给予老年人体面的照护：为什么尊严很重要——欧洲经验

在医学哲学领域以及相关领域中,“尊严”的概念越来越受到关注。最近,在生物伦理学的国际会议中很流行这个概念。同时,在欧洲的许多国家中,“尊严”的概念也被引入到有关卫生保健的国家立法和政策制定中。本文将从检验一个在关于尊严和老年人的欧洲计划中产生的尊严理论模型开始。然后根据参与这个计划的老年人和卫生及社会保健的专业人员那里得到的经验进行研究,有6个国家参加这项研究。结果证明尊严是一个非常重要的事情,尤其是对那些弱势群体来说。本文结论认为对于虚弱的老年人,相对于那种强调自主的医学伦理,长期的保健需要注重一个范围更为广泛的伦理内容。     

Autonomy in the medical profession in the United Kingdom – an historical perspective

This paper reviews the concept of professional autonomy from anhistorical perspective. It became formalised in the United Kingdom onlyafter a long struggle throughout most of the nineteenth century. In itspure form professional autonomy implies unlimited powers to undertakemedical investigations and to prescribe treatment, irrespective of cost.Doctors alone should determine the quality of care and the levels ofremuneration to which they should be entitled. In the second half of thetwentieth century a steady erosion of professional autonomy occurred inthe United Kingdom. The level of remuneration has been restricted formost doctors for nearly fifty years, whilst the costs of health carehave steadily reduced the doctor's ability to provide unrestricted carewithin the health care system. Reorganisation of the National HealthService in 1983 and 1991 has substantially eroded professional autonomy,to the point where research developments, clinical judgement and ethicalstandards are all now being placed at risk.     

The importance of perceived autonomy support for the psychological health and work satisfaction of health professionals: Not only supervisors count, colleagues too!

Previous studies show that supervisors?? autonomy-supportive style predicts greater psychological health (Baard et al. in J Appl Soc Psychol 34:2045?C2068, 2004; Blais and Brière 1992; Lynch et al. in Prof Psychol Res Pract 36:415?C425, 2005) and lower psychological distress (Deci et al. in Personal Soc Psychol Bull 27:930?C942, 2001). The goal of the present study is to extend these results and investigate the contribution of colleagues?? perceived autonomy support in the prediction of health professionals?? work satisfaction and psychological health. The combined impact of supervisors?? and colleagues?? perceived autonomy support is also examined. A sample of 597 health professionals from the province of Quebec (Canada) completed a questionnaire, which included measures of perceived supervisors?? and colleagues?? autonomy support and outcome variables. Results confirm that supervisors?? and colleagues?? perceived autonomy support predict health professionals?? work satisfaction and psychological health. Results also show that colleagues?? perceived autonomy support adds to the prediction of health professionals?? work satisfaction, subjective well-being, and suicidal ideation above and beyond supervisors?? perceived autonomy support.     

Patient Autonomy and Quality of Care in Telehealthcare

Telemedicine is a complex field including various applications and target groups. Especially telehealthcare is seen by many as a means to revolutionize medicine. It gives patients the opportunity to take charge of their own health by using self-tracking devices and allows health professionals to treat patients from a distance. To some, this means an empowerment of patient autonomy as well as an improvement in the quality of care. Others state the dangers of depersonalization of medicine and the pathologization of daily life. This paper examines the ethical implications of telehealthcare, focusing on patient autonomy and quality of care by analyzing metareviews, randomized controlled trials and narrative ethical analyses on the topic. As a result, we conclude that the technically enhanced encounter between patients and health professionals may mean an empowerment of patient autonomy when it goes along with a personal relationship based on trust, assistance and support. When it comes to the quality of care, telehealthcare may lead to an improvement as long it is adopted to the patient’s individual needs.     

Solidarity,justice, and recognition of the other

Solidarity has for a long time been referred to as the core value underpinning European health and welfare systems. But there has been debate in recent years about whether solidarity, with its alleged communitarian content, can be reconciled with the emphasis on individual freedom and personal autonomy. One may wonder whether there is still a place for solidarity, and whether the concept of justice should be embraced to analyse the moral issues regarding access to health care. In this article, I will answer this question by analysing the normative foundations of the concept of justice, followed by a deeper examination of the concept of solidarity in continental philosophy. More specifically, I will compare the philosophical traditions rooted in Kant (with emphasis on autonomy and individual rights) to approaches rooted in Hegel (with emphasis on individual relations of recognition). In addition, I will present the work of Avishai Margalit on the decent society to criticize a predominantly liberal approach to access to health care. The importance of solidarity lies particularly in its emphasis on relational aspects and the role of recognition in care practices, which are usually ignored in liberal approaches to justice. However, the article will argue that solidarity is not an alternative to a rights-based concept of justice, but must be considered as a necessary complement to it.     

