Ethics and public health emergencies: encouraging responsibility

The three primary ethical challenges in preparing for public health emergencies - addressing questions of rationing, restrictions and responsibilities - all entail confronting uncertainty. But the third, considering whether people and institutions will live up to their responsibilities in a crisis, is perhaps the hardest to predict and therefore plan for. The quintessential example of a responsibility during a public health emergency is that of health care professionals' obligation to continue caring for patients during epidemics. Historically, this 'duty to treat' has sometimes gone unrecognized or ignored, but it has also famously been adhered to, including during the recent SARS epidemic. And non-crisis examples of health professionals working in the face of personal risk are very common. The duty to treat should be circumscribed by several considerations, including the levels or risk and benefit at issue, the degree of public reliance on health professional action, and the nature of the individual health professional's acceptance of greater than usual risk. Examining the professional duty to treat and the legitimate questions it raises can provide insight into other actors' responsibilities. Public health ethics as well as professional ethics can help frame answers to some key questions: How strong are ethical responsibilities during crises? To whom do they apply? Should they be more explicit - and hence more circumscribed - or less explicit and hence largely aspirational? And how can public health policies encourage responsible actions?     

Seeking the perfect balance: Perfectionism and work–family conflict

This study considers the relationship between perfectionism and perceptions of work–family conflict. A situational component to perfectionism was found, with higher standards and a higher perceived discrepancy between standards and performance at home versus at work. Findings suggest perfectionism predicts work–family conflict, beyond the effects of the Big Five, trait affectivity and achievement. Further, findings indicate those with adaptive perfectionism (AP; work and home) tend to have lower strain and time‐based family interfering with work and lower behaviour‐based work interfering with family, compared with maladaptive perfectionists (home) and non‐perfectionists (work and home). Gender differences were found and considered in a more exploratory manner.     

The ethics of enforced medical treatment: the balance model

ABSTRACT When is it right to enforce medical treatment on a patient who is refusing that treatment? English law recognises two ethical principles as of paramount importance: the autonomy of the patient; and the consequences of not treating compared with treating. The law, by and large, operates these principles in succession. Thus, in the case of a patient refusing treatment, the law asks first, is the patient competent? Only if the answer is no, are the consequences considered. We criticise the position taken by English law and argue, first, that competence is a graded and not a binary concept, and secondly, that the two ethical principles should be applied not sequentially but at the same time. These two ideas form what we have called the balance model. This model could be used for an empirical study of individuals’ ethical beliefs, and in particular to test the hypothesis that the ethical beliefs of most individuals conform to the balance model rather than to the position taken by English law.     

Living liver donation: Attitudes of the general public and general practitioners in Scotland

In April 2006, the Scottish Liver Transplant Unit in Edinburgh became the first NHS transplant unit in the UK to offer adult-to-adult living donor liver transplantation (LDLT). This procedure allows a healthy individual to donate part of their liver to someone with end-stage liver disease. With donations from the deceased in short supply, this procedure has the capacity to save lives. The aim of this study was to explore the attitudes of the general public and general practitioners (GPs) towards LDLT, before its implementation. A total of 1041 members of the Scottish general public and 155 GPs working in Scotland completed a short questionnaire devised for this study. The majority of participants supported the option of LDLT, but frequency counts showed that only 34% of the general public wish to donate their organs following death compared to 85% of GPs. With regards to an acceptable risk of death before volunteering to donate, 25% of GPs would accept a 1 in 20 risk of death, whereas 50% of the general public either could not make a decision or selected ‘No risk’. The question of how well people understand the concept of risk was again highlighted in this study.     

Integrating medical ethics with normative theory: Patient advocacy and social responsibility

It is often assumed that the chief responsibility medical professionals bear is patient care and advocacy. The meeting of other duties, such as ensuring a more just distribution of medical resources and promoting the public good, is not considered a legitimate basis for curtailing or slackening beneficial patient services. It is argued that this assumption is often made without sufficient attention to foundational principles of professional ethics; that once core principles are laid bare this assumption is revealed as largely unwarranted; and, finally, that these observations at the level of moral theory should be reflected, in various ways, in medical practice. Specifically, this essay clarifies a tension that exists between different kinds of moral principles and explores the possibility of dissipating that tension by shoring up foundational principles. The paper begins by setting out three alternative models of how best to balance patient advocacy responsibilities with broader social responsibilities. It then turns to critically assess these models and argue that one has several advantages over the others.     

突发事件中民众责任归因的心理需求与应对

突发事件发生后,通过责任归因对事件原因和责任归属进行推断是民众心理活动的重要特征之一。从民众心理需要来看,突发事件带来的不确定感驱使个体寻找事件的解释来实现认知闭合,控制感的不足则会让个体更加强调外部世界的秩序性,这两种需要也是事件中阴谋论传播和替罪羊效应的心理基础。相应地,在事件中负有责任的组织主体,也应当基于民众的心理需要采取适当的应对策略,来重塑组织形象和民众的信任,避免责任规避带来的负面效应。未来研究可以进一步从心理学视角补充整合性的实证证据,对突发事件的不同类型进行区分,关注责任归因与其他社会心理学变量之间的联系,以及探索适合中国社会的有效应对措施。     

