The Clash of Medical Civilizations: Experiencing “Primary Care” in a Neoliberal Culture

An anthropologist describes how he found himself at the vortex of a “clash of medical civilizations:” neoliberalism and the international primary health care movement. His involvement in a $6 million social change initiative in medical education became a basis to unlock the hidden tensions, contradictions and movements within the “primary care” phenomenon. The essay is structured on five ethnographic stories, situated on a continuum from “natural” species-level primary care to “unnatural” neoliberal primary care. Food is an element of all tales. Taking the long view of history/prehistory permits us to better recognize ideological distortions in order to more capably transform medicine.     

“Caring‐about” and the Problem of Overwhelming Obligations

Care theorists often think of care as involving (at least) “caring‐about”—concern or attentiveness—and “caring‐for”—acting to nurture, look after, or meet needs. One problem for any theory of care is the scope of our obligations to care in both of those senses; in particular, our capacities for “caring‐about” often outrun our capacities for “caring‐for.” Accounts of care as potentially global in scope may ascribe overwhelming obligations to moral agents; however, we are often tempted to avoid or ignore situations that may call for a caring response. I suggest that some Kantian ideas may help to strike a reasonable balance.     

A Proposal for a Spiritual Care Assessment Toolkit for Religious Volunteers and Volunteer Service Users

Based on the idea that volunteer services in healthcare settings should focus on the service users’ best interests and providing holistic care for the body, mind, and spirit, the aim of this study was to propose an assessment toolkit for assessing the effectiveness of religious volunteers and improving their service. By analyzing and categorizing the results of previous studies, we incorporated effective care goals and methods in the proposed religious and spiritual care assessment toolkit. Two versions of the toolkit were created. The service users’ version comprises 10 questions grouped into the following five dimensions: “physical care,” “psychological and emotional support,” “social relationships,” “religious and spiritual care,” and “hope restoration.” Each question could either be answered with “yes” or “no”. The volunteers’ version contains 14 specific care goals and 31 care methods, in addition to the 10 care dimensions in the residents’ version. A small sample of 25 experts was asked to judge the usefulness of each of the toolkit items for evaluating volunteers’ effectiveness. Although some experts questioned the volunteer’s capacity, however, to improve the spiritual care capacity and effectiveness provided by volunteers is the main purpose of developing this assessment toolkit. The toolkit developed in this study may not be applicable to other countries, and only addressed patients’ general spiritual needs. Volunteers should receive special training in caring for people with special needs.     

Graphic Somatography: Life Writing,Comics, and the Ethics of Care

This essay considers the ways in which graphic caregiving memoirs complicate the idealizing tendencies of ethics of care philosophy. The medium’s “capacious” layering of words, images, temporalities, and perspectives produces “productive tensions. . . The words and images entwine, but never synthesize” (Chute 2010, 5). In graphic memoirs about care, this “capaciousness” allows for quick oscillation between the rewards and struggles of care work, representing ambiguous, even ambivalent attitudes toward care. Graphic memoirs effectively represent multiple perspectives without synthesis, part of a structural and thematic ambivalence that provides a provocative counterpart to the abstract idealism of ethics of care philosophy.     

Assessing the acceptability of staff management procedures to direct care and supervisory staff

Direct care and supervisory staff in five residential training programs for persons with mental retardation in North Dakota rated the acceptability of six staff management procedures. Overall, staff rated “Instructions”, “Instructions and Modeling”, “Feedback and Praise”, and “Instructions, Feedback, and Praise”, as significantly more acceptable than “Self-Management” and “Self-Management, Feedback and Praise”. There was a significant group by treatment interaction in which supervisors and direct care staff had significantly different acceptability rating for four of the six procedures. The results were further analyzed by group and implications and future research are discuessed.     