Ethical Considerations for Providing In-Home Mental Health Services for Homebound Individuals

The number of homebound individuals in the United States is on the rise, causing health-care professionals to expand in-home health services to help meet the increased demand. Due to the prevalence of feelings of isolation and depression in this population, it is imperative that mental health professionals join this effort to increase access to mental health services. Delivering psychotherapy in clients’ homes presents many advantages to these homebound individuals, but there is a dearth of literature addressing how therapists should handle unique ethical issues that arise in this type of setting. This article addresses ethical considerations and guidelines for in-home provision of mental health services. General ethical issues related to home-based psychotherapy include boundaries, confidentiality and privacy, competency, insurance coverage, and autonomy. Issues pertaining to different categories of homebound individuals, including persons with agoraphobia, chronic illnesses, and older adults, are then discussed in turn. Recommendations on how to best manage these issues by applying the American Psychological Association’s, the American Counseling Association’s, and the National Association of Social Workers’ Ethics Codes are provided.     

Prescriptions: Autonomy,Humanism and the Purpose of Health Technology

My purpose is to examine two of the foundations of medical ethics: the principle of autonomy and the concept of the human. I also investigate the extent to which health technology makes autonomy and humanness possible. I begin by underlining Illich's point that the same health technology designed to promote health and autonomy also is pathogenic. I proceed to analyse the Kantian concept of autonomy, a concept which is closely associated with health and which continues to determine current ethical thinking. In so doing, I uncover an unexpected ontological function of health technology, a function described in Heidegger's work on technology. Based on this discovery, I suggest that calls for Kantian autonomy may often be self-defeating or even sometimes harmful. I conclude by calling for continued ethical vigilance, but also for a questioning of the hitherto virtually unquestionable concepts of ethics and humanness which may themselves play a role in our era's greatest problems.     

Freedom and insanity

The paper describes the refusal of the liberal community to assert the right of persons accused of mental illness to be free of coercive psychiatric intrusion. It suggests that the penchant for benevolent governmental intrusion into other social problems may be at fault and recommends that intervention be abandoned in favor of a return to human autonomy as a basis of the concept of freedom.     

The travails of Martin Orne: On privacy,public disclosure,and confidentiality in psychotherapy

The experiences of one psychotherapist have brought to the fore the entire issue of privacy and confidentiality and the responsibilities of mental health professionals. In a computer driven culture, where data about patients become subject to public scrutiny, how does the mental health professional practice, guided by the concept of confidentiality? Where does confidentiality begin and end? What about the patient's right to self-disclose? What about patient autonomy? In this paper, illustrated by one particular case where the rule of absolute confidentiality, an intrinsic part of the practice of psychotherapy, was questioned, our current confusion comes to the surface. The reader is urged to re-think the concept of confidentiality and patient self-disclosure.     

Integrating Care for Persons, Not Only Diseases

Integrated care is geared toward enhancing usual care and decision-making for common combinations of medical and mental health conditions, including the behavioral health and behavioral change aspects. Yet even with comprehensive and well-integrated care for health conditions and well-coordinated teamwork in place, some patients do not engage or respond to care in the way clinicians would like or predict. This troubles patients and clinicians alike and may be chalked up informally to things like medical complexity (multiple co-existing conditions), mental health conditions (that complicate care), or simply the case being considered complex or difficult. It also raises the question of how to address person-specific factors that interfere with care of whatever conditions the patient may have, and invites behavioral health clinicians in medical settings to look beyond care of conditions to the care of persons, and to look beyond disease-specific care management protocols to master generic practices of care management across whatever conditions the person may have. This person-centered emphasis is intrinsic to the concept of the “patient-centered medical home” which has burst into animated discussion and demonstration among providers, health plans, government plans, employer purchasers, and professional associations across public and private entities. This represents an opportunity for collaborative care clinicians to help shape the national state of the art in medical home and includes a range of person-oriented (rather than disease-oriented) practices for care management, including working systematically with complex patients and difficult patient–clinician relationships.     

The Self‐Care of Psychologists and Mental Health Professionals: A Review and Practitioner Guide

It has been documented in the professional literature that psychologists and mental health professionals in general tend to neglect their own mental health, despite serving in a field that promotes the health and well‐being of others. Numerous empirical studies support the need for psychologists and mental health professionals to be more conscientious of the effect that stress and the nature of their work has on them. This article reviews some of the recent literature and discusses the pertinent issues at hand. A number of interventions are suggested along with tips for professionals to consider in order to function in a more productive and ethical fashion.     

