Forensic case formulation: theoretical, ethical and practical issues

ARGUMENT

Forensic case formulation, of increasing interest to practitioners and researchers raises many ethical, theoretical and practical issues for them.

CONCLUSION

Systemic, contextual and individual factors which need to be considered include the multitude of staff often involved with any one individual, the pressure to 'get it right' because of the range of risk implications that are associated with individuals within forensic mental health settings, and individual parameters, for example reluctance to be engaged with services.

Using personal health information: do we manage conflicting interests?

The discipline of health informatics is concerned with developing the information systems that facilitate collection, manipulation and dissemination of personal health information. It promotes the benefits of using personal health information for secondary purposes, including policy development, service planning and research. At the same time the health informatics community is a strong advocate of privacy and the need to protect individuals from negative consequences arising from unauthorised use of their personal health information. This creates a dilemma for health informatics professionals since there will be occasions when the rights and interests of individuals conflict with the rights and interests of the public, or particular sections of the public. In such instances, the community as a whole, and individual members, may be required to take a stance on whether to prioritise privacy over public needs and interests. Such instances are likely to increase in the future as demands for access to personal health information increase. This paper considers the way the health informatics community approaches the dilemma. It reports on a study which analysed various perspectives on the issue as expressed in HISA conference proceedings. The study identified six discourses, each of which focuses on different uses of personal health information. The study found that the discourses expressed strong support for expanded use of personal health information where the public interest was convincingly argued, although the interpretation of what constituted public interest varied between the discourses. The study also found that while higher level discussions highlight the potential for negative consequences arising from expanded uses of personal health information, this was not often discussed in the conference texts. It is argued that such concerns should be considered, particularly in the light of discussions around the Commonwealth government's Individual Health Identifier and Personally Controlled Electronic Health Records initiatives.

Professionalism: challenges for dentistry in the future

While countries varies significantly in the financing of dental care, they are much more alike in the delivery of dentistry. Dental care is principally provided in dental offices and clinics that are independent business entities whose business leaders are most often the dentists themselves. However society expects from dentists a level of professionalism (i.e. habitually acting ethically, both in terms of competence and conduct) in contrast to the methods and motivations of the marketplace. This is why the single most important challenge of dental professional ethics continues to be giving proper priority to patients' well being and building ethically correct decision-making relationships with patients while, at the same time, trying to maintain a successful business operation. If we look into dentistry's future, the centrality of this aspect of professional ethics is not likely to change, although the ways in which dentists might violate this trust will probably multiple as funding mechanisms become increasingly complex. It is important that dentists reflect with fresh eyes on their ethical commitments. One challenge is the increased availability of oral health information to the public and the fact that so many people are uncritical of the accuracy of information in the media and on the web. A second is the increase in the amount of health care advertising in many societies. A third is the growth of aesthetic dentistry that differs from standard oral health care in important and ethically significant ways. The fourth is insurance that frequently complicates the explanation of a patient's treatment alternatives and often brings a third party into the treatment decision relationship. The ethical challenges of each of these factors will be considered and ultimately tying it to the central theme of dental professionalism.

A capacity-based approach for addressing ancillary care needs: implications for research in resource limited settings

A paediatric clinical trial conducted in a developing country is likely to encounter conditions or illnesses in participants unrelated to the study. Since local healthcare resources may be inadequate to meet these needs, research clinicians may face the dilemma of deciding when to provide ancillary care and to what extent. The authors propose a model for identifying ancillary care obligations that draws on assessments of urgency, the capacity of the local healthcare infrastructure and the capacity of the research infrastructure. The model lends itself to a decision tree that can be adapted to the local context and resources so as to provide procedural guidance. This approach can help in planning and establishing organisational policies that govern the provision of ancillary care.

Palliative sedation: not just normal medical practice. Ethical reflections on the Royal Dutch Medical Association's guideline on palliative sedation

The main premise of the Royal Dutch Medical Association's (RDMA) guideline on palliative sedation is that palliative sedation, contrary to euthanasia, is normal medical practice. Although we do not deny the ethical distinctions between euthanasia and palliative sedation, we will critically analyse the guideline's argumentation strategy with which euthanasia is demarcated from palliative sedation. First, we will analyse the guideline's main premise, which entails that palliative sedation is normal medical treatment. After this, we will critically discuss three crucial propositions of the guideline that are used to support this premise: (1) the patient's life expectancy should not exceed 2 weeks; (2) the aim of the physician should be to relieve suffering and (3) expert consultation is optional. We will conclude that, if inherent problematic aspects of palliative sedation are taken seriously, palliative sedation is less normal than it is now depicted in the guideline.

Evaluating a patient's request for life-prolonging treatment: an ethical framework

Contrary to the widespread concern about over-treatment at the end of life, today, patient preferences for palliative care at the end of life are frequently respected. However, ethically challenging situations in the current healthcare climate are, instead, situations in which a competent patient requests active treatment with the goal of life-prolongation while the physician suggests best supportive care only. The argument of futility has often been used to justify unilateral decisions made by physicians to withhold or withdraw life-sustaining treatment. However, we argue that neither the concept of futility nor that of patient autonomy alone is apt for resolving situations in which physicians are confronted with patients' requests for active treatment. Instead, we integrate the relevant arguments that have been put forward in the academic discussion about 'futile' treatment into an ethical algorithm with five guiding questions: (1) Is there a chance that medical intervention will be effective in achieving the patient's treatment goal? (2) How does the physician evaluate the expected benefit and the potential harm of the treatment? (3) Does the patient understand his or her medical situation? (4) Does the patient prefer receiving treatment after evaluating the benefit-harm ratio and the costs? (5) Does the treatment require many resources? This algorithm shall facilitate approaching patients' requests for treatments deemed futile by the physician in a systematic way, and responding to these requests in an ethically appropriate manner. It thereby adds substantive considerations to the current procedural approaches of conflict resolution in order to improve decision making among physicians, patients and families.

Different labs

In this case a young dentist has signed onto a managed care plan that has several attractive features. Eventually, however, he notices that he makes little or no net revenue for some of the work that he does. A colleague recommends that he use different labs for different patients, with labs matched to each patient's dental plan and coverage. Offshore labs are used for managed care patients. Three knowledgeable experts comment on the case, two with many years of private practice experience, two who are dental educators holding master's degrees in philosophy and bioethics.

[The ethical, legislative and regulatory basis of therapeutic education]

Beyond its interest in the field of public health and the political aspect with the "Hospital, patients, health and territories" law, therapeutic education now occupies an important place in nursing care. This new nursing culture provides another clinical approach for the nurse and a real means of learning for the patient in the framework of a support and guidance plan drawn up together.

[Ethics of the care given to premature newborns]

The treatment of premature newborns has evolved a lot in France over the last decade. It can be examined with regard to the four main principles of biomedical ethics: beneficence, non-maleficence, autonomy and justice. Consequently the combination of medical-nursing vigilance and individualised developmental care enables the premature baby to benefit from truly "ethical" healthcare.

[From policy to unique care in psychiatry, the place of ethics]

Ethical reflection is an aid to psychiatrists in their role as caregiver and policy implementer. Ethics takes root in commitment, the act of resistance enables the caregiver not to be carried away by the dominant approach, but rather to be an individual subject respecting the singularity of others.

[The ethics of the nursing commitment in psychiatry]

The referral nurse represents the care environment, he/she is the guarantor of the care plan and forms a commitment with regard to the patient. This positioning, arising from the empathy he/she has for the patient in a situation of vulnerability, may lead him/her to object to and question a medical decision.