From pillars to posts: some reflections on community service six years on

Speech-Language Therapy and Audiology graduates have worked in community service for 6 years. An evaluation of the impact of this strategy is now seen as important. In this discussion paper we report on the content and process of feedback sessions with 132 graduates from the University of the Witwatersrand during their community service placements from 2003-2008. Experiences and perceptions of these graduates are discussed in relation to a model as well as in relation to additional research conducted with our profession and other community service professions. Themes discussed include professional and technical issues, systemic and managerial issues, interpersonal issues and ethical issues. Perceptions on the adequacy of training are also described. The overall goals of community service are considered as well as indices for measuring success. Implications are considered for training institutions, for the Department of Health and for the profession.

The role of ethical banks in health care policy and financing in Spain

OBJECTIVES

Ethical, social, or civic banks, constitute a secondary source of financing, which is particularly relevant in Southern and Central Europe. However there is no information on the scientific literature on this source of health care financing.

METHOD

We review the characteristics of saving banks in Spain and illustrate the contribution of one institution "Obra Social Caixa Catalunya" (OS-CC) to the health care financing in Spain.

RESULTS

Savings bank health care funding was equivalent to 3 percent of the public health expenditure for 2008. The programs developed by OS-CC illustrate the complex role of savings banks in health financing, provision, training, and policy, particularly in the fields of integrated care and innovation.

CONCLUSIONS

Financing is a basic tool for health policy. However, the role of social banking in the development of integrated care networks has been largely disregarded, in spite of its significant contribution to complementary health and social care in Southern and Central Europe. Decision makers both at the public health agencies and at the social welfare departments of savings banks should become aware of the policy implications and impact of savings bank activities in the long-term care system.

Attrition in the RAND Health Insurance Experiment: a response to Nyman

In a prior article in this journal, John Nyman argues that the effect on health care use and spending found in the RAND Health Insurance Experiment is an artifact of greater voluntary attrition in the cost-sharing plans relative to the free care plan. Specifically, he speculates that those in the cost-sharing plans, when faced with a hospitalization, withdrew. His argument is implausible because (1) families facing a hospitalization would be worse off financially by withdrawing; (2) a large number of observational studies find a similar effect of cost sharing on use; (3) those who left did not differ in their utilization prior to leaving; (4) if there had been no attrition and cost sharing did not reduce hospitalization rates, each adult in each family that withdrew would have had to have been hospitalized once each year for the duration of time they would otherwise have been in the experiment, an implausibly high rate; (5) there are benign explanations for the higher attrition in the cost-sharing plans. Finally, we obtained follow-up health-status data on the great majority of those who left prematurely. We found the health-status findings were insensitive to the inclusion of the attrition cases.

American health policy: cracks in the foundation

Much American health policy over the past thirty-five years has focused on reducing the additional health care that is consumed when a person becomes insured, that is, reducing moral hazard. According to conventional theory, all of moral hazard represents a welfare loss to society because its cost exceeds its value. Empirical support for this theory has been provided by the RAND Health Insurance Experiment, which found that moral hazard--even moral hazard in the form of effective and appropriate hospital procedures--could be reduced substantially using cost-sharing policies with little or no measurable effect on health. This article critically analyzes these two cornerstones of American health policy. It holds that a large portion of moral hazard actually represents health care that ill consumers would not otherwise have access to without the income that is transferred to them through insurance. This portion of moral hazard is efficient and generates a welfare gain. Further, it holds that the RAND experiment's finding (that health care could be reduced substantially with little or no effect on health) may actually be caused by the large number of participants who voluntarily dropped out of the cost-sharing arms of the experiment. Indeed, almost all of the reduction in hospital use in the cost-sharing plans could be attributed to this voluntary attrition. If so, the RAND finding that cost sharing could reduce health care utilization, especially utilization in the form of effective and appropriate hospital procedures, with no appreciable effect on health is spurious. The article concludes by observing that the preoccupation with moral hazard is misplaced and has worked to obscure policies that would better reduce health care expenditures. It has also led us away from policies that would extend insurance coverage to the uninsured.

Banking on it: public policy and the ethics of stem cell research and development

If the therapeutic potential of stem cell-based therapies is ever realized, demand for stem cells and derivative tissues will be tremendous and will create new challenges for health care systems, especially publicly funded health care systems. We propose a framework for the ethical analysis of stem cell research and development that considers the welfare of communities, tissue recipients, and cell sources in relation to a range of stem cell production and distribution options. Ethical desiderata include: equitable access, maximized potential therapeutic benefit across demographic and disease groups, and reasonable cost. Other ethical priorities include the minimization of stem cell line and tissue wastage, risk of immune rejection, risk of transmitting diseases, the use of human embryos, and risk to those contributing source cells. We array plausible sources of stem cells and distribution strategies to characterize 12 potential models for producing and distributing cells and tissues in the future. We describe "personalized", "matched", and "universalized" models, and compare the ethical acceptability of these models. Popular and scientific discourses about stem cells typically emphasize personalized or matched stem cell distribution models. We show that universalized models may ultimately best serve the interest of taxpayers, communities and patients who hold high stakes in the therapeutic success of stem cell science. They are therefore highly worthy of scientific pursuit. This conclusion is provisional and the framework must be reapplied as scientific knowledge, technological capacity and ethical mores evolve.

