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Seidlein AH, Kuhn E. [Live-ins: A mapping of relevant actors and moral norms at the public health level]. Pflege 2024; 37:215-222. [PMID: 38130154 DOI: 10.1024/1012-5302/a000969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Live-ins: A mapping of relevant actors and moral norms at the public health level Abstract: Background: Live-ins are embedded in a network of multiple actors that shape their current working and living situation. The causes and effects of live-in arrangements go far beyond the actual care relationship and include structures and stakeholders that are interconnected at the Public Health level. Besides a legal responsibility, these actors also have a moral responsibility, which the article focuses on. Aim: The article provides an overview of relevant actors and moral norms in the context of live-ins at the public health level. Methods: The method followed the "Context and Actor Analysis". Actors at the public health level that are relevant for the live-ins' situation were identified, and the responsibilities and tasks presented in their websites as well as their respective target groups were collected. The ethical dimension was extracted from these self-descriptions. Results: The 23 actors address the live-ins directly or indirectly in their various social roles. The self-given tasks and the moral norms deduced from them, for which the actors are particularly responsible, illustrate the importance of justice and respect. Conclusions: The work provides the basis for an urgently needed empirical-ethical analysis on the current state of responsibility-taking. Not only the variety of the live-ins' roles, but also the multitude of actors involved and shared norms illustrate the necessity of close cooperation to be able to fulfil their responsibility.
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Affiliation(s)
- Anna-Henrikje Seidlein
- Institut für Ethik und Geschichte der Medizin, Universitätsmedizin Greifswald, Deutschland
| | - Eva Kuhn
- Sektion Global Health, Institut für Hygiene und Öffentliche Gesundheit, Universitätsklinikum Bonn, Deutschland
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Spranzi M, Foureur N, Faidherbe V. From “exceptional ethics” to public health ethics. Patients and proxies facing COVID-19. Ethics and public health during COVID-19. SANTE PUBLIQUE (VANDOEUVRE-LES-NANCY, FRANCE) 2024; 36:97-108. [PMID: 38580472 DOI: 10.3917/spub.241.0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
The study aimed to elicit the perception and ethical considerations of patients and proxies with respect both to the individual medical decisions and public health decisions made during the COVID-19 crisis. It used a qualitative, multi-center study based on semi-directive interviews, conducted by an interdisciplinary team. The analysis was conducted using a thematic analysis approach and an ethical framework. Three themes emerged from the analysis: 1) patients, unlike proxies, did not complain about their diminished role in the decision-making process. Both highlighted the importance of “basic care” as opposed to a technical approach to treatment; 2) despite the transparency of the information process, a deep “crisis of trust” has developed between citizens and public authorities; 3) although both patients and proxies accepted the limitations of personal liberties imposed in the name of public health, they argued that these limitations should respect certain boundaries, both temporal and spacial. Above all, they should not affect basic affective human relationships, even if such boundaries are a factor in an increased risk of infection. The study showed that there is a need to reconsider the definition and the main principles of public health ethics, namely transparency and proportionality.
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Affiliation(s)
- Marta Spranzi
- Maîtresse de conférences en éthique médicale, UFR Simone Veil – santé, UVSQ
- Consultante d’éthique, Centre d’éthique clinique (AP-HP)
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Young MJ. Disorders of Consciousness Rehabilitation: Ethical Dimensions and Epistemic Dilemmas. Phys Med Rehabil Clin N Am 2024; 35:209-221. [PMID: 37993190 DOI: 10.1016/j.pmr.2023.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Patients with disorders of consciousness who survive to discharge following severe acute brain injury may face profoundly complex medical, ethical, and psychosocial challenges during their courses of recovery and rehabilitation. Although issues encountered in caring for such patients during acute hospitalization have received substantial attention, ethical challenges that may arise in subacute and chronic phases have been underexplored. Shedding light on these issues, this article explores the landscape of normative issues in the course of treating and facilitating access to care for persons with disorders of consciousness during rehabilitation and examines potential implications for patients, clinicians, family members, and society.
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Affiliation(s)
- Michael J Young
- Department of Neurology, Massachusetts General Hospital, Center for Neurotechnology and Neurorecovery, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA.