Counselors Within the Chronic Care Model: Supporting Weight Management

The Chronic Care Model developed for the multidisciplinary management of chronic diseases provides a blueprint for the integrated role of mental health counselors supporting clients with obesity seeking weight management treatment. Counselors can support clients and the team of health care professionals treating obesity within each of the 6 components of the model: (a) health care organization, (b) delivery‐system design, (c) clinical information systems, (d) decision support, (e) client self‐management support, and (f) community resources.     

HUMANITY AS AN OBJECT OF RESPECT: IMMANUEL KANT'S ANTHROPOLOGICAL APPROACH AND THE FOUNDATION FOR MORALITY

The article deals with Kant's understanding of personhood and autonomy. It highlights the connection of autonomy and human dignity within Kant's appreciation of morality, and indicates how his distinction between the empirical and transcendental spheres enables Kant to extend dignity even to humans who are not actually autonomous. Turning to contemporary approaches within ethics that refer to Kant but omit this transcendental framework, it defends the necessity of a trans‐empirical frame within the Kantian system and hints at consequences for bioethics. It concludes that Kant works with neither an absolutist notion of freedom in terms of solipsistic autarky, nor an empirical freedom and autonomy that begin and end at certain points of time.     

The development of an Autonomy scale based on recent insights into gender identity

The concept of autonomy has a long history, not only in psychology, but also in philosophy. In this article, the concept is discussed in relation to gender and mental health. The criticisms of several authors with regard to the classical psychological concept of autonomy are reviewed. Also, some recent theoretical developments which start from a psychoanalytical perspective are discussed. Then the reader is introduced to the construction of a new Autonomy scale that takes the criticism mentioned into account and connects with new insights into gender identity. Two studies are presented in which the structure of the scale, as well as it validity and reliability, is investigated. The Autonomy scale appears to measure consistently three aspects: Self-awareness, Sensitivity to Others, and Capacity for Managing New Situations. Reliability and validity are satisfactory. Furthermore, in a third study the factor structure found in Studies 1 and 2 was cross-validated in a more heterogeneous, adult sample. This cross-validation was also done across the sexes. It is concluded that the Autonomy scale is a valid and reliable instrument for measuring the new autonomy concept in various populations. Secondly, the scale seems to fill the gap that is left open by more classically oriented autonomy (and dependence) scales by measuring Sensitivity to Others, an important aspect of femininity and thus for female identity.     

Professional Autonomy in the Health Care System

Professional autonomy interferes at a structural level with the variousaspects of the health care system. The health care systems that can bedistinguished all feature a specific design of professional autonomy,but experience their own governance problems. Empirical health caresystems in the West are a nationally coloured blend of ideal type healthcare systems. From a normative perspective, the optimal health caresystem should consist of elements of all the ideal types. A workableoptimum taking national values into account could be attained bygovernance structures that also introduce elements from other ideal typesystems. Thus a normative approach to medical practice guaranteeing anessential degree of professional autonomy for a relationship of trustbetween the patient and the physician, could be combined with anefficient and equitable allocation of health care resources.     

RECENT TRENDS IN RESPONSE TO CHILD VICTIMIZATION

Abstract

This chapter serves as an introduction to the many roles of health care professionalsin the assessment, care, and treatment of child victimization. It concentrates on those professionals caring for the physical health of victims of child abuse and neglect, although there are many similarities between child maltreatment and other family violence victims. In reviewing the health impact of maltreatment and the historical contributions of health care professionals, it discusses the roles that health care disciplines play in clinical care, training, research, and advocacy and their interaction with the community's child welfare, legal, and criminal justice systems.     

The development of personal autonomy throughout cultures

It is argued here that autonomy entails universal psychological needs pertaining to agency and identity formation, expressed in different ways over different developmental periods. As children develop skills and abilities related to psychological needs for self-expression and competence, they will claim areas related to the exercise of these abilities, in accordance with the possibilities afforded by different cultural environments. The development of a sphere of autonomous functioning is postulated to be central to conceptions of personal freedom and rights, placing limits on the legitimate actions of authorities and other social agents. Concepts of personal freedom and associated rights are often constructed in the context of conflict, in which children's attempts to claim personal freedom is met with opposition by parents or other authorities. Evidence is reviewed indicating that the developmental pathway toward autonomy shows many similarities across diverse cultures that are only beginning to be recognized and systematically investigated.     

Etiology and Management of Elder Self‐Neglect

This article addresses the challenges of defining and accurately identifying elder self‐neglect and explores an interdisciplinary team model, including counselors and mental health professionals, designed to implement prevention and intervention strategies. The challenge of striking a balance between the need to respect the individual elders' autonomy and the need to attend to their health care needs is underscored.