Stephen Scher and Kasia Kozlowska: Rethinking health care ethics

Theoretical Medicine and Bioethics -     

Boundaries,journals and counselling psychology: Stephen Palmer interviews Kasia Szymanska

You have just retired from editing Counselling Psychology Review, the in-house journal of the British Psychological Society, Division of Counselling Psychology. It seems an appropriate moment to interview you for Counselling Psychology Quarterly. In this interview I want to focus on a topic I know you are interested in, client-therapist boundary issues, and your experience editing the journal. But I'd like to start off at a slight tangent. What encouraged you to go into counselling psychology as a profession?     

Rethinking technology, revitalizing ethics: Overcoming barriers to ethical design

This paper explores the role of ethics in design. Traditionally, ethical questions have been seen as marginal issues in the design of technology. Part of the reason for this stems from the widely held notion of technology being “out of control.” This notion is a barrier to what I call “ethical design” because it implies that ethics has no role to play in the development of technology. This view, however, is challenged by recent work in the field of Science and Technology Studies (STS). Looking into the dynamics of technological change, STS scholars argue that human choices are present at every stage of a technology’s development and, furthermore, that human values are reflected in the very design of artifacts. This alternative view suggests that ethics can and should be included in the design process. Drawing on examples from the privacy arena. I point to some of the potential advantages of addressing ethical concerns early on in the design of a technology. I conclude with some general strategies for bringing ethics back into design. A version of this paper was presented at ETHICOMP98, the Fourth International Conference on Ethical Issues of Information Technology, March 25–27, 1998, Erasmus University, the Netherlands. Patrick Feng is a Ph.D. student in the Science and Technology Studies Department at Rensselaer. His research focuses on the development of technical standards that are designed to address social values such as privacy and trust.     

Double agency and the ethics of rationing health care: a response to Marcia Angell

The arguments against doctors as "double agents" that are presented by Marcia Angell in the preceding article do not defeat the core justification for rationing some relatively high-expense, low-benefit care, and they do not enable us to conclude that clinicians should be barred from any active, substantive role in decisions to limit that care. They do, however, reveal several important conditions that need to govern cost-conscious medial practice in order to preserve an ethic of fidelity to patients: insurers' profits and providers' incomes must be fair, providers must inform patients of any economic reasons that lead to the foregoing of care, and "direct incentive" arrangements must not be used to contain costs.     

The ethics of everyday practice in primary medical care: responding to social health inequities

Background  

Social and structural inequities shape health and illness; they are an everyday presence within the doctor-patient encounter yet, there is limited ethical guidance on what individual physicians should do. This paper draws on a study that explored how doctors and their professional associations ought to respond to the issue of social health inequities.     

Reflections on teaching health care ethics on the web

As web instruction becomes more and more prevalent at universities across the country, instructors of ethics are being encouraged to develop online courses to meet the needs of a diverse array of students. Web instruction is often viewed as a cost-saving technique, where large numbers of students can be reached by distance education in an effort to conserve classroom and instructor resources. In practice. however, the reverse is often true: online courses require more of faculty time and effort than do many traditional classes. Based on personal experience teaching an online course in health care ethics for students in the Allied Health Professions, it is evident that there are both benefits and challenges in teaching online courses, particularly in ethics. Examples of benefits are (1) the asynchronous nature of web instruction allows students to progress through the course at their own pace and at times that are convenient given their clinical responsibilities; (2) web courses allow for a standardization of content and quality of instruction over a diversity of programs; and (3) examples can be tailored to the differing experiences of students in the course. Some challenges to teaching online ethics courses include (1) the fact that online instruction benefits visual learners and disadvantages those lacking good reading comprehension or strong writing skills; (2) developing meaningful student-student and student-instructor interaction; and (3) teaching ethics involves teaching a process rather than a product. Allowing students to apply their knowledge to real-world cases in their disciplines and encouraging them to share experiences from clinical practice is an effective way to meet several of these challenges. Building an online community is another good way to increase the interaction of students and their engagement with the material.     

Organizational ethics in Catholic health care: honoring stewardship and the work environment.

