection of subjects. Regulations and policy documents regarding the ethical conduct of research have focused on vulnerability in terms of limitations of the capacity to provide informed consent. Other interpretations of vulnerability have emphasized unequal power relationships between politically and economically disadvantaged groups and investigators or sponsors. So many groups are now considered to be vulnerable in the context of research, particularly international research, that the concept has lost force. In addition, classifying groups as vulnerable not only stereotypes them, but also may not reliably protect many individuals from harm. Certain individuals require ongoing protections of the kind already established in law and regulation, but attention must also be focused on characteristics of the research protocol and environment that present ethical challenges.     

The limitations of "vulnerability" as a protection for human research participants

Vulnerability is one of the least examined concepts in research ethics. Vulnerability was linked in the Belmont Report to questions of justice in the selection of subjects. Regulations and policy documents regarding the ethical conduct of research have focused on vulnerability in terms of limitations of the capacity to provide informed consent. Other interpretations of vulnerability have emphasized unequal power relationships between politically and economically disadvantaged groups and investigators or sponsors. So many groups are now considered to be vulnerable in the context of research, particularly international research, that the concept has lost force. In addition, classifying groups as vulnerable not only stereotypes them, but also may not reliably protect many individuals from harm. Certain individuals require ongoing protections of the kind already established in law and regulation, but attention must also be focused on characteristics of the research protocol and environment that present ethical challenges.     

Environmental Modesty

Despite this virtue's history as an instrument of women's oppression, modesty, at its most basic, means voluntary restraint of one's power, undertaken for the sake of others. It is a mechanism that modifies unequal power relationships and encourages greater compassion and fairness. I use a Christian perspective with influences from Jewish and Muslim sources to examine modesty. The modest person, I argue, must be in relationship with others, must be honestly aware of her impacts on others, must be sensitive to those impacts, compassionate toward others, and willing to hold back for others' sakes. Moreover, modesty is not only a virtue that pertains to sexuality and clothing, but it also can promote virtuous environmental behavior, particularly as it leads to awareness of, and sensitivity to, the effects of everyday behaviors on vulnerable others.     

Attending to social vulnerability when rationing pandemic resources

Pandemic plans are increasingly attending to groups experiencing health disparities and other social vulnerabilities. Although some pandemic guidance is silent on the issue, guidance that attends to socially vulnerable groups ranges widely, some procedural (often calling for public engagement), and some substantive. Public engagement objectives vary from merely educational to seeking reflective input into the ethical commitments that should guide pandemic planning and response. Some plans that concern rationing during a severe pandemic recommend ways to protect socially vulnerable groups without prioritizing access to scarce resources based on social vulnerability per se. The Minnesota Pandemic Ethics Project (MPEP), a public engagement project on rationing scarce health resources during a severe influenza pandemic, agrees and recommends an integrated set of ways to attend to the needs of socially vulnerable people and avoid exacerbation of health disparities during a severe influenza pandemic. Among other things, MPEP recommends: 1. Engaging socially vulnerable populations to clarify unique needs and effective strategies; 2. Engaging socially vulnerable populations to elicit ethical values and perspectives on rationing; 3. Rejecting rationing based on race, socioeconomic class, citizenship, quality of life, length of life-extension and first-come, first-served; 4. Prioritizing those in the general population for access to resources based on combinations of risk (of death or severe complications from influenza, exposure to influenza, transmitting influenza to vulnerable groups) and the likelihood of responding well to the resource in question. 5. Protecting critical infrastructures on which vulnerable populations and the general public rely; 6. Identifying and removing access barriers during pandemic planning and response; and 7. Collecting and promptly analyzing data during the pandemic to identify groups at disproportionate risk of influenza-related mortality and serious morbidity and to optimize the distribution of resources.     

Collecting Informed Consent with Juvenile Justice Populations: Issues and Implications for Research

Researchers must provide participants with opportunities to make informed decisions about whether to participate in research studies. Investigators conducting research with youth in the juvenile justice system face unique ethical, legal, and practical challenges to obtaining informed consent. Juvenile justice researchers must navigate multiple legal and ethical standards for collecting informed consent, take into account youths’ dual vulnerabilities as children and prisoners, and overcome practical limitations to obtaining parental/guardian permission. Given the challenges and complexity of obtaining standard informed consent of youth in juvenile justice facilities, this paper provides suggestions for overcoming obstacles to recruiting these youth for research participation. It offers guidance for fostering the enrollment of juvenile justice youth in research studies using procedures that comply with ethical and legal standards for research with this dually vulnerable population. Copyright © 2013 John Wiley & Sons, Ltd.     

