Is the Appeal of the Doctrine of Double Effect Illusory?

Scanlon (2008) has argued that his theory of permissibility (STP) has more explanatory power than the Doctrine of Double Effect (DDE). I believe this claim is wrong. Borrowing Michael Walzer’s method of inquiry, I will evaluate the explanatory virtue of these accounts by their understanding of actual moral intuitions originated in historical cases. Practically, I will evaluate these accounts as they explain cases of hostage crises. The main question in this context is: is it permissible that nation-states act with military force in order to liberate hostages, even if those actions put the lives of the hostages at risk? The first part of this paper has an operative reconstruction of the relevant theories. In the second section, two cases of hostage crises will be considered: the Moscow theater hostage crisis of 2002, and the Jaque Operation, which occurred in Colombia in 2008. Additionally, it will be shown that DDE explains these cases better than STP. Finally, this paper offers a critical analysis of Scanlon’s account of the explanatory power of both STP and DDE.     

The Call of the Wild Woman

Abstract

Women have a longstanding and unique connection to healing and health care. The feminine perspective, however, has been discounted and decimated through the last 600 years. Now general social and political changes, as well as increasing numbers of women practitioners in health and mental health, are leading to a re-emergence of the feminine perspective in addressing women's needs and in providing health care. This paper traces some of the elements in the history of women and their influences on present day models of health care. It emphasizes women's roles as healers, as patients and as crafters of a new synthesis of health care delivery in the 21st century.     

The experiences of gender diverse and trans children and youth considering and initiating medical interventions in Canadian gender-affirming speciality clinics

Abstract

Background: Canadian specialty clinics offering gender-affirming care to trans and gender diverse children and youth have observed a significant increase in referrals in recent years, but there is a lack of information about the experiences of young people receiving care. Furthermore, treatment protocols governing access to gender-affirming medical interventions remain a topic of debate.

Aims: This qualitative research aims to develop a deeper understanding of experiences of trans youth seeking and receiving gender-affirming care at Canadian specialty clinics, including their goals in accessing care, feelings about care and medical interventions they have undergone, and whether they have any regrets about these interventions.

Methods: The study uses an adapted Grounded Theory methodology from social determinants of health perspective. Thirty-five trans and gender diverse young people aged 9 to 17?years were recruited to participate in semi-structured interviews through the specialty clinics where they had received or were waiting for gender-affirming medical interventions such as puberty blockers, hormone therapy, and surgery.

Results: Young people felt positively overall about the care they had received and the medical interventions they had undergone, with many recounting an improvement in their well-being since starting care. Most commonly shared frustrations concerned delays in accessing interventions due to clinic waiting lists or treatment protocols. Some youth described unwanted medication side-effects and others said they had questioned their transition trajectory at certain moments in the past, but none regretted their choice to undergo the interventions.

Discussion: The results suggest that trans youth and gender diverse children are benefiting from medical gender-affirming care they receive at specialty clinics, providing valuable insight into their decision-making processes in seeking care and specific interventions. Providers might consider adjusting aspects of treatment protocols (such as age restrictions, puberty stage, or mental health assessments) or applying them on a more flexible, case-by-case basis to reduce barriers to access.     

The Doctor-Patient Relationship in the Post-Managed Care Era

The growth of managed care was accompanied by concern about the impact that changes in health care organization would have on the doctor-patient relationship (DPR). We now are in a “post-managed care era,” where some of these changes in health care delivery have come to pass while others have not. A re-examination of the DPR in this setting suggests some surprising results. Rather than posing a new and unprecedented threat, managed care was simply the most recent of numerous strains on the DPR that have occurred throughout the century. These strains are a constant, inevitable consequence of the varying needs and concerns of patient and physicians as they seek to balance their desires for a certain type of DPR with their simultaneous desire for other aspects of care such as lower costs, greater technological sophistication, and improved outcomes.     

Group psychotherapy process in the treatment of hostages taken in prison

Group psychotherapeutic techniques with former correctional hostages are discussed. Recommendations are offered regarding the management of such individuals with regard to returning to work, administrative management, hostages' families and the inevitable court appearances. A brief overview of hostage symptom psychodynamics is offered.     