Cultural competence in HIV prevention and care: different histories, shared future

The importance of cultural competence in social work practice is becoming increasingly more evident as the dividing lines between countries and cultures continue to fade away. Successful practice in today's global environment hinges on the ability to accept differences and to work towards a shared future. The necessity of cultural competence is painfully obvious when considering HIV prevention and care. From the start, HIV has been a global epidemic that has devastated many regions of world. The current paper examines the issue of HIV care and prevention from the perspective of Indonesia and the United States. Juxtaposition of these two countries reveals that they have approached HIV care and prevention differently because of their different histories. However, it is advanced that the two countries are likely to have a shared future given the highest infection rates are locating in similar populations, i.e., sex trade workers, intravenous drug users, street children-generally the poor, the oppressed, and their partners. Culturally competent social workers can play an important role in the fight against HIV by understanding and adapting to cultural differences and by merging best practices.

We care don't we? Social workers, the profession and HIV/AIDS

The HIV/AIDS epidemic has impacted all levels of society from the individual to the macro-economic. The continuing spread of infection around the world means that traditional methods of care and support are put under extreme pressure and many families lose their capacity to cope. Social workers are involved in providing care, counseling and support to those affected, and in developing programmes and other interventions to prevent the spread of the disease. Prevention and behaviour change are vital, but access to treatment is an ethical imperative, particularly in developing countries where the epidemic is most prevalent. Social work is a profession uniquely situated to demonstrate leadership in multi-sectoral collaboration in responding to this pandemic. Consequently this paper briefly reviews the scale and current nature of the epidemic and then considers how social workers can help build more compassionate policies at an international level. Social workers can help to create awareness of the negative effects of poverty, tackle gender inequity, help build more effective coalitions and partnerships, and work with other concerned groups and organisations to end stigma and discrimination. Using case examples the paper considers how social workers can help develop caring strategies that improve the lives of those living with HIV and AIDS.

Ethical preferences for the clinical practice of empowerment social work

Social workers in health care and mental health benefit from interventions that integrate principles of contextual social work practice with standards for clinical practice. The authors articulate a conceptual framework for the ethical practice of social work that complements the social justice purpose. The sixteen ethical preferences in this framework are the ethics of care, autonomy, power, change, respect, critical thinking, praxis, discourse, critique, justice, contextual practice, inclusion, anti-oppression, advocacy, collaboration, and politicized practice.

Promoting older people's voices- the contribution of social work to inter-disciplinary research

UK government policies over the last decade or more have focussed on giving older people more voice in the design, delivery and assessment of services. Mirroring these trends, there has been a shift towards increased involvement of older people in the research process. Drawing on three research studies, this paper examines the contribution of social work to an inter-disciplinary research agenda designed to promote increased involvement of older people in issues of service quality in primarily health settings. Challenges and opportunities are discussed. Each of the studies illustrates the importance of promoting research practice congruent with social work's commitment to partnership and empowering forms of practice. This, it is argued, requires the challenging of ageist assumptions, the use of a range of research methods and the valuing of different forms of knowledge.

Keeping the contract: an interview with the new AHA chair-elect. Interview by Mary Grayson

Kevin Lofton, CEO of Catholic Health Initiatives in Denver and chair-elect of the AHA, remains passionate about health care. In this first-person interview, he describes the need for hospitals to live up to their community contracts by building bridges with others, striving for transparency in safety and quality, and nurturing diversity on their executive teams.

The physician charter on medical professionalism: a Jewish ethical perspective

The physician charter on medical professionalism creates standards of ethical behaviour for physicians and has been endorsed by professional organisations worldwide. It is based on the cardinal principles of the primacy of patient welfare, patient autonomy, and social welfare. There has been little discussion in the bioethics community of the doctrine of the charter and none from a Jewish ethical perspective. In this essay the authors discuss the obligations of the charter from a Jewish ethical viewpoint and call on other cultures to develop their own unique perspectives on this important document.

Equity, capabilities and health

This paper provides an introduction to a collection of articles concerning the relevance of Amartya Sen's work, the capability approach and related ethical claims, to health-care rationing.

Communitarian claims and community capabilities: furthering priority setting?

Priority setting in health care is generally not done well. This paper draws on ideas from Amartya Sen and Martha Nussbaum and adds some communitarian underpinnings to provide a way of improving on current uses of program budgeting and marginal analysis (PBMA) in priority setting. The paper suggests that shifting to a communitarian base for priority setting alters the distribution of property rights over health service decision making and increases the probability that recommendations from PBMA exercises will be implemented. The approach is built on a paradigm which departs from three tenets of welfarism as it is normally conceived: (i) individuals qua individuals seek to maximise their individual utility/well-being; (ii) individuals want to do this; and (iii) it is the values of individuals qua individuals that count. Some of the problems of PBMA, as it has been applied to date, are highlighted. It is argued that these are due largely to a lack of 'credible commitment'. Bringing in the community and communitarian values to PBMA priority setting exercises can help to overcome some of the barriers to getting PBMA recommendations implemented. The approach has the merit of reflecting Sen's concept of capabilities (but extending that to a community level). It avoids the often consequentialist base of a conventional welfarist framework, and it allows community values as opposed to individual values to come to the fore. How to elicit communitarian values is explored.

