Caring: A Pluralist Account

In this paper, I argue that care ethics should be understood as a form of value pluralism. Writers on the ethics of care tend not explicitly to address issues in the theory of value, although much of what has been written about care ethics may be taken to suggest that it endorses some form of value monism. I argue against this conception of care ethics by showing that the practical reality of caregiving is more accurately represented by a pluralist account of value. Practices of care are plausibly guided by a number of distinct and potentially conflicting values. These include quality of life, autonomy, dignity, personal development, and the value of nurturant relationships. Whilst caring takes each of these values to be important in its own right, they are not always jointly realisable, and carers are sometimes forced to promote one such value at the expense of another. The possibility of conflict between values is, of course, precisely what a pluralist conception of value tells us to expect. In this respect, then, value pluralism more faithfully reflects the reality of caregiving than does value monism, and care ethicists ought for this reason to endorse it.     

Transgender Primary Medical Care

SUMMARY

Transgender medical care involves addressing general medical conditions and those related specifically to transgender issues. This article summarizes existing research in transgender medicine and provides guidance for family physicians and nurses in adapting standard primary care protocols relating to health maintenance, acute illness, and chronic disease management to address trans-specific clinical oncerns. Trans-specific issues in physical examination, health history, interpretation of laboratory tests, vaccination, screening, and treatment are explored, and the role of the primary care provider in caring for patients undergoing hormonal or surgical change is discussed.     

Clinical Geropsychology: Implications for Practice in Medical Settings

Older adults are a rapidly growing segment of the population, who have high rates of chronic illness and who utilize health care resources heavily. Psychologists must become better prepared to work with older patients in geriatric settings, including geriatric assessment units, memory disorders clinics, and nursing homes. In addition, all psychologists will increasingly encounter older patients in environments such as primary care clinics, rehabilitation settings, and disease management programs focusing on problems that are prevalent in older patients (e.g., cancer, diabetes). Suggestions are offered for adaptation of usual clinical practice to address the special needs of older patients and their families, and recommendations made for advancing and expanding the practice of clinical geropsychology.     

Primary health care for women: What is it and who provides it?

Recent federal policy has highlighted historically underrecognized women's health issues. Women comprise the majority of the population, especially the elderly. Women's health care needs, utilization patterns, and outcomes vary from those of men, and often among each other. Primary health care services for women are multidisciplinary and emphasize prevention, education, and early intervention as well as treatment. Psychologists and other primary health care providers can collaborate to provide their services in a cost-effective manner that optimizes quality of care and comprehensive health care.     

Commitment and Partialism in the Ethics of Care

It is plausible to think that practices of caring are partly constituted by a caregiver's commitment to a cared‐for. However, discussions of caring often contain no explicit discussion of such commitments, and do not attempt to draw any philosophical conclusions from the nature of caring relations as committed. A discussion of caring practices that emphasizes the importance of commitment therefore has the potential to generate important new insights for our understanding of caring. This essay begins that project by arguing that a commitment‐centric conception of caring entails the truth of moral partialism. Although many care‐ethicists are sympathetic to partialism, the arguments in its defense remain controversial. As I show in this article, however, partialism is necessarily true given the committed nature of caring. This is because the concept of commitment is itself a necessarily partial one: to say that we are equally committed to everyone or everything is equivalent to saying that we are not committed to anything. Thus, when viewed as a species of commitment, it is part of the concept of caring that it requires us to put the needs of those we care for before the needs of those unknown to us.     

Implications of Healthcare Payment Reform for Clinical Psychologists in Medical Settings

Health reform, post the passing of the Patient Protection and Affordable Care Act, has highlighted the need to better address critical issues such as primary care, behavioral health, and payment reform. Much of this need is subsequent to robust data showing the seemingly uncontrollable growth of healthcare costs, and the exacerbation of these costs for patients with comorbid behavioral health and medical conditions. There is increasing recognition that incorporating behavioral health in primary care leads to improved outcomes and better care. To address these problems, primary care will play critical roles across the healthcare system, especially in the delivery of behavioral health services. Psychologists are uniquely positioned to take advantage of this propitious moment and can help facilitate the integration of behavioral and primary care by developing competencies in integrated care, training a capable workforce, and advocating for integrated care as the status quo.     

Adolescent Health Care Training in Predoctoral Psychology Internship Programs: A Model of Interdisciplinary Training Needs in Health Care

This needs assessment of predoctoral psychology programs in a large southeastern state reveals that although many programs include adolescent health issues and often involve the psychiatry discipline in their curricula, many trainees do not have exposure to medicine, nutrition, or nursing disciplines. Opportunities for greater interdisciplinary adolescent health care training exist in psychology training programs in this southeastern state. Integrating such training into psychology programs may enhance psychology's ability to function as a vital component of adolescent health care teams within academic medical centers across the country.     