Cultural safety in Muslim aged care: Taking the bull by the horns

ABSTRACT

Cultural safety is critical to providing holistic, person-centred care. Where “deep” or core cultural elements are primarily shaped and influenced by religion, it becomes important to recognise and understand the religious values and traditions in planning, designing, and delivering care. Such an approach is significantly important for communities essentially identified by their faith, such as the Muslim community. Muslims living in the West face challenges owing to their minority status and these are increasing in the current geopolitical context. These challenges contribute to individual Muslims and their families feeling vulnerable within an aged-care system that is mostly unfamiliar, and often confusing and frightening to them. This article attempts to make a case for cultural safety in the context of Muslim aged care. It does not offer an answer or a definite solution to the cultural risks Muslims may face in care settings. Rather, the article seeks to explore avenues for creating an environment of cultural safety without delving specifically into culturally safe care practices. It is only possible to offer culturally safe care when the environment in which care is to be delivered is respectful and supportive.     

Reducing obstacles to the provision of quality diabetic care

Abstract

High quality diabetic care is seen as influenced by the organisation of care, health care workers' involvement in diabetes-specific areas, co-operation among staff members, the availability of resources, and the competence of medical staff (including both physicians and nurses). In a prospective study we have tested a programme for improvements of the quality of diabetes services which combined organisational development and continuing medical education (CME) measures. The study involved 34 primary health care centres over an 18 month period and was based on the responses to questionnaires answered by 123 general practitioners and 247 registered nurses at the 34 PHCCs.

The combined programme had a considerable influence on inter-group co-operation, staff members' perceptions of resources available, and nurses' involvement in diabetic care (54 versus 30% seeing diabetic patients for regular check-ups).

The results show that, in order to diminish obstacles to high quality care, organisation of care as well as care workers' theoretical knowledge has to be focused.     

Experiences of surgery readiness assessments in British Columbia

Abstract

Background: A surgical readiness assessment is a major step in the medical journey of trans people seeking gender-affirming surgery. Much of the peer-reviewed literature surrounding surgical readiness assessments emphasizes the perspectives of academics and clinicians, leaving the voices of trans and gender diverse patients largely unheard.

Aims: This paper foregrounds patient experiences with surgery readiness assessments to discuss the tensions, challenges and opportunities they generate.

Methods: We conducted a thematic analysis of 35 in-depth interviews with trans people who accessed or were seeking to access gender-affirming surgery in British Columbia.

Results: We developed three main themes to capture participants’ narratives of their surgical assessment experiences. The first, assessments as gatekeeping, explores the stories of people who described their assessments as outdated and even discriminatory processes. The second, assessments as a barrier to care, discusses the informational missteps, bureaucratic regulations, economic issues, and geographic concerns that made assessments difficult to access. The third, assessments as useful, includes positive stories about assessments that often involved feeling supported by an assessor and feeling prepared for the next steps.

Discussion: These narratives demonstrate how much variation exists among people’s experiences of readiness assessments for gender-affirming surgery. No matter how their actual assessment turned out, many participants approached their appointments with a great deal of anxiety and trepidation. We attributed this stress was to challenges ranging from lengthy wait times, arbitrary medical gatekeeping, a lack of access to knowledgeable and supportive providers, unclear or changing administrative processes, and insufficient communication. To address these challenges, it is crucial for the medical system to create more accessible pathways with centralized, up-to-date information for people trying to access assessments. Patients are best served by multi-disciplinary gender-affirming teams that provide individualized care.     

The ‘Connection’ Health Care Providers Make with Dying Patients

SUMMARY

The literature confirms illness and hospitalisation can become spiritual encounters for patients and their families. Further, it has been established that both patients and their families are better equipped to deal with loss and change if they have a healthily developed spiritual sense of self. The aim of the study sought to determine the benefit or otherwise of a previous model of spiritual care. It asked ‘from the perspective of the nurse and other health care providers, what constitutes spiritual care giving?’ An ethnography was undertaken where data consisted of field notes, interviews, records, and diary entries. This paper reports on interview data, from which themes were derived. The major theme titled their space is expressed via a new model of spiritual care. It was shown that when caring for patients and their relatives, nurses and other health care professionals enter the world of the other to determine the other's needs. In so doing they typify agapé (altruistic love), where the individual cares for a complete stranger as if that stranger were family. This connection with the patient and their family is the foundation for spiritual care.     

The enemy within An exploration of the concept of boundaries in a GP's surgery

Abstract

This paper looks at two GPs' surgeries and the way that they deal with the anxieties aroused when trying to meet patients' needs in primary health care. The practice counsellor is both an observer and a participant in this. The physical surroundings seem to influence the way these anxieties are acted out. Each surgery has to create an enemy in order to live with their anxiety.     