Redefining dementia care barriers for ethnic minorities: the religion–culture distinction

Barriers to healthcare services experienced by black and minority ethnic (BME) persons with dementia are labelled as “cultural” in existing research. This is a promising shift from an ethno-centric approach to dementia care provision, yet very little research is dedicated to specifically how religion – as distinct from culture – influences healthcare practice. Further consideration of the religion–culture distinction is required; religion and culture are two distinct entities, which inevitably interlink. Cultural themes such as “God's will”, “Religious Ritual” and “Religious Duty”, warrant re-categorisation as “religious”. Sensitivity to the nuances between cultural and religious themes will provide clearer knowledge of how and why BME persons with dementia experience barriers to accessing care services. Further research is needed with regard to the role of religion specifically on dementia care access for BME persons to aim to improve care provision for this underrepresented demographic.     

Computerized encounter registers in primary care research: Is there a gold standard?

Computer technology as well as the need to conduct research in primary care settings, has stimulated the creation in the U.S. of information networks linking private physicians' offices and other primary care practice sights. These networks give rise to several problems which have philosophic interest. One is a “numerator problem” created by the difficulty in primary care of using the more complicated or invasive diagnostic technologies commonly employed in tertiary care research. Another is a “denominator problem” arising from the difficulties in determining which and how many patients constitute the population from which a practice is drawn. Finally, this mode of research raises questions about the social construction of medical reality and how “objective” medical truth is actually based on carefully selected patient experience. All these questions combine to challenge the “gold standard” view on medical research: the idea that some sorts of medical knowledge are epistemologically privileged and can serve as a bench-mark to determine whether new data are valid.     

Clarifying the task

Those who would enquire into therelationship between “health conceptions” and “health care consequences” are faced with a formidable task. In order to make this challenge manageable it is necessary to define the scope of the task as precisely as possible. Are we, for instance, faced with a purely theoretical challenge; a task for applied philosophy, or must we employ multi-disciplinary methods? This paper argues that while philosophy has a central clarifying role, inquiry into the relationship between “health conceptions” and “health care organisation” can be done properly only through the combined efforts of several disciplines. Unless we are to be concerned only with abstract models it is essential to take account of the reality of health care situations. Given this it is suggested that the study of “health conceptions” is only a part of a greater task (unless all conceptions are to count as “health conceptions”). What is needed is understanding of the possible and actual purposes of health care, and detailed study of their practical implications.     

Ce que soigner veut dire. Le peintre,le patient et le bon samaritain

The hyper-medicalization of our societies and our absolute confidence in curative medicine have made us gradually lose the deep meaning of the words of ailments. Many are now calling on the public authorities to promote a “policy of Care”. The use of anglicisms is certainly “trendy” but opposing “cure” and “care” does not make sense. We invite our readers to try to recover the meaning and the value of the verb to treat and the word care(s), plural and yet so singular. To carry out this quest, we will focus our attention on a few works of art which will perhaps allow us, in three stages, to (re)discover the deep meaning of the care relationship.     

Listening for Safe Places: Networks of Playing and Chalcedon in Disaster Pastoral Care

Disaster pastoral care operates in diverse contexts, which may challenge clergy responders in ecclesiological meaning‐making of their practices of care. This article argues that pastoral care may be imagined as part of a larger “network” of caring acts understood as a collective, multiple care practice. Such practice reflects deep‐rooted movements described in psychoanalytical theory as playing, and the christological idea of communication of properties. Therein, spiritual “safe places” can be seen to emerge, even in the midst of traumatic events.     

Colonialism and Its Others: Considerations On Rights and Care Discourses

I point to a colonial care discourse that enabled colonizers to define themselves in relationship to “inferior” colonized subjects. The colonized, however, had very different accounts of this relationship. While contemporary care discourse correctly insists on acknowledging human needs and relationships, it needs to worry about who defines these often contested terms. I conclude that improvements along dimensions of care and of justice often provide “enabling conditions” for each other.     