Why physicians should not do ethics consults

Increasing complexities facing physicians negotiating the bedside decision continue to fuel the debate over who is the appropriate party to offer ethics consults, should one be needed, during the decision-making process. Some very good arguments have been put forth on behalf of clinical ethicists as being the proper and best party to engage in ethics consultations. However, serious questions remain about the role of the clinical ethicist and his ability to provide the necessary level of objectivity called for in an ethics consult. I argue that the clinician's professional psyche, or mode of thinking as a professional, leaves him little room to maneuver as an objective and detached third party ethics consultant. Several factors are cited and discussed that greatly influence the analyses applied to a case problem by physicians. The most formidable of these factors are habits and the practice of defensive medicine. I conclude that clinical ethicists are less suited for the overall tasks required of an objective consultant in medical cases that appear to involve insurmountable ethical issues.     

The Will to Care: Performance,Expectation, and Imagination

This article addresses the world's contemporary crisis of care, despite the abundance of information about distant others, by exploring motivations for caring and the role of imagination. The ethical significance of caring is found in performance. Applying Victor Vroom's expectancy theory, caring performances are viewed as extensions of rational expectations regarding the efficacy of actions. The imagination creates these positive or negative expectations regarding the ability to effectively care. William James's notion of the will to believe offers a unique twist on rational expectations in that he regards humans as having the capacity to work within uncertainty to take decisive action. Applying this idea to caring performance is, this article argues that people can have the will to care, beyond strict rational calculations or limits of social norms. Historically, caring has been associated with the imagination's ability to empathize, but the will to care offers another role for the imagination in envisioning effective action. Given the significance of the imagination for ethical behavior, this article explores the implications for cultivating care in terms of what educating for care might look like. The work of feminist care ethicists, particularly Nel Noddings, is discussed, and contemporary case examples of caring performances are investigated.     

Report of the Working Group on Clinical Services

Prepared by the Working Group on Clinical Services from the November 1995 Georgetown conference sponsored by the Association of Medical School Psychologists, this paper focuses upon issues related to the effects of health care reform and changes to the health care system on psychologists practicing within academic health care settings. Discussion of the changes in the health care economic system and the call for cost-effectiveness produced five specific suggestions for psychology to establish accountable, data-based models of behavioral health care.     

Rights, Wrongs, and Aristotelian Egoism: Illuminating the Rights/Care Dichotomy

Since the recent work of Carol Gilligan, Nel Noddings, and others, it has become commonplace in moral philosophy to employ a dichotomy between an ethics of "Care" and an ethics of "Rights." Gilligan claims that men and women view moral issues in fundamentally divergent ways. Responses to moral problems tend to divide along lines emphasizing respect for rights, in the case of men, and caring for others, in the case of women. Inspired by these findings, several authors have classified moral theories in two basic camps, revolving around the injunction to care or the mandate to respect rights. While many concede that the Care and Rights perspectives are not mutually exclusive, it is increasingly common to view ethicists as forced to choose between these two types of theories.     

Ethics and Culture in Mental Health Care

This article examines the complex relationship between culture, values, and ethics in mental health care. Cultural competence is a practical, concrete demonstration of the ethical principles of respect for persons, beneficence (doing good), nonmaleficence (not doing harm), and justice (treating people fairly)—the cornerstones of modern ethical codes for the health professions. Five clinical cases are presented to illustrate the range of ethical issues faced by mental health clinicians working in a multicultural environment, including issues of therapeutic boundaries, diagnosis, treatment choice, confidentiality and informed consent, and the just distribution of limited health care resources.     

加强管理，改善流动人口卫生保健服务利用

为改善流动人口卫生保健服务利用水平,通过现场调查、焦点组访谈和二级资料提取等定性定量研究方法收集上海流动人口卫生保健服务利用情况的资料。在对上海流动人口卫生保健服务利用现状、存在的问题和利用障碍进行了分析的基础上,提出了加强管理,改善流动人口卫生保健服务利用的8项建议。     

Aboriginal Health Care and Bioethics: A Reflection on the Teaching of the Seven Grandfathers

Contemporary bioethics recognizes the importance of the culture in shaping ethical issues, yet in practice, a process for ethical analysis and decision making is rarely adjusted to the culture and ethnicity of involved parties. This is of a particular concern in a health care system that is caring for a growing Aboriginal population. We raise the possibility of constructing a bioethics grounded in traditional Aboriginal knowledge. As an example of an element of traditional knowledge that contains strong ethical guidance, we present the story of the Gifts of the Seven Grandfathers. We note a resemblance of this Ojibway teaching to virtue ethics in European traditions, but we suggest that there are also important differences in how these two traditions are currently presented. We hope that further engagement with a variety of indigenous moral teachings and traditions could improve health care involving Aboriginal patients and communities, and enrich the discipline of bioethics.     