The identity of the sport psychology profession: A multinational perspective

ObjectiveTo ensure public safety, duty of care, and professional advancement, there is a need for scholars to explore factors that impact the professional experiences of sport psychology professionals (SPPs). One such factor is professional identity, which has been shown to positively contribute to an enhanced sense of legitimacy of the profession in the eye of the public and sport stakeholders (i.e., athletes, coaches, sport scientists, administrators) and to positively impact the experience and effectiveness of practitioners. Yet, little research has directly examined the construct of professional identity within sport psychology, with this oversight posing a risk to the future of the profession.DesignThis interview-based study was situated within critical realism. We conducted a qualitative study using semi-structured interviews to explore the understanding and perceptions and experiences of the professional identity among SPPs.MethodsFollowing theoretical criterion-based sampling, we interviewed 33 expert (n = 13), experienced (n = 12), and early career (n = 8) SPPs regarding their views on PI. The nationalities of these SPPs (male n = 16; female n = 17) represented sixteen different countries on four different continents.ResultsData were analyzed using reflexive thematic analysis and showed a relatively shared meaning of professional identity which unfolded across the career span. Moreover, the professionals in this study seemed to identify their pride for and their knowledge of the profession as key factors in the development of their PI. Furthermore, they identified how their professional role, expertise, and interactions with other professionals within the field played an important role in sustaining a professional identity.ConclusionWe interpreted the interview data as supporting the importance of professional identity for SPPs and consider the contribution of this within a developmental framework for effective practice.     

Women,Mental Health,and Managed Care

Abstract

Managed care has changed the way that mental health care is provided. These insurers manage such factors as length and type of therapy made available, access to therapy, and level of payment for therapy. Women, as the majority of those insured by managed care and as consumers of mental healthcare, are differentially affected by these changes.     

Perceptions of health care social workers in Ontario: challenges and facilitators to reflective practice

Background: Reflective practice in health care social work ensures that social workers provide effective and efficient services to clients as well as maintaining their mental and physical health. In this study, we aim to determine how health care social workers engage in and describe reflective practice and challenges related to their reflective practice in their work in the health care system.

Methods: We used the Reflective Dialogue Rating Scale (RDRS) developed by Marion Bogo et al. to structure qualitative face-to-face interviews with 23 health care social workers employed in a hospital in a large urban area in Ontario, Canada.

Results: Findings illustrated that all participants regularly engaged in reflective practice in order to carry out everyday social work activities, promote ethical practice, and to enhance the provision of services to their clients. The social worker participants consistently agreed that as a profession they faced challenges maintaining their knowledge of current research due to few opportunities for professional development, workload competing with educational opportunities, and a work climate that is not conducive to gaining professional development, thereby challenging reflective practice. Supportive working environments include: peer supervision, safe and private spaces to talk to colleagues, a supportive supervisor, and an overall positive organizational culture.

Discussion and conclusion: Reflective practice is a key component in health care social work. All 23 social workers stated that they used reflective techniques (such as peer supervision and debriefing) to deal with their own reactions and operated in a purposeful and intentional manner to form therapeutic relationships with clients. As such, participants stated that lifelong learning was paramount in providing quality care to clients.     

Theology at the Freak Show: St Uncumber and the Discourse of Liberation

Abstract

Christian theology can begin to contemplate release or escape from a gendered theological hierarchy which has been mapped onto the cultural view of gender normativity by following the ancient saintly pattern of St Uncumber's tradition. St Uncumber responds to the call to difference by retaining her anomalous sexual characteristics —as the bearded lady. And tradition, by making of her a liberator, opens up the possibility of configuring her as a liberator from the imprisonment of biological essentialisms or normative sex gender.     

Fonctionnements et dysfonctionnements des psychothérapies : synthèse de la littérature et présentation de deux méthodologies associées aux meilleurs résultats

IntroductionPsychological difficulties are part of higher stakes health issues. What are the real effects and the difficulties to generate results of psychotherapies?Literature resultsPsychotherapy is efficient for multiple psychological disorders, as well in controlled as in naturalistic studies, and participate in reduction of health expenditure. However, all patients do not get real benefits from care, patients can deteriorate or drop-out treatment, and persistent side effects can occur; clinicians overestimate their efficiency and their performances decline during their career. Two promising methodologies seems to be associated with better outcomes: Routine Outcome Monitoring (ROM) and a specific form of training clinician expertise named “Deliberate Practice”.DiscussionUsing client feedback allows to implement ROM and “Deliberate Practice” in routine care.ConclusionImplementation of Routine Outcome Monitoring should be encouraged in French Speaking countries to produce evidence-informed practice for the delivering, the improvement and the payment for psychotherapy expenditure.     