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Mitchell P, Reinap M, Moat K, Kuchenmüller T. An ethical analysis of policy dialogues. Health Res Policy Syst 2023; 21:13. [PMID: 36707839 PMCID: PMC9881302 DOI: 10.1186/s12961-023-00962-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 01/13/2023] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND A policy dialogue is a tool which promotes evidence-informed policy-making. It involves deliberation about a high-priority issue, informed by a synthesis of the best-available evidence, where potential policy interventions are discussed by stakeholders. We offer an ethical analysis of policy dialogues - an argument about how policy dialogues ought to be conceived and executed - to guide those organizing and participating in policy dialogues. Our analysis focuses on the deliberative dialogues themselves, rather than ethical issues in the broader policy context within which they are situated. METHODS We conduct a philosophical conceptual analysis of policy dialogues, informed by a formal and an interpretative literature review. RESULTS We identify the objectives of policy dialogues, and consider the procedural and substantive values that should govern them. As knowledge translation tools, the chief objective of policy dialogues is to ensure that prospective evidence-informed health policies are appropriate for and likely to support evidence-informed decision-making in a particular context. We identify five core characteristics which serve this objective: policy dialogues are (i) focused on a high-priority issue, (ii) evidence-informed, (iii) deliberative, (iv) participatory and (v) action-oriented. In contrast to dominant ethical frameworks for policy-making, we argue that transparency and accountability are not central procedural values for policy dialogues, as they are liable to inhibit the open deliberation that is necessary for successful policy dialogues. Instead, policy dialogues are legitimate insofar as they pursue the objectives and embody the core characteristics identified above. Finally, we argue that good policy dialogues need to actively consider a range of substantive values other than health benefit and equity. CONCLUSIONS Policy dialogues should recognize the limits of effectiveness as a guiding value for policy-making, and operate with an expansive conception of successful outcomes. We offer a set of questions to support those organizing and participating in policy dialogues.
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Affiliation(s)
- Polly Mitchell
- Centre for Public Policy Research, King's College London, London, United Kingdom. .,World Health Organization Regional Office for Europe, Copenhagen, Denmark. .,School of Education, Communication & Society, King's College London, Waterloo Bridge Wing, Franklin-Wilkins Building, Waterloo Road, London, SE1 9NH, United Kingdom.
| | - Marge Reinap
- grid.420226.00000 0004 0639 2949World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Kaelan Moat
- grid.25073.330000 0004 1936 8227McMaster Health Forum, McMaster University, Hamilton, ON Canada
| | - Tanja Kuchenmüller
- grid.3575.40000000121633745World Health Organization, Geneva, Switzerland
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Willison CE, Falkenbach M, Greer SL, Singer PM. Backsliding among indicators of democratic stability relevant to public health: Risks in OECD nations. WORLD MEDICAL & HEALTH POLICY 2022. [DOI: 10.1002/wmh3.558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Charley E. Willison
- Department of Public and Ecosystem Health Cornell University Ithaca New York USA
| | - Michelle Falkenbach
- Department of Public and Ecosystem Health Cornell University Ithaca New York USA
| | - Scott L. Greer
- Department of Health Management and Policy University of Michigan Ann Arbor Michigan USA
| | - Phillip M. Singer
- Department of Political Science University of Utah Salt Lake City Utah USA
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Zhang R, Zhang Z, Peng Y, Zhai S, Zhou J, Chen J. The multi-subject cooperation mechanism of home care for the disabled elderly in Beijing: a qualitative research. BMC PRIMARY CARE 2022; 23:186. [PMID: 35883031 PMCID: PMC9327313 DOI: 10.1186/s12875-022-01777-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 06/17/2022] [Indexed: 05/06/2023]
Abstract
BACKGROUND Currently, population aging has been an obstacle and the spotlight for all countries. Compared with developed countries, problems caused by China's aging population are more prominent. Beijing, as a typical example, is characterized by advanced age and high disability rate, making this capital city scramble to take control of this severe problem. The main types of care for the disabled elderly are classified as home care, institutional care, and community care. With the obvious shortage of senior care institutions, most disabled elderly people are prone to choose home care. This kind of elderly care model is in line with the traditional Chinese concept and it can save the social cost of the disabled elderly to the greatest extent. However, home care for the disabled elderly is facing bumps from the whole society, such as lack of professional medical care, social support and humanistic care, and the care resources provided by a single subject cannot meet the needs of the disabled elderly. OBJECTIVE Based on the demands of the disabled elderly and their families, this study aims to explore the current status of home care service, look for what kind of care is more suitable for the disabled elderly, and try to find an appropriate elderly care mechanism which could meet the diverse needs of the disabled elderly. METHODS A total of 118 disabled elderly people and their primary caregivers were selected from four districts of Beijing by using multi-stage