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.     

The Virtue of Care

There have been many attempts to define care in terms of the virtues, but meta‐analyses of these attempts are conspicuously absent from the literature. No taxonomies have been offered to situate them within the broader care ethical and virtue theoretical discourses, nor have any substantial discussions of each option's merits and shortcomings. I attempt to fill this lacuna by presenting an analysis of the claim that care is a virtue (what I call the “virtue thesis” about care). I begin by distinguishing weaker and stronger versions of the virtue thesis, arguing that the weaker version is an orthodox view among care ethicists. I then go on to develop a taxonomy of approaches available to care ethicists seeking to flesh out the virtue thesis. The three I identify are analogical approaches, according to which care is analogous to some existing virtue; supplementalist approaches, according to which care is a novel virtue; and cardinalist approaches, according to which care is a cardinal virtue. Following this, I defend the virtue thesis from some foreseeable objections and argue that its most promising version is analogical.     

An analysis of ethics consultation in the clinical setting

Only recently have ethicists been invited into the clinical setting to offer recommendations about patient care decisions. This paper discusses this new role for ethicists from the perspective of content and process issues. Among content issues are the usual ethical dilemmas such as the aggressiveness of treatment, questions about consent, and alternative treatment options. Among process issues are those that relate to communication with the patient. The formal ethics consult is discussed, the steps taken in such a consult, and whether there should be a fee charged. We conclude with an examination of the risks and benefits of formal ethics consults.     

Parallel,Embedded or Just Part of the Team: Ethicists Cooperating Within a European Security Research Project

Different methods have been developed to address ethical issues during research. Most of these methods were developed at universities. In this article ethical parallel research within a Research and Technology Organization is described. Within a European project about perceived security, CPSI, the ethical issues were identified by ethicists cooperating in the project. The project CPSI was aimed at developing a research method that can be used by (local) government to monitor or assess perceived and actual security. Together with the researchers a way was sought to address the ethical issues. Several issues could be addressed by choices with regard to the design of the validation study, in this case a survey. The ethical and legal reasons that were relevant for choices in the design of the validation study were made an integral part of these decisions. Some issues were already identified during the writing of the proposal others were only identified during the research. Participating in the research gave the ethicists access to all relevant information. It made it possible to address the ethical issues when they became relevant. Ethical reasons were part of some of the discussions on research method. It proved possible to address most ethical issues satisfactorily during the research project.     

Maximal care considerations when treating patients with end-stage heart failure: ethical and procedural quandaries in management of the very sick

Deciding who should receive maximal technological treatment options and who should not represents an ethical, moral, psychological and medico-legal challenge for health care providers. Especially in patients with chronic heart failure, the ethical and medico-legal issues associated with providing maximal possible care or withholding the same are coming to the forefront. Procedures, such as cardiac transplantation, have strict criteria for adequate candidacy. These criteria for subsequent listing are based on clinical outcome data but also reflect the reality of organ shortage. Lack of compliance and non-adherence to lifestyle changes represent relative contraindications to heart transplant candidacy. Mechanical circulatory support therapy using ventricular assist devices is becoming a more prominent therapeutic option for patients with end-stage heart failure who are not candidates for transplantation, which also requires strict criteria to enable beneficial outcome for the patient. Physicians need to critically reflect that in many cases, the patient’s best interest might not always mean pursuing maximal technological options available. This article reflects on the multitude of critical issues that health care providers have to face while caring for patients with end-stage heart failure.     

Who is my neighbor? A communitarian analysis of access to health care for immigrants

Immigrants lacking health insurance access the health care system through the emergency departments of non-profit hospitals. Because these persons lack health insurance, continued care can pose challenges to those institutions. I analyze the values of our health care institutions, utilizing a Walzerian approach that describes its appropriate sphere of justice. This particular sphere is dominated by a caring response to need. I suggest that the logic of this sphere would be best preserved by providing increased access to health insurance to this population. This access would marry the rights of these members of our community to access care to our responsibility to contribute to financing of the system. I close with some considerations on what it means to be a member of the community.