Death, organ transplantation and medical practice

A series of papers in Philosophy, Ethics and Humanities in Medicine (PEHM) have recently disputed whether non-heart beating organ donors are alive and whether non-heart beating organ donation (NHBD) contravenes the dead donor rule. Several authors who argue that NHBD involves harvesting organs from live patients appeal to "strong irreversibility" (death beyond the reach of resuscitative efforts to restore life) as a necessary criterion that patients must meet before physicians can declare them to be dead. Sam Shemie, who defends our current practice of NHBD, holds that in fact physicians consider patients to be dead or not according to physician intention to resuscitate or not. We suggest that criteria for a concept are not necessarily truth conditions for assertions involving the concept. Hence, non-heart beating donors may be declared dead without meeting the criterion of strong irreversibility even though strong irreversibility is implied by the concept of death. Our perception that a concept applies in a given case is determined not by the concept itself but by our necessary skill and judgment when using it. In the case of deciding that a patient is dead, such judgment is learned by physicians as they learn the practice of medicine and may vary according to circumstances. Current practice of NHBD can therefore be defended without abandoning death as an empirical concept, as Shemie appears to do. We conclude that the dead donor rule continues to be viable and ought to be retained so as to guarantee what the public most cares about as regards organ donation: that physicians can be trusted to make determinations of eligibility for organ donation in the interests of patients and not for other purposes such as increasing the availability of organs.     

Board oversight of community benefit: an ethical imperative

Board oversight of community benefit responsibility in tax-exempt organizations in the nonprofit health care sector is attracting considerable attention. Scrutiny by the IRS and other official bodies has led to stricter measures of compliance with the community benefit standard. But stricter compliance does not sufficiently engage the underlying ethical imperative for boards to provide effective oversight--an imperative that recent research suggests has not been sufficiently honored. This analysis considers why there is a distinctively ethical imperative for board oversight, the organizational nature of the imperative involved, and practical ways to fulfill its obligations. We adopt an organizational ethics paradigm to illuminate the constituent components of the ethical imperative and to clarify emerging benchmarks as flexible guidelines. As these emerging benchmarks enhance board oversight of community benefit they also can shed light on what it means to be a virtuous organization.     

Private virtues, public detriment: allocating scarce medical resources to the elderly

Churchill reviews Norman Daniels' Am I My Parents' Keeper (Oxford University Press; 1988) and Daniel Callahan's Setting Limits (Simon & Schuster; 1987). Both books present their authors' reflections on one of the most pressing problems of social ethics, how to allocate health care resources to the elderly in a climate of scarcity. Churchill first analyzes Daniels' response to the problem, the "prudential lifespan account," by which health care rights might give persons legitimate claims to services at one stage of their lives but not at another. This approach is contrasted with Callahan's "return to virtue" argument, which rests upon two major claims, one about the appropriate ends of medicine and the other about the meaning of old age. Churchill discusses both works within the context of the problematic relation in the United States between private and public goods, and between individual and social well-being.     

Personal responsibility,empowerment and medical utilization: a theoretical framework for considering counselling and offset costs

The problem of effectively managing patients with functional somatic symptoms remains huge in both primary and hospital care, although the potential benefits of mental health interventions such as counselling or psychotherapy are still not widely accepted. Unfortunately, the cost-effective evaluation of counselling has been beset by methodological problems, which stem from attempting to make comparisons between counsellors with different types of training, therapeutic approach and case mix. Since these real-world variations in counselling practice are likely to remain, it is proposed that a different approach to the evaluation of cost-effectiveness should be adopted in the hope of accelerating acceptance of the value of psychological interventions for the army of patients who are currently labelled as ‘difficult’ or ‘heartsink’ and who do not receive the treatment they deserve from the health-care services. It is proposed that, since the common aim of almost all mental health interventions is to engender or enhance a sense of ‘personal responsibility’ in patients/clients, this core objective should form an agreed ‘yardstick’ against which to evaluate the impact of various mental health interventions. Furthermore, since personal responsibility and future health-care utilization (and associated costs) can be assumed to be directly causally related, it is proposed that offset costs should form the basis for future cost-effectiveness evaluations.     

Perceived responsibility to act: An investigation with respect to registering willingness to become a posthumous organ donor

Two questionnaire studies (Ns=238 and 497) were guided by the original theoretical specification of the triangle model of responsibility. These investigated the relationship between perceived responsibility to register willingness to posthumously donate one's organs and people's self‐reported actual and intended registration behaviour. Exploratory factor analyses suggested that various responsibility‐related constructs could be differentiated, several of which explained unique variance in participants' registration status. Although predominantly derived from it, these constructs provided little support for the specific manner in which the triangle model has previously been conceptualized and operationalized. Implications for theoretical development, future empirical research, and organ procurement are discussed.     

Breaching confidentiality to protect the public: evolving standards of medical confidentiality for military detainees

Confidentiality is a core value in medicine and public health yet, like other core values, it is not absolute. Medical ethics has typically allowed for breaches of confidentiality when there is a credible threat of significant harm to an identifiable third party. Medical ethics has been less explicit in spelling out criteria for allowing breaches of confidentiality to protect populations, instead tending to defer these decisions to the law. But recently, issues in military detention settings have raised the profile of decisions to breach medical confidentiality in efforts to protect the broader population. National and international ethics documents say little about the confidentiality of detainee medical records. But initial decisions to use detainee medical records to help craft coercive interrogations led to widespread condemnation, and might have contributed to detainee health problems, such as a large number of suicide attempts several of which have been successful. More recent military guidance seems to reflect lessons learned from these problems and does more to protect detainee records. For the public health system, this experience is a reminder of the importance of confidentiality in creating trustworthy, and effective, means to protect the public's health.