stratified proportional sampling method. A one-to-one and semi-structured in-depth qualitative interview were conducted in the study to find out the health status of the disabled elderly, the relationship between the disabled elderly and their primary caregivers, and utilization of elderly care resources, etc. The views of the interviewees were analyzed through the thematic framework method. All the methods were carried out in accordance with relevant guidelines and regulations. RESULTS The results showed that the average age of 118 disabled elderly is 81.38 ± 9.82 years; 86 (72.9%) are severe disability; 105 (89.0%)are plagued by chronic diseases; the average duration of disability is 5.63 ± 5.25 years; most of disabled elderly have 2 children, but the primary caregiver are their own partner (42, 35.6%), and there is an uneven sharing of responsibilities among the disabled elderly's offspring in the process of home care. The disabled elderly enjoy medical care services, rehabilitation training, daily health care, psychological and other demands. However, the disabled elderly and their families in Beijing face a significant financial burden, as well as physical and psychological issues. The care services provided by the government, family doctors, family members and social organizations fall far short of satisfying the diverse care needs of the disabled elderly. CONCLUSIONS In order to effectively provide home care services for the disabled elderly, it is therefore necessary to establish a coordination mechanism of multiple subjects and give full play to the responsibilities of each subject. This study proposes a strengthening path for the common cooperation of multiple subjects, which taking specific responsibilities and participating in the home care for the disabled elderly: (1) The government should give full play to the top-level leading responsibilities and effectively implement people-oriented measures to the disabled elderly. (2) Family doctors strengthen their responsibilities as health gatekeepers and promote continuous health management of the disabled elderly. (3) Family members assume the main responsibility and provide a full range of basic care services. (4) Social forces promote supplementary responsibilities of public welfare and expand the connotation of personalized care services. (5) The disabled elderly should shoulder appropriate personal responsibility and actively cooperate with other subjects.
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Affiliation(s)
- Ruyi Zhang
- School of Medical Humanities, Capital Medical University, No. 10, Xitoutiao, You An Men Wai, Fengtai District, Beijing, 100069, China
| | - Zhiying Zhang
- School of Medical Humanities, Capital Medical University, No. 10, Xitoutiao, You An Men Wai, Fengtai District, Beijing, 100069, China
| | - Yingchun Peng
- School of Medical Humanities, Capital Medical University, No. 10, Xitoutiao, You An Men Wai, Fengtai District, Beijing, 100069, China.
| | - Shaoqi Zhai
- School of Medical Humanities, Capital Medical University, No. 10, Xitoutiao, You An Men Wai, Fengtai District, Beijing, 100069, China
| | - Jiaojiao Zhou
- Fengtai District, Xiluoyuan Community Health Service Center, Beijing, 100077, China
| | - Jingjing Chen
- Huairou District, Liulimiao Community Health Service Center, Beijing, 101400, China
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Abstract
Because America has a foundation of anti-Black racism, being born Black in this nation yields an identity that breeds the consequences of a chronic condition. This article highlights several ways in which medicine and clinical ethics, despite the former's emphasis on doing no harm and the latter's emphasis on nonmaleficence, fail to address or acknowledge some of the key ways in which physicians can-and do-harm patients of color. To understand harm in a way that can provide real substance for ethical standards in the practice of medicine, physicians need to think about how treatment decisions are constrained by a patient's race. The color of one's skin can and does negatively affect the quality of a person's diagnosis, promoted care plan, and prognosis. Yet racism in medicine and bioethics persist-because a racist system serves the interests of the dominant caste, White people. As correctives to this system, the authors propose several antiracist commitments physicians or ethicists can make.
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Are healthful behavior change policies ever unethical? J Public Health Policy 2022; 43:685-695. [PMID: 36289325 PMCID: PMC9750897 DOI: 10.1057/s41271-022-00372-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2022] [Indexed: 01/15/2023]
Abstract
Public health experts often assume that any policy promoting healthful behavior change is inherently and self-evidently ethical. This assumption is incorrect. This Viewpoint describes why evaluating the ethics of a policy to promote healthful behavior change should require (1) valuing consequences for wellbeing proportionately to consequences for health, (2) valuing changes to the distributional equity of health and wellbeing together with their aggregate improvement, and (3) anticipating and surveilling for unintended consequences sufficiently important to offset benefits. I illustrate these three requirements through a hypothetical salt restriction policy, which is unethical if it evokes strong preferences that detract from wellbeing, disproportionately confers health benefits to those who are already healthy, or elicits unintended consequences that offset health benefits. I discuss why analogies of salt restriction mandates are inappropriate. In summary, public health decision-makers should employ more structured, explicit and comprehensive criteria when considering the ethical consequences of policies.
