What setting limits may mean: a feminist critique of Daniel Callahan's Setting Limits

In Setting Limits, Daniel Callahan advances the provocative thesis that age be a limiting factor in decisions to allocate certain kinds of health services to the elderly. However, when one looks at available data, one discovers that there are many more elderly women than there are elderly men, and these older women are poorer, more apt to live alone, and less likely to have informal social and personal supports than their male counterparts. Older women, therefore, will make the heaviest demand on health care resources. If age were to become a limiting factor, as Dr. Callahan sug-gests it should, the limits that will be set are limits that will affect women more dras” tically than they affect men. This review essay examines the implications of Callahan's thesis for elderly women.     

Recognition and Treatment of Late-Life Addictions in Medical Settings

Addictive disorders among the elderly have emerged as a growing public health concern. As the proportion of the elderly population increases, more and more older adults will either develop addictions as a dysfunctional means of coping with the psychosocial consequences of aging, or will carry their long-standing addictive behaviors with them into later life. Among the most common of these addictions are smoking, excess consumption of alcohol, and gambling. This article briefly reviews these three addictive disorders and examines assessment and treatment options. The current cohort of older adults tends not to seek help for addiction problems in specialty mental health or substance abuse treatment. To improve rates of cessation and abstinence, assessment and intervention should be delivered in general medical settings such as primary care. With the addition of a behavioral health specialist, primary care has the potential to offer improved interventions in a cost-effective and time-efficient manner.     

Is Social Justice Relative When It Comes to Oral Health? The Realities of a Complex Health Issue

For decades pastoral theology has emphasized care for the whole person and, more recently, this focus has been expanded to include caring for the physical health of parishioners. However, an overlooked area of general fitness has been the importance of oral health. Dental caries and periodontal disease are among the most common chronic diseases that disproportionately affect the most vulnerable populations. Despite significant progress in preventing and managing these oral diseases, there is a large segment of the population that have not experienced the same gains. This paper seeks to begin to fill this gap by identifying key epidemiological, professional and ethical issues related to social justice and oral health. Disparities of oral disease and access to oral health care in the United States will be addressed by examining questions and issues related to social justice. Critical problems are identified, including inadequate financial resources, a disjointed infrastructure of care, separation from the general medical care system, and poor understanding of important oral health determinants. Furthermore, if oral health is integral to one’s overall health and general well-being, then the concept of a basic human right should be entertained. Faith-based groups could provide a link for bridging this disparity gap in oral health among their parishioners through active listening, advocacy and targeted educational programs.     

Succeeding in Rural Mental Health Practice: Being Sensitive to Culture by Fitting in and Collaborating

Sustainable solutions to the access to mental health care problems are complex and must address both the availability of mental health care resources and the acceptability of those resources to consumers. The purpose of this study was to determine how to address the acceptability problem by learning from medical and mental health care providers what mental health therapists need to know to be successful in providing care in rural communities. Using a qualitative design, focus groups were conducted in three rural communities (<2,500) with medical and mental health care providers practicing in these communities. Data were analyzed using inductive qualitative methods. Results indicate that in addition to sound clinical skill, mental health therapists should (A) be sensitive to the culture of the rural community in which they are working and (B) practice in a way that accommodates to the care culture of the community. The latter includes spending time with patients commensurate with what is expected by other providers, engaging in generalist practice, and collaborating with local providers in patient care. An important implication of these results is that mental health care must be acceptable to both the residents of the community and the gatekeepers to health care.     

Development of a Brief Group CBT Intervention to Reduce COVID-19 Related Distress Among School-Age Youth

School-aged youth have been significantly impacted by the COVID-19 pandemic. The effects of the pandemic will likely have long-standing effects on the well-being of youth, and access to mental health care is even more critical during this time. For the past 5 years, TRAILS (Transforming Research into Action to Improve the Lives of Students) has been working throughout the state to increase utilization of evidence-based mental health practices among K-12 school mental health professionals (SMHPs). By leveraging SMHPs who are widely accessible to students, TRAILS seeks to improve youth access to effective mental health care and reduce current mental health inequities. In March 2020, TRAILS responded to the COVID-19 pandemic by developing a group manual designed to be delivered virtually by SMHPs to help students develop effective coping skills to mitigate the impact of COVID-19. TRAILS focuses on promoting use of CBT and mindfulness, as these skills are ideally suited for school-based delivery, and thus the new manual, Coping with COVID-19 (CC-19), was grounded in these modalities. This article will describe the design, development, and deployment of the CC-19 program to address the mental health needs of students in the context of the pandemic. Early acceptability and penetration data will also be discussed.     

Public and private responsibility for mental health services. A report on the Tennessee Task Force

The "privatization" of mental health services during the last decade has literally reshaped the way state and county departments of mental health go about fulfilling their statutory responsibilities. In Tennessee, a conference and later a task force examined the implications of this trend for the future. Two issues came to the forefront: Is it appropriate or possible for the private sector to take over the delivery of all mental health services, and if so, who will ensure that the poor receive adequate care? The Tennessee task force concluded that the privatization trend is appropriate and should be encouraged by government. It further concluded that government is ultimately responsible for ensuring access to care for the poor and uninsured although private facilities should provide some free care. Government best serves the poor by providing them the financial means to purchase care from private providers.     