Understanding trust and confidence: two paradigms and their significance for health and social care

Trusting agents characteristically anticipate beneficial outcomes, under conditions of uncertainty, in their engagement with others. However, debates about trust incorporate different interpretations of risk, uncertainty, calculation, affect, morality and motivation in explaining when trust is appropriate and how it operates. This article argues that discussions about trust have produced a concept without coherent boundaries and with little operational value. Two paradigms are identified, which distinguish the characteristics of trust and confidence. It is argued that a reliance on confidence in human affairs makes trust redundant and that this has undesirable moral consequences. Discussion is illustrated by the UK Government's 'modernisation' policy in health and social care, which privileges confidence in systems over trust in moral agents.

Urban bioethics: adapting bioethics to the urban context

Urban bioethics is an area of inquiry within the discipline of bioethics that focuses on ethical issues, problems, and conflicts relating to medicine, science, health care, and the environment that typically arise in urban settings. Urban bioethics challenges traditional bioethics (1) to examine value concerns in a multicultural context, including issues related to equity and disparity, and public health concerns that may highlight conflict between individual rights and the public good, and (2) to broaden its primary focus on individual self-determination and respect for autonomy to include examination of the interests of family, community, and society. Three features associated with urban life-density, diversity, and disparity-affect the health of urban populations and provide the substrate for identifying ethical concerns and value conflicts and creating interventions to affect population health outcomes. The field of urban bioethics can be helpful in creating ethical foundations and principles for public health practice, developing strategies to respect diversity in health policy in a pluralistic society, and fostering collaborative work among educators, social scientists, and others to eliminate bias among health professionals and health care institutions to enhance patients' satisfaction with their care and ultimately affect health outcomes. Educational programs at all levels and encompassing all health professions are needed as a first step to address the perplexing and important problem of eliminating health disparities. Urban bioethics is both contributing to the social science literature in this area and helping educators to craft interventions to affect professional attitudes and behaviors.

[Hunger, solidarity, and ethics: discourse analysis of the movement Citizen's Action against Hunger and Poverty and for Life]

The article analyzes the discourse of Citizen's Action against Hunger and Poverty and for Life, a social movement led by sociologist Herbert de Souza (Betinho) that was at its peak between 1993 and 1994. From the perspective of certain concepts and principles introduced and disseminated by so-called bio-ethics, the present study identifies within this campaign an attempt to construct a social movement in Brazil displaying characteristics quite similar to those associated with 'practical ethics'. These features are apparent in the three major principles that the movement applied as strategies for fighting hunger and poverty - to wit, solidarity, partnership, and decentralization.

Utilitarian theories reconsidered: common misconceptions, more recent developments, and health policy implications

Despite the prevalence of the terms utilitarianism and utilitarian in the health care and health policy literature, anecdotal evidence suggests that authors are often not fully aware of the diversity of utilitarian theories, their principles, and implications. Further, it seems that authors often categorically reject utilitarianism under the assumption that it violates individual rights. The tendency of act utilitarianism to neglect individual rights is attenuated, however, by the diminishing marginal utility of wealth and the disutility of a protest by those who are disadvantaged. In practice, act utilitarians tend to introduce moral rules and preserve traditional rules. At the same time, the tenability of rule utilitarianism is limited because it ultimately collapses into act utilitarianism or a deontological theory. Negative utilitarianism is a viable utilitarian variant only if we accept complete aversion to suffering, ie, if we disregard any forgone opportunities to increase pleasure. Finally, the adoption of preference utilitarianism requires us to accept the subjectivity of individual claims which may be perceived as unfair.

Is Christian religious conservatism compatible with the liberal social welfare state?

This article examines the rise of Christian religious conservatism and explores whether the theological views of the conservative Christian movement are compatible with the liberal social welfare state. The authors conclude that the driving force behind social change should remain with the state, even though faith-based initiatives can provide some basic supports that the social welfare state can use.

Exploring social welfare functions and violation of monotonicity: an example from inequalities in health

The social welfare function (SWF) has been used within the economics literature, to study trade-offs between equality and efficiency. These SWFs are characterised by properties determined by traditional welfare economics. One of these properties, the monotonicity principle is explored in this paper. In the context of health there may be occasions when the monotonicity principle is violated as there may be circumstances where distributional issues dominate efficiency concerns. When this is the case, conventional SWFs are not flexible enough to represent such social preferences. Therefore, we propose a SWF with an alternative specification, which is general enough to accommodate preferences that are not necessarily monotonic. A survey of the Spanish general public was undertaken to estimate preferences regarding equality in health, relative to efficiency in health. The results (with 973 usable responses) give strong support to the existence of public preferences which violate the monotonicity principle, and thus to the usefulness of the alternative specification proposed here.