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McKerracher L, Núñez-de la Mora A. More voices are always better: Tackling power differentials in knowledge production and access in human biology. Am J Hum Biol 2021; 34 Suppl 1:e23712. [PMID: 34931739 DOI: 10.1002/ajhb.23712] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/29/2021] [Accepted: 12/06/2021] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Academic human biology seeks to characterize and explain human biocultural variation in terms of adaptations to local environments. Understanding and educating about such variation, if not carried out thoughtfully, can reinforce power asymmetries around who can produce and access the knowledge, and in what ways and places. One of many factors contributing to power inequities in knowledge production and access concerns histories of state-driven colonization, with people(s) dispossessed of land through colonization generally having relatively less power. Because human biologists disproportionately work with communities/sub-populations living in marginal environments, most of which have been moved, dispossessed, and/or reconfigured through colonization, we are prone to reproducing these land-related power imbalances but we are also well-situated to level them. METHODS Here, we do three things we hope will move us toward research and teaching practices that recognize and begin to disrupt colonial power inequities in human biology knowledge production and access. RESULTS First, after defining terms core to understanding the power matrices at stake, we outline likely benefits to human biologists of using anticolonial approaches. Second, we highlight two frameworks offering anticolonial tools (community-based participatory research and "two-eyed seeing"). Third, we suggest several practical, behavioral changes to make and skills to develop for human biologists looking to shift power balances. CONCLUSION We conclude by reflecting on our own positions along the colonially rooted power gradients structuring human biology. We argue that doing so constitutes an essential early step toward creating anticolonial spaces for more ethical and just production, consumption, and application of knowledge.
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Saleh BM, Aly EM, Hafiz M, Abdel Gawad RM, El Kheir-Mataria WA, Salama M. Ethical Dimensions of Public Health Actions and Policies With Special Focus on COVID-19. Front Public Health 2021; 9:649918. [PMID: 34409003 PMCID: PMC8365183 DOI: 10.3389/fpubh.2021.649918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 06/24/2021] [Indexed: 01/10/2023] Open
Abstract
During pandemics, the ethicists, public health professionals, and human rights advocates raise a red flag about different public health actions that should, at best, be addressed through integrated, global policies. How to rationalize the healthcare resources and prioritize the cases is not a recent challenge but the serious concern about that is how to achieve this while not increasing the vulnerability of the disadvantaged population. Healthcare professionals use different scoring systems as a part of their decision-making so the medical teams and triage committees can allocate resources for predictable health outcomes and prognosis as well as to appropriately triage the patients accordingly. However, the value of the existing scoring systems to manage COVID-19 cases is not well-established yet. Part of this problem includes managing non-COVID patients with chronic medical conditions like non-communicable diseases and addressing their medical needs during the pandemic complex context in a way to avoid worsening their conditions and, on the other hand, avoid hindering the establishment of comprehensive standards for dealing with COVID-19. In this article, we discuss this dilemma as well as how preexisting ethical standards were challenged by COVID-19. We also discuss how monitoring the consistent application of ethical standards during the medical trials of new medications, vaccines, or unproven medical interventions is also a critical issue.
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Affiliation(s)
- Basma M. Saleh
- Institute of Global Health and Human Ecology, School of Science and Engineering, The American University in Cairo, Cairo, Egypt
| | - Eman Mohamed Aly
- Institute of Global Health and Human Ecology, School of Science and Engineering, The American University in Cairo, Cairo, Egypt
| | - Marwa Hafiz
- Institute of Global Health and Human Ecology, School of Science and Engineering, The American University in Cairo, Cairo, Egypt
| | - Rana M. Abdel Gawad
- Institute of Global Health and Human Ecology, School of Science and Engineering, The American University in Cairo, Cairo, Egypt
| | - Wafa Abu El Kheir-Mataria
- Institute of Global Health and Human Ecology, School of Science and Engineering, The American University in Cairo, Cairo, Egypt
| | - Mohamed Salama
- Institute of Global Health and Human Ecology, School of Science and Engineering, The American University in Cairo, Cairo, Egypt
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
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Onarheim KH, Wickramage K, Ingleby D, Subramani S, Miljeteig I. Adopting an ethical approach to migration health policy, practice and research. BMJ Glob Health 2021; 6:e006425. [PMID: 34321236 PMCID: PMC8319989 DOI: 10.1136/bmjgh-2021-006425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/02/2021] [Indexed: 11/05/2022] Open
Abstract
Migration health is affected by decision making at levels ranging from global to local, both within and beyond the health sector. These decisions impact seeking, entitlements, service delivery, policy making and knowledge production on migration health. It is key that ethical challenges faced by decision makers are recognised and addressed in research and data, clinical practice and policy making on migration health. An ethical approach can provide methods to identify ethical issues, frameworks for systematising information and suggesting ethically acceptable solutions, and guidance on procedural concerns and legitimate decision making processes. By unpacking dilemmas, conflicts of interests and values at stake, an ethical approach is relevant for all who make decisions about migration health policy and practice. Adopting an ethical approach to migration health benefits governments, organisations, policy makers, health workers, data managers, researchers and migrants themselves. First, it highlights the inherent normative questions and trade-offs at stake in migration health. Second, it assists decision makers in deciding what is the ethically justifiable thing to do through an 'all things considered' approach. Third, ethical frameworks and technical guidance set normative and practical standards for decision makers facing ethical questions - from 'bedside rationing' to collection of big data or in policy making - that can ensure that migrants' interests are considered. Fourth, there is a need for greater transparency and accountability in decision making, as well as meaningful participation of migrant groups. An ethical approach connects to public health, economic and human rights arguments and highlights the urgent need to mainstream concerns for migrants in global and national health responses.