Organizational ethics refers to the integration of values into decision making, policies, and behavior throughout the multi-disciplinary environment of a health care organization. Based upon Catholic social ethics, stewardship is at the heart of organizational ethics in health care in this sense: stewardship provides the hermeneutic filter that enables basic ethical principles to be realized practically, within the context of the Catholic theology of work, to concerns in health care. This general argument can shed light on the specific topic of non-executive compensation programs as an illustration of organizational ethics in health care.     

The ethics of animal research: a survey of pediatric health care workers

Introduction

Pediatric health care workers (HCW) often perform, promote, and advocate use of public funds for animal research (AR). We aim to determine whether HCW consider common arguments (and counterarguments) in support (or not) of AR convincing.

Design

After development and validation, an e-mail survey was sent to all pediatricians and pediatric intensive care unit nurses and respiratory therapists (RTs) affiliated with a Canadian University. We presented questions about demographics, support for AR, and common arguments (with their counterarguments) to justify the moral permissibility (or not) of AR. Responses are reported using standard tabulations. Responses of pediatricians and nurses/RTs were compared using Chi-square, with P?<?.05 considered significant.

Results

Response rate was 53/115(46%) (pediatricians), and 73/120(61%) (nurses/RTs). Pediatricians and nurses/RTs are supportive of AR. Most considered ‘benefits arguments’ sufficient to justify AR; however, most acknowledged that counterarguments suggesting alternative research methods may be available, or that it is unclear why the same ‘benefits arguments’ do not apply to using humans in research, significantly weakened ‘benefits arguments’. Almost all were not convinced of the moral permissibility of AR by ‘characteristics of non-human-animals arguments’, including that non-human-animals may not be sentient, or are simply property. Most were not convinced of the moral permissibility of AR by ‘human exceptionalism’ arguments, including that humans have more advanced mental abilities, are of a special ‘kind’, can enter into social contracts, or face a ‘lifeboat situation’. Counterarguments explained much of this, including that not all humans have these more advanced abilities [the argument from species overlap], and that the notion of ‘kind’ is arbitrary [e.g., why are we not of the kind ‘sentient animal’ or ‘subject-of-a-life’]. Pediatrician and nurse/RT responses were similar.

Conclusions

Most respondents were not convinced of the moral permissibility of AR when given common arguments and counterarguments from the literature. HCW should seriously consider arguments on both sides of the AR debate.

     

Fulfilling institutional responsibilities in health care: organizational ethics and the role of mission discernment

In this paper we highlight the emergence of organizational ethics issues in health care as an important outcome of the changing structure of health care delivery. We emphasize three core themes related to business ethics and health care ethics: integrity, responsibility, and choice. These themes are brought together in a discussion of the process of Mission Discernment as it has been developed and implemented within an integrated health care system. Through this discussion we highlight how processes of institutional reflection, such as Mission Discernment, can help health care organizations, as well as corporations, make critical choices in turbulent environments that further the core mission and values and fulfill institutional responsibilities to a broad range of stakeholders.     

At the crossroads: managed mental health care,the ethics code,and ethnic minorities

Mental health clinicians are facing an increasing number of ethical problems related to the delivery of managed mental health care services to ethnic minorities. The authors argue that (a) economic pressures have led to the development of the managed health care movement; (b) the combination of such economic pressures and the development of that managed care movement have influenced the promulgated ethical standards of the American Psychological Association; and (c) those influences may have a negative impact on the mental health services available to ethnic minority individuals and communities. The authors review some of the specific potential threats to mental health services for minorities in the face of such health management policy and psychologists' professional standards.     

Future ethics: risk,care and non-reciprocal responsibility

As the number of intrinsically unknowable technologically produced risks global society faces continues to grow, it is evident that the question of our responsibilities towards future people is of urgent importance. However, the concepts with which this question is generally approached are, it is argued, deficient in comprehending the nature of these risks. In particular, the individualistic language of rights presents severe difficulties. An alternative understanding of responsibility is required, which, it is argued, can be developed from phenomenological and feminist concepts of care. Such concepts privilege an understanding of human beings that is primarily relational rather than individualistic, and show that responsibility is, in the first place, about connection rather than respecting separation. Care, by opening up for us an understanding of the diversity of values that are constitutive of a worthwhile life, also connects us to the future as the future of care. As such, it provides us with ethical resources that can guide us in the face of uncertainty, including general principles of action and the desire for institutions that can articulate them.