Mental Health Concerns of Older Adults Living in Long-Term Care Facilities: An Area of Expansion for MFTs

As baby boomers reach retirement age, the number of older adults living in long-term care will inevitably increase. Living in long-term care often brings psychological, relational, and emotional challenges for older adults, their families, and professional care-providers. Despite these trends and associated challenges, there appears to be an underrepresentation of attention addressing the mental health care of older adults and their families in marriage and family therapy (MFT) literature. Emphasis needs to be turned to assessing the quality and effectiveness of mental health resources for older adults in residential facilities, and to filling the gap where needed services are unavailable. The current review summarizes research addressing residential care for older adults, detailing a) mental health challenges faced by residents, families, and professional care-providers, b) effective mental health treatment options, and c) how MFTs are uniquely suited to working in long-term care settings.     

Jewish and Roman Catholic approaches to access to health care and rationing

In addressing issues of access to health care and rationing, Jewish and Roman Catholic writers identify similar guiding values and specific concerns. Moral thinkers in each tradition tend to support the guarantee of universal access to at least a basic level of health care for all members of society, based on such values as human dignity, justice, and healing. Catholic writers are more likely to frame their arguments in terms of the common good and to be more accepting of rationing that denies beneficial and needed health care to some persons. Jewish writers are more likely to consider individual responsibility for illness in allocation decisions and to accept differences in health care that different members of society receive. The article considers the relevance of both shared and complementary perspectives for deliberations in nations such as the United States.     

The mental health system and older adults in the 1990s.

Trends in mental health services for older adults during the past decade were used to predict salient issues for the current decade. These include overreliance on inpatient treatment, increased use of general hospitals as treatment sites, inadequate integration with the nursing-home industry, and insufficient mental health referrals from general medical providers. In the decade ahead, the mental health needs of older adults are unlikely to be an identified focus; rather the issues will overlap with other priorities (e.g., biomedical research on brain functioning, alternative treatment programs for the chronically mentally ill, and containing health care costs). Advocates for the elderly will be successful to the extent that they cast aging services within the context of these other concerns.     

Improving access to psychological treatments: lessons from developing countries

Even though psychological treatments have been advocated as treatments for a range of mental disorders by the WHO for scaling up through primary care globally, the vast majority of potential beneficiaries are unable to access these treatments. Two major barriers impede the path between evidence based treatments and improved access: the lack of skilled human resources and the acceptability of treatments across cultures. This essay synthesizes the experiences of programs which developed and evaluated psychological treatments for depression in three resource poor developing countries. These programs addressed the human resource barrier by training lay or community health workers to deliver the treatments and addressed the acceptability barrier by systematically adapting the treatment to contextual factors. All programs demonstrated significant benefits in recovery rates when compared with usual care demonstrating the effectiveness of the approach. The implications for these experiences to improving access to psychological treatments in the global context are discussed.     

Issues in Publicly Subsidized Long Term Care Systems and Implications for the Religous Sector

Given the increasing numbers of elderly in need of long term care services and the harsh reality of finite resources, new models are required which define those elderly persons who should remain eligible for publicly subsidized long term care. If, in fact, a method is established for serving only a limited number of older persons, i.e., the truly vulnerable elderly, by way of the public system of long term care, a large constituency of older Americans will be left to exist on the margins. The church as an informal care system may appropriately assume the role of ensuring that the available public funds are used wisely and that service gaps inevitably left bewteen the increasing number of older persons and shrinking public support are bridged. In addition, the church must assist in improving all long term services by contributing to public policy formation.     

Just health care (II): Is equality too much?

In a previous essay I criticized Engelhardt's libertarian conception of justice, which grounds the view that society's obligation to assure access to adequate health care for all is a matter of beneficence [1]. Beneficence fails to capture the moral stringency associated with many claims for access to health care. In the present paper I argue that these claims are really matters of justice proper, where justice is conceived along moderate egalitarian lines, such as those suggested by Rawls and Daniels, rather than strong egalitarian lines. Further, given the empirical complexity associated with the distribution of contemporary health care, I argue that what we really need to address the relevant policy issues adequately is a theory of health care justice, as opposed to an all-purpose conception of justice. Daniels has made an important start toward that goal, though there are some large policy areas which I discuss that his account of health care justice does not really speak to. Finally, practical matters of health care justice really need to be addressed in a ‘non-ideal’ mode, a framework in which philosophers have done little.     