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Affiliation(s)
| | - Kolitha Wickramage
- Migration Health Division, International Organization of Migration, Manila, Philippines
| | - David Ingleby
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, Netherlands
| | - Supriya Subramani
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Ingrid Miljeteig
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Research and Development, Haukeland Universitetssjukehus, Bergen, Norway
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Henein M, Ells C. Identifying and Classifying Tools for Health Policy Ethics Review: A Systematic Search and Review. HEALTH CARE ANALYSIS 2021; 29:1-20. [PMID: 33386534 DOI: 10.1007/s10728-020-00422-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 11/26/2022]
Abstract
Ethical review and analysis of health policy may help to ensure policies address the needs of society and align with relevant values and principles. Indeed, researchers and bioethicists have recognized the need for ethical frameworks specifically for public health applications. The objective of this research was to compile structured tools for ethical review of (drafted or existing) health policy and to analyze these tools for their scope and philosophical underpinnings. A systematic search and review of academic and grey literature was conducted to compile existing tools designed for health policy ethics review. The search yielded 13 health policy ethical review tools. Qualitative content analysis revealed that all of the tools were influenced by multiple ethical values and that a majority were influenced by more than one ethical theory. The most common values were non-maleficence and beneficence (92.3%). The most common influencing ethical theory was the Principles Approach (92.3%). The structure of the tools demonstrates a heterogeneity of methodology designs to approach policy ethics review. This research offers a unique contribution to the bioethics field that provides a useful resource and understanding of the current ethical review tools for health policy.
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Affiliation(s)
- Mary Henein
- Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada.
| | - Carolyn Ells
- Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada
- Biomedical Ethics Unit, McGill University, 3647 Peel Street, Montreal, QC, H3A 1X1, Canada
- Department of Medicine, McGill University, 1001 Decarie Boulevard, Montreal, QC, H4A3J1, Canada
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13
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Stratil JM, Voss M, Arnold L. WICID framework version 1.0: criteria and considerations to guide evidence-informed decision-making on non-pharmacological interventions targeting COVID-19. BMJ Glob Health 2020; 5:bmjgh-2020-003699. [PMID: 33234529 PMCID: PMC7688443 DOI: 10.1136/bmjgh-2020-003699] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 01/12/2023] Open
Abstract
Introduction Public health decision-making requires the balancing of numerous, often conflicting factors. However, participatory, evidence-informed decision-making processes to identify and weigh these factors are often not possible- especially, in the context of the SARS-CoV-2 pandemic. While evidence-to-decision frameworks are not able or intended to replace stakeholder participation, they can serve as a tool to approach relevancy and comprehensiveness of the criteria considered. Objective To develop a decision-making framework adapted to the challenges of decision-making on non-pharmacological interventions to contain the global SARS-CoV-2 pandemic. Methods We employed the ‘best fit’ framework synthesis technique and used the WHO-INTEGRATE framework as a starting point. First, we adapted the framework through brainstorming exercises and application to case studies. Next, we conducted a content analysis of comprehensive strategy documents intended to guide policymakers on the phasing out of applied lockdown measures in Germany. Based on factors and criteria identified in this process, we developed the WICID (WHO-INTEGRATE COVID-19) framework version 1.0. Results Twelve comprehensive strategy documents were analysed. The revised framework consists of 11+1 criteria, supported by 48 aspects, and embraces a complex systems perspective. The criteria cover implications for the health of individuals and populations due to and beyond COVID-19, infringement on liberties and fundamental human rights, acceptability and equity considerations, societal, environmental and economic implications, as well as implementation, resource and feasibility considerations. Discussion The proposed framework will be expanded through a comprehensive document analysis focusing on key stakeholder groups across the society. The WICID framework can be a tool to support comprehensive evidence-informed decision-making processes.