Object elicitation: A compassionate and culturally informed method for psychotherapy research

This study provides an innovative, compassionate and culturally informed method for psychotherapy research, using object elicitation with 13 participants from vulnerable groups. It examines the positive impact it has on building the research alliance, enhanced depth of sharing within qualitative research interviews and emic ways of knowing through the engagement with a culturally relevant, tangible, internalised or transitional object brought by vulnerable participants from diverse cultural contexts of origin. Results showcase how a creative and compassionate research method can promote a culturally informed research alliance with vulnerable participants, helping to build trust, rapport and relational depth; encourage elicitation of experiences; and empower emic and subjugated voices. The implications of this study make the case for the inclusion of object elicitation as a creative and compassionate method in qualitative research with traumatised and vulnerable individuals, which should be used as part of a culturally informed approach to psychotherapy research.     

Addiction as an indicator of vulnerability: The case of indoor tanning

Research concerning the marketing of potentially harmful products to vulnerable consumer segments reveals difficulties in identifying vulnerable consumers. Businesses must be able to identify such segments if they are to avoid regulation and consumer activism. Whether a measure of nonsubstance addiction is an appropriate indicator of vulnerability is examined here in the context of indoor tanning. Three studies of young adult tanners indicate that (a) a modified alcohol addiction scale, the CAGE index, can be used to measure other addictions; (b) addicted indoor tanners have high motivation to meet social appearance norms and to experience the feeling of tanning, which may make them susceptible to marketing cues for indoor tanning; and (3) addicted and nonaddicted indoor tanners are similar in their knowledge of the dangers of indoor tanning, thus supporting the assertion that addicted tanners' decisions to tan indoors are likely more influenced by addiction than by informed decision making.     

The perils of protection: vulnerability and women in clinical research

Subpart B of 45 Code of Federal Regulations Part 46 (CFR) identifies the criteria according to which research involving pregnant women, human fetuses, and neonates can be conducted ethically in the United States. As such, pregnant women and fetuses fall into a category requiring “additional protections,” often referred to as “vulnerable populations.” The CFR does not define vulnerability, but merely gives examples of vulnerable groups by pointing to different categories of potential research subjects needing additional protections. In this paper, I assess critically the role of this categorization of pregnant women involved in research as “vulnerable,” both as separate entities and in combination with the fetuses they carry. In particular, I do three things: (1) demonstrate that pregnant women qua pregnancy are either not “vulnerable” according to any meaningful definition of that term or that such vulnerability is irrelevant to her status as a research participant; (2) argue that while a fetus may be vulnerable in terms of dependency, this categorization does not equate to the vulnerability of the pregnant woman; and (3) suggest that any vulnerability that appends to women is precisely the result of federal regulations and dubious public perceptions about pregnant women. I conclude by demonstrating how this erroneous characterization of pregnant women as “vulnerable” and its associated protections have not only impeded vital research for pregnant women and their fetuses, but have also negatively affected the inclusion of all women in clinical research.     

Psychological Distress in Orphan,Vulnerable Children and Non-Vulnerable Children in High Prevalence HIV/AIDS Communities

The degree of psychological distress and access social support is investigated in children (n = 741) living in nine high prevalence HIV/AIDS communities. They comprised (i) vulnerable, maternally-orphaned (n = 319); (ii) vulnerable and not orphaned (n = 276); and (iii) typically developing (n = 146). The following psychometric tests were administered: The Trauma Symptom Checklist for Children (Townsend, 2002); the Reynolds Depression Scale for Children (Reynolds, 1989); and the Social Support Scale (Beale Spencer, Cole, Jones & Phillips Swanson, 1997). Primary caregivers completed the Conners' Parent Rating Scale (Conners, Parker, Sitarenios, & Epstein, 1998) and an Adversity Index (Killian, 2004a) to establish the vulnerability status of each child. The data were analysed to distinguish the groups from each other regarding profiles of distress. The findings suggest that vulnerable children, be they orphaned or not, manifest similar degrees of emotional distress and perceived themselves as unable to access social support. Interventions should address the needs of both orphans and other vulnerable children, without prioritising the needs of orphans over other vulnerable children.     

美国与知情同意有关的一些问题

知情同意是医疗保健和医学研究的一个基本的伦理学要求。这两种情况中,当医学研究的知情同意标准比医疗保健要求更加严格时,知情同意包含了3种要素：（1）告知病人或受试者该研究的性质。包括益处,危险和其他有关内容;（2）确保病人受试者理解所提供的信息;（3）得到病人或受试者自愿的同意,没有能力参与知情同意的病人包括患痴呆和危重病等无决断 能力的病人,这些病人属弱势病人。如要获许对他们的疾病进行研究,我们必须制定保护弱势受试者有效的伦理政策,提出了关于对痴呆病人、危重病人,脑死亡病人研究的伦理学政策。