An in-situ examination of the timing of information pick-up for interception by cricket batsmen of different skill levels

ObjectivesCricket batting is performed under demanding constraints, which requires rapid and accurate decision making for successful achievement of the skill goal. To understand how batsmen negotiate these constraints, the capability of highly skilled and low skilled cricket batsmen to utilise visual information prior to and during sections of ball flight to strike balls delivered by fast bowlers was examined.MethodSix highly skilled and six low skilled batsmen faced different types of balls delivered by three fast bowlers. Batsmen wore vision occlusion spectacles and were required to strike delivered balls, while their vision of the bowler's delivery action and ball flight was selectively occluded. Three vision conditions were randomly designed that included temporal occlusion at: (i) a point prior to ball release (providing only advance information), (ii) a point prior to ball bounce (providing advance and ball flight information) and (iii) no occlusion (where all advance, ball flight and bounce information were visible). Foot movements made forward or backward were assessed as a measure of ball length judgement, while the quality of bat–ball contact was assessed as a measure of interception.ResultsResults demonstrated the superior capability of highly skilled batsmen to utilise information prior to ball release to judge short ball length. Expert batsmen were better able to utilise ball flight information prior to and post-bounce to attain a superior number of bat–ball contacts.ConclusionsFindings demonstrate that the mechanism of experts to deal with task constraints when attempting to intercept a delivered ball is their capability to pick-up visual information to judge ball landing position.     

Considerations on medical training for gender-affirming care: Motivations and perspectives

Abstract

Background: Many transgender individuals lack access to needed medical care, partially due to a lack of providers with experience in gender-affirming healthcare.

Aims: The purpose of this study was to identify professional motivators for medical providers seeking out training in gender-affirming care and to define which training experiences were most beneficial to their career development. By identifying experienced providers’ recommendations on which training modalities are most relevant to their practice, we aim to suggest future directions for medical education initiatives to effectively expand the transgender care workforce.

Methods: A voluntary cross-sectional electronic survey was distributed through professional listservs and publicly-available referral lists to interdisciplinary providers who self-identified as having experience in providing care to transgender individuals.

Results: One hundred and fifty-three (n?=?153) physicians, physician assistants, or advance-practice nurses responded to the survey. The majority (96.7%) were located in the United States, representing 37 states. The two most common motivators for seeking out training in gender-affirming care were filling a need in the community (73.0%) and/or having met a transgender-identified person in a clinical setting who requested care (63.8%). While many providers gained skills independently (57.3%), the two most commonly-available training opportunities were professional conferences (57.3%) and mentorship (41.3%). Respondents were most likely to recommend that others in their field be trained via structured clinical experience (e.g., a rotation or longitudinal exposure during training), rather than additional didactic training.

Discussion: This study identifies key high-yield training methodologies which could improve access to quality gender-affirming healthcare. Through integration of structured clinical experiences during training, direct clinical mentorship, and professional development at conferences on gender-affirming care, the workforce of welcoming and prepared healthcare providers for transgender patients will increase. This will lead to a tremendous improvement on access to gender-affirming care in our communities.     

The Tarasoff Warning and the Duty to Protect

Summary

Since the case of Tarasoff v. Regents of the University of California, mental health professionals have had an explicit legal duty to warn potential adult victims of violence. Subsequent case law expanded this standard to a broader duty-to-protect. Primary health care providers are increasingly treating psychiatric patients for whom the duty to protect is applicable. However, these providers are often unaware of the legal, ethical, and clinical issues involved. Assessment of violence risk should include demographic, psychiatric, and social dimensions. Interventions include notifying law enforcement authorities, potential victims, and possible use of psychiatric hospitalization to prevent aggressive behavior. The duty-to-protect as a standard-of-care has been applied to several other clinical situations, including impaired driving capacity, high-risk HIV behavior, and child sexual abuse. The article includes a step-by-step clinical protocol for evaluation and intervention in dangerous situations.     

A meta-ethnography of parents’ experiences of their children’s life-limiting conditions

ABSTRACT

As many children’s life-limiting illnesses (LLCs) are now often viewed as curable, there is an inevitable tension between providing good treatment and addressing patients and their families’ needs. For health care providers to provide optimal care, they must understand parents’ experiences of illness. Therefore, this article provides a meta-ethnography of parents’ experiences of their children’s LLCs by examining the findings of existing interpretative phenomenological analysis studies. Seventeen studies were included, which allowed the development of a conceptual model. Two multifaceted concepts emerged from the data, namely living in a bounded and polarised space and living in a collapsed time, and these are discussed with reference to their subconcepts. Recommendations for future research and practice are provided.