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Affiliation(s)
- Jan M Stratil
- Institute for Medical Informatics, Biometry and Epidemiology - IBE and Pettenkofer School of Public Health, LMU Munich, Munich, Bavaria, Germany
| | - Maike Voss
- Global Issues Division, German Institute for International and Security Affairs, Berlin, Germany
| | - Laura Arnold
- Epidemiology and Health Reporting, Academy of Public Health Services, Duesseldorf, North Rhine-Westphalia, Germany
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Hawthorne SCC, Williams-Wengerd A. 'Effective' at What? On Effective Intervention in Serious Mental Illness. HEALTH CARE ANALYSIS 2020; 27:289-308. [PMID: 30895412 DOI: 10.1007/s10728-019-00367-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The term "effective," on its own, is honorific but vague. Interventions against serious mental illness may be "effective" at goals as diverse as reducing "apparent sadness" or providing housing. Underexamined use of "effective" and other success terms often obfuscates differences and incompatibilities in interventions, degrees of effectiveness, key omissions in effectiveness standards, and values involved in determining what counts as "effective." Yet vague use of such success terms is common in the research, clinical, and policy realms, with consequences that negatively affect the care offered to individuals experiencing serious mental illness. A pragmatist-oriented solution to these problems suggests that when people use success terms, they need to explain and defend the goals and supporting values embedded in the terms, asking and answering the questions, "Effective at what? For whom? How effective? And why that goal?" Practical and epistemic standards for effectiveness will likely remain plural for good reasons, but each standard should be well explained and well justified.
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Affiliation(s)
- Susan C C Hawthorne
- Philosophy Department, St. Catherine University, 2004 Randolph Ave, St. Paul, MN, 55105, USA.
| | - Anne Williams-Wengerd
- Psychology Department, St. Catherine University, 2004 Randolph Ave, St. Paul, MN, 55105, USA
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15
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Stratil JM, Baltussen R, Scheel I, Nacken A, Rehfuess EA. Development of the WHO-INTEGRATE evidence-to-decision framework: an overview of systematic reviews of decision criteria for health decision-making. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:8. [PMID: 32071560 PMCID: PMC7014604 DOI: 10.1186/s12962-020-0203-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 01/24/2020] [Indexed: 01/08/2023] Open
Abstract
Background Decision-making in public health and health policy is complex and requires careful deliberation of many and sometimes conflicting normative and technical criteria. Several approaches and tools, such as multi-criteria decision analysis, health technology assessments and evidence-to-decision (EtD) frameworks, have been proposed to guide decision-makers in selecting the criteria most relevant and appropriate for a transparent decision-making process. This study forms part of the development of the WHO-INTEGRATE EtD framework, a framework rooted in global health norms and values as reflected in key documents of the World Health Organization and the United Nations system. The objective of this study was to provide a comprehensive overview of criteria used in or proposed for real-world decision-making processes, including guideline development, health technology assessment, resource allocation and others. Methods We conducted an overview of systematic reviews through a combination of systematic literature searches and extensive reference searches. Systematic reviews reporting criteria used for real-world health decision-making by governmental or non-governmental organization on a supranational, national, or programme level were included and their quality assessed through a bespoke critical appraisal tool. The criteria reported in the reviews were extracted, de-duplicated and sorted into first-level (i.e. criteria), second-level (i.e. sub-criteria) and third-level (i.e. decision aspects) categories. First-level categories were developed a priori using a normative approach; second- and third-level categories were developed inductively. Results We included 36 systematic reviews providing criteria, of which one met all and another eleven met at least five of the items of our critical appraisal tool. The criteria were subsumed into 8 criteria, 45 sub-criteria and 200 decision aspects. The first-level of the category system comprised the following seven substantive criteria: “Health-related balance of benefits and harms”; “Human and individual rights”; “Acceptability considerations”; “Societal considerations”; “Considerations of equity, equality and fairness”; “Cost and financial considerations”; and “Feasibility and health system considerations”. In addition, we identified an eight criterion “Evidence”. Conclusion This overview of systematic reviews provides a comprehensive overview of criteria used or suggested for real-world health decision-making. It also discusses key challenges in the selection of the most appropriate criteria and in seeking to implement a fair decision-making process.