The Use of a Family History Risk Assessment Tool within a Community Health Care System: Views of Primary Care Providers

Primary care providers (PCPs) offered input regarding the incorporation of a family health history (FHH) risk assessment tool into a community health care system (CHCS). Sixteen PCPs participated in one of three focus groups. Perceived impediments included the lack of standard screening guidelines, effective screening tests, genetic counseling resources, and services for high-risk patients. The PCPs were concerned about their level of expertise, the cost of preventive health care, and genetic discrimination. They also were concerned about the use of a FHH tool by oncologists within the CHCS because of communication gaps between oncologists and PCPs, lack of clarity regarding follow-up and legal liability, and reimbursement issues. To integrate a FHH tool into a CHCS, PCPs will need consultation and referral services, evidence-based recommendations, and "just-in-time" educational resources. Oncologists who use the tool will need to develop a streamlined communication system with PCPs, establish clearly defined roles, and ensure patient follow-up.     

The ethics of the pharmaceutical industry and the need for a dual market system

In an era of increasing medical costs and cries for health care reform in the United States, the pharmaceutical industry has come under intense scrutiny. Ethical issues are inherent in the pharmaceutical marketplace, and there is a need to address the moral rights and responsibilities of drug manufacturers consumers, health care professionals, and governmental agents in the production, distribution, regulation, and use of these products. A dual market system protecting individual rights to access and autonomy without placing an undue strain on societal resources would provide an adequate and equitable framework for an ethical pharmaceutical industry.     

Intelligence artificielle et médecine : quelles règles éthiques et juridiques pour une IA responsable ?

Combining AI and medicine means talking about the medicine of the future, but even more about improving the quality of care. Its fields of application: predictive medicine, precision medicine, decision support, prevention, computer-assisted surgery, robotic support for the elderly, etc. are all related concerns: the possibility of maintaining human contact with the patient, the explicability of the algorithm - the collection of health data - and the improvement of the health care system. AI applications are already improving the quality of care. Its deployment at the heart of the medicine of the future is in constant evolution. To be acceptable and legitimate, the decisions of any algorithm must be understood and therefore explained. Only a good understanding of the diagnoses and therapies proposed by the AI application will allow doctors to discuss with their patients and to explain the possible alternatives. In the opposite case, the doctor risks to dismiss the use of algorithms because he will not be able to justify the decisions which will pose problems in terms of liability research in particular.     

Les autorisations d’équipements lourds d’imagerie médicale : un désordre organisé

Medical imaging is essential for all medical specialties and it is natural that the government wants to create a real healthcare provision policy in this area. Medical imaging and particularly the “heavy” equipment are subject to a regulatory and legal framework. This framework results in respect of administrative authorization mechanism. These authorizations are a major tool for development of medical imaging on French territory. This mechanism is an important instrument of economic regulation in controlling health costs. However, the access to this kind of equipment raises various issues in governance and administration but also in matter of economic regulation, distribution of healthcare supply in medical imaging in health territories and respect of public health issues. The authorization mechanism raises questionings, not only at national and regional level in terms of unequal access, but also at European and international level. Indeed, France is among the last countries in the ranking of CT (computed tomography) and MRI (magnetic resonance imaging) equipment rates in comparison with many OECD (Organization for Economic Cooperation and Development) countries. Now, these authorizations will integrate much more the concepts of accessibility and quality of patient care. The legal and regulatory framework of these authorizations will have to evolve and to adapt to new technologies and practices, which today should be a source of significant cost savings.     

The Middle Aging of America: Spiritual and Educational Dilemmas for Clergy Education

This paper summarizes a fellowship project completed in 1982 at the Hebrew Rehabilitation Center for Aged (The Center) in Boston, Massachusetts. The fellowship was jointly funded by a W. K. Kellogg Fellowship granted by the Hospital Research and Educational Trust, Chicago, Illinois and by The Center. At its completion, the project proposed a concept of supportive elderly congregate housing designed for persons not only requiring assistance with such vital activities as eating, dressing, and grooming but also lacking adequate support from family and friends. Confronted by gaps in our health and social service systems, these elderly often struggle with whether to remain in independent living arrangements without adequate coping mechanisms or to enter long term care institutions which mav provide more services than are needed. Four components of this housing are discussed: A Tenant Profile describing potential residents; recommendations for environmental features;skrvices to be provided; and financial resources. Data was drawn from a variety of sources including applicants and residents of a large long-term care facility and tenants of a large housing project. Ten site visits were made and research findings were reviewed. Interdisciplinary committees evaluated the data to develop goals, criteria, and recommendations. With refined selection techniques and good management, this housing should be cost effective and complement emerging life-styles of Americans. It should also be highly beneficial for a segment of the elderly who might otherwise reside, unnecessarily, in nursing homes.     

What to Do When Evidence-Based Treatment Manuals Are Not Enough? Adapting Evidence-Based Psychological Interventions for Primary Care

Significant barriers exist in accessing high-quality, evidence-based psychological interventions in traditional mental health settings. Adapting these interventions for delivery within primary care is particularly advantageous given that the majority of individuals with mental health conditions are more likely to seek care in this environment much earlier in their course of illness than in specialty mental health clinics. The aim of this paper is to summarize efforts at Mayo Clinic to develop and disseminate evidence-based psychological interventions across multiple primary care clinics. Adaptations aimed at improving access to care, enhancing the quality of care, and incorporating a system of measurement-based outcomes are unique features that are essential to the sustainability and advancement of integrated behavioral health programs within primary care.