Building Bridges with Accessible Care: Disability Studies,Feminist Care Scholarship,and Beyond

This article uses elements of autoethnography to theorize an in/formal support relationship between a friend with a physical disability, who uses attendant services, and me. Through thinking about our particular “frien‐tendant” relationship, I find the common scholarly orientations toward “care” are inadequate. Starting from the conversations between feminist and disability perspectives on care, I build on previous work to further develop the theoretical framework of accessible care. Accessible care takes a critical, engaged approach that moves beyond understanding “accessibility” as merely concrete solutions to create more inclusive forms of care. Care, in this context, is positioned as an unstable tension among competing definitions, including that it is a complex form of oppression. Accessible care draws on feminist disability perspectives and the feminist political ethic of care to build bridges in four areas: from daily experiences of disability and support to theoretical discussions; across feminist care research and disability perspectives; across divisions and anxieties within disability communities; and from the local to transnational applications. These bridges do not aim to resolve debates but allow us to travel back and forth between differing perspectives and demonstrate the tenuous possibility of accessible practices and concepts of care.     

Standards of Care: Potential Implications for the Counseling Profession

The potential implications for development of professionally defined “standards of care” treatment procedures for mental health counseling are presented. The role of xpert witnesses in malpractice cases is examined as one source from which the standards are currently derived. The influence of managed care on the current clinical practices is noted. Finally, the importance of using outcome research as the basis for developing a “best practices” concept of standards of care is discussed. The authors note difficulties and challenges involved in making a commitment to what could be the next major impetus to the mental health movement.     

Health care responsibility

The general and deep dissatisfaction with the present-day status of health care is of such intensity that one speaks of a health care crisis. What is most disturbing to the physicians is that society directs its accusation mainly at the health care professional for being responsible for this crisis. If we want to abolish the crisis we must try to get a renewed look at its source, i.e., to answer the questions “where did health care go wrong primarily?” and “with whom lies the ultimate responsibility for health care?”. In the following discourse these questions are discussed. Based on the assumption that every human being is a free rational agent the ultimate health care responsibility is assigned to the citizen. Of course, whether such an approach will in fact solve the problems inherent in present-day health systems cannot be predicted.     

Comme réponse à la précarité du lien mère–bébé, les « Petits Pas » : un réseau en périnatalité…

The “Baby Steps” network includes a multi-disciplinary team and aims to accompany parents-to-be and young parents as they meet their newborns. The exchange and development relationships that professionals develop among themselves help to support the notion of parenthood and circumscribe any potential risk. The professionals in the network hail from a variety of backgrounds but they are all involved in perinatal care and by grouping their skills can adapt and optimise the assistance and care they offer to parents. The “Parent Island” reception area and the mother-baby therapy group with a separate father oriented structure are the truly original aspects of the network. Prevention is vital, as is providing therapeutic care for disturbances related to early parent-child relationships. With a strong “group psychology focus” the network creates a sufficiently solid structure to receive any unconscious negative projections from momentarily or deeply distressed parents.     

The “religiosity gap” in a clinical setting: experiences of mental health care consumers and professionals

ABSTRACT

In Western countries, professionals in mental health care (“professionals”) tend to be less religious than “consumers”. This qualitative study explores the meaning of this “religiosity gap” for professionals and consumers in mental health care. Both a regular, secular and a Christian clinic in the Netherlands participated in this study. Content analysis was applied to 35 consumer interviews and 18 interviews with professionals. Consumers reported negative experiences (e.g., perceived disrespect and a lack of confidence) and/or negative expectations (e.g., misunderstanding and misinterpretation) related to a religiosity gap. They also mentioned advantages of a “religiosity match”, like safety and confidence and appreciated professionals’ religious/spiritual self-disclosure. Professionals in secular care setting tended to avoid religion and spirituality. In both clinics, they tended to neutralise religious/spiritual differences and be reticent in self-disclosure. Professionals are recommended to recognise the relevance of a religiosity gap and to consider different strategies in approaching religion/spirituality.     