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Affiliation(s)
- J M Stratil
- 1Institute for Medical Information Processing, Biometry and Epidemiology, Pettenkofer School of Public Health, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - R Baltussen
- 2Department for Health Evidence, Radboud University Medical Center, P.O.Box 9101, 6500 HB Nijmegen, The Netherlands
| | - I Scheel
- 3Department of Global Health, Norwegian Institute of Public Health, PO Box 4404, Nydalen, 0403 Oslo, Norway
| | - A Nacken
- 1Institute for Medical Information Processing, Biometry and Epidemiology, Pettenkofer School of Public Health, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - E A Rehfuess
- 1Institute for Medical Information Processing, Biometry and Epidemiology, Pettenkofer School of Public Health, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
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Esquivel-Sada D, Lévesque E, Hagan J, Knoppers BM, Simard J. Envisioning Implementation of a Personalized Approach in Breast Cancer Screening Programs: Stakeholder Perspectives. Healthc Policy 2019; 15:39-54. [PMID: 32077844 PMCID: PMC7020798 DOI: 10.12927/hcpol.2019.26072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Advances in genomics and epidemiology can foster the implementation of a risk-based approach to current age-based breast cancer screening programs. This personalized approach would challenge the trajectory for women in the healthcare system by adding both a risk-assessment step (including a genomic test) and screening options. OBJECTIVE The aim of this study is to explore, from an organizational perspective, the acceptability of different proposals for each step of the trajectory for women in the healthcare system should a personalized approach be implemented in the province of Quebec. METHODS We interviewed 20 professional stakeholders who are either involved in the current breast cancer screening program in Quebec or who are likely to play a role in the future implementation of a personalized risk-based approach. RESULTS|DISCUSSION Preferences are split between proposals supporting self-management by the women themselves (e.g., solicitation through media campaign, self-collection of information and sample and results provided by letter) and proposals prioritizing more interaction between women and healthcare providers (e.g., solicitation by health professionals, collection of information and samples by a nurse and results provided by health professionals).
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Affiliation(s)
- Daphne Esquivel-Sada
- Sociologist, Centre of Genomics and Policy, Department of Human Genetics, Faculty of Medicine, McGill University, Montreal, QC
| | - Emmanuelle Lévesque
- Lawyer and Academic Associate, Centre of Genomics and Policy, Department of Human Genetics, Faculty of Medicine, McGill University, Montreal, QC
| | - Julie Hagan
- Academic Associate, Centre of Genomics and Policy, Department of Human Genetics, Faculty of Medicine McGill University, Montreal, QC
| | - Bartha Maria Knoppers
- Professor, Department of Human Genetics, Faculty of Medicine, McGill University, Montreal, QC, Director, Centre of Genomics and Policy, Department of Human Genetics, Faculty of Medicine, McGill University, Montreal, QC
| | - Jacques Simard
- Professor, Department of Molecular Medicine, Faculty of Medicine, Université Laval, Québec City, QC
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Akrami F. Requirement of Considering the Ethical Issues in Elderly Health Care Policy. Int J Prev Med 2019; 10:25. [PMID: 30967911 PMCID: PMC6413521 DOI: 10.4103/ijpvm.ijpvm_149_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 12/07/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Forouzan Akrami
- Department of Bioethics, Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Public Health, Ministry of Health and Medical Education, Tehran, Iran
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Rehfuess EA, Stratil JM, Scheel IB, Portela A, Norris SL, Baltussen R. The WHO-INTEGRATE evidence to decision framework version 1.0: integrating WHO norms and values and a complexity perspective. BMJ Glob Health 2019; 4:e000844. [PMID: 30775012 PMCID: PMC6350705 DOI: 10.1136/bmjgh-2018-000844] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 07/05/2018] [Accepted: 07/20/2018] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Evidence-to-decision (EtD) frameworks intend to ensure that all criteria of relevance to a health decision are systematically considered. This paper, part of a series commissioned by the WHO, reports on the development of an EtD framework that is rooted in WHO norms and values, reflective of the changing global health landscape, and suitable for a range of interventions and complexity features. We also sought to assess the value of this framework to decision-makers at global and national levels, and to facilitate uptake through suggestions on how to prioritise criteria and methods to collect evidence. METHODS In an iterative, principles-based approach, we developed the framework structure from WHO norms and values. Preliminary criteria were derived from key documents and supplemented with comprehensive subcriteria obtained through an overview of systematic reviews of criteria employed in health decision-making. We assessed to what extent the framework can accommodate features of complexity, and conducted key informant interviews among WHO guideline developers. Suggestions on methods were drawn from the literature and expert consultation. RESULTS The new WHO-INTEGRATE (INTEGRATe Evidence) framework comprises six substantive criteria-balance of health benefits and harms, human rights and sociocultural acceptability, health equity, equality and non-discrimination, societal implications, financial and economic considerations, and feasibility and health system considerations-and the meta-criterion quality of evidence. It is intended to facilitate a structured process of reflection and discussion in a problem-specific and context-specific manner from the start of a guideline development or other health decision-making process. For each criterion, the framework offers a definition, subcriteria and example questions; it also suggests relevant primary research and evidence synthesis methods and approaches to assessing quality of evidence. CONCLUSION The framework is deliberately labelled version 1.0. We expect further modifications based on focus group discussions in four countries, example applications and input across concerned disciplines.