Research in Emergency and Critical Care Settings: Debates,Obstacles and Solutions

Research is an integral part of evidence-based practice in the emergency department and critical care unit that improves patient management. It is important to understand the need and major obstacles for conducting research in emergency settings. Herein, we review the literature for the obligations, ethics and major implications of emergency research and the associated limiting factors influencing research activities in critical care and emergency settings. We reviewed research engines such as PubMed, MEDLINE, and EMBASE for the last two decades using the key words “emergency department”, “critical care”, “research”, “consent”, and “ethics” as the search terms. Research within emergency settings is slow or non-existent due to time and financial constraints as well as the lack of a research tradition. There are several barriers to conducting research studies in emergency situations such as who, what, when, and how to obtain patient consent. The emergency environment is highly pressurized, emotional, and overburdened. The time taken for research is a particular risk that could delay the desired immediate interventions. Ethical issues abound, particularly relating to informed consent. Research in emergency settings is still in its infancy. Thus, there is a strong need for extensive research in the emergency setting through community awareness, resource management, ethics, collaborations, capacity building, and the development of a research interest for the improvement of patient care and outcomes. We need to establish a well-structured plan to assess and track the decision-making capacity, consider a multistep enrolment and consent strategy, and develop an integrated approach for recruitment into studies.     

Why Should a Knower Care?

This paper argues that the concept of care is significant not only for ethics, but for epistemology as well. After elucidating caring as a five‐step dyadic relation, I go on to show its epistemic significance within the general framework of virtue epistemology as developed by Ernest Sosa, Alvin Goldman, and Linda Zagzebski. The notions of “care‐knowing” and “care‐based epistemology” emerge from construing caring (respectively) as a reliabilist and responsibilist virtue.     

Les grands magasins de la médecine de Milton Friedman

The coronavirus pandemic has brought back the question in Western countries of the solidity of their health systems. This article discusses Friedman's 1962 piece of work, “Capitalism and Freedom”, and more specifically his presentation based on American occupational licensure. This research insists beyond the complexity of “de-licensing laws” passed for some U.S. health care facilities, on the consequences of a parasitic competition on health care ethics.     

The moral psychology of rationing among physicians: the role of harm and fairness intuitions in physician objections to cost-effectiveness and cost-containment

Introduction

Physicians vary in their moral judgments about health care costs. Social intuitionism posits that moral judgments arise from gut instincts, called “moral foundations.” The objective of this study was to determine if “harm” and “fairness” intuitions can explain physicians’ judgments about cost-containment in U.S. health care and using cost-effectiveness data in practice, as well as the relative importance of those intuitions compared to “purity”, “authority” and “ingroup” in cost-related judgments.

Methods

We mailed an 8-page survey to a random sample of 2000 practicing U.S. physicians. The survey included the MFQ30 and items assessing agreement/disagreement with cost-containment and degree of objection to using cost-effectiveness data to guide care. We used t-tests for pairwise subscale mean comparisons and logistic regression to assess associations with agreement with cost-containment and objection to using cost-effectiveness analysis to guide care.

Results

1032 of 1895 physicians (54%) responded. Most (67%) supported cost-containment, while 54% expressed a strong or moderate objection to the use of cost-effectiveness data in clinical decisions. Physicians who strongly objected to the use of cost-effectiveness data had similar scores in all five of the foundations (all p-values?>?0.05). Agreement with cost-containment was associated with higher mean “harm” (3.6) and “fairness” (3.5) intuitions compared to “in-group” (2.8), “authority” (3.0), and “purity” (2.4) (p?<?0.05). In multivariate models adjusted for age, sex, region, and specialty, both “harm” and “fairness” were significantly associated with judgments about cost-containment (OR?=?1.2 [1.0-1.5]; OR?=?1.7 [1.4-2.1], respectively) but were not associated with degree of objection to cost-effectiveness (OR?=?1.2 [1.0-1.4]; OR?=?0.9 [0.7-1.0]).

Conclusions

Moral intuitions shed light on variation in physician judgments about cost issues in health care.