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Affiliation(s)
- Eva A Rehfuess
- Institute for Medical Information Processing, Biometry and Epidemiology, Pettenkofer School of Public Health, LMU Munich, Munich, Germany
| | - Jan M Stratil
- Institute for Medical Information Processing, Biometry and Epidemiology, Pettenkofer School of Public Health, LMU Munich, Munich, Germany
| | - Inger B Scheel
- Department of Global Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Anayda Portela
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Susan L Norris
- Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland
| | - Rob Baltussen
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
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Akrami F, Zali A, Abbasi M, Majdzadeh R, Karimi A, Fadavi M, Mehrabi Bahar A. An ethical framework for evaluation of public health plans: a systematic process for legitimate and fair decision-making. Public Health 2018; 164:30-38. [PMID: 30170266 PMCID: PMC7118744 DOI: 10.1016/j.puhe.2018.07.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 06/08/2018] [Accepted: 07/14/2018] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Given the increasing threats of communicable and non-communicable diseases, it is necessary for policy-makers and public health (PH) professionals to address ethical issues in health policies and plans. This study aimed to develop a practical framework for the ethical evaluation of PH programs. STUDY DESIGN A multidisciplinary team developed an ethical framework to evaluate PH plans from 2015 to 2017. METHODS In this study, the multi-method approach was used. First, a list of moral norms in PH policy and practice was drafted and completed in two interactive sessions. Then, the Delphi method was used for consensus about the structural components to be adopted in the framework. After developing the framework, its efficiency was assessed by evaluating Iran's Fourth Strategic Plan for HIV/AIDS Prevention and Control. RESULTS The framework was developed in the following three sections: (i) determination of the general moral norms in PH practice and policy; (ii) five steps of evaluation; and (iii) a procedural evaluation step to ensure fair decision-making. The ratio of the ethical points of the PH plan increased by 46% after implementation of the framework, and the frequency of ethical points increased significantly after applying the framework (P = 0.001). CONCLUSION The application of the framework for the ethical evaluation of various PH programs ensures a comprehensive and scientific-deliberative decision-making process, while also contributing to the development of the framework.
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Affiliation(s)
- F Akrami
- Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - A Zali
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M Abbasi
- Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - R Majdzadeh
- Community Based Participatory Research Center and Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - A Karimi
- Faculty of Law and Political Science, University of Tehran, Tehran, Iran
| | - M Fadavi
- Medical Ethics Department, Faculty of Traditional Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - A Mehrabi Bahar
- School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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20
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Zolala S, Almasi-Hashiani A, Akrami F. Severity and frequency of moral distress among midwives working in birth centers. Nurs Ethics 2018; 26:2364-2372. [PMID: 30348054 DOI: 10.1177/0969733018796680] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND When individuals are aware of the appropriate ethical practice, but lack the ability to do it, they will suffer from moral distress. Moral distress is a frequent phenomenon in clinical practice which can have different effects on the performance of physicians, nurses, and midwives, and therefore patients and health care systems. RESEARCH OBJECTIVE The present study aimed to determine the severity and frequency of moral distress in midwives working in birth centers. RESEARCH DESIGN This study is a descriptive cross-sectional research. Researcher-made questionnaire was used to gather data. PARTICIPANTS AND RESEARCH CONTEXT A total of 180 midwives working in the labor ward of the public birth centers affiliated to Shahid Beheshti University of Medical Sciences were included to the study by census. ETHICAL CONSIDERATIONS Official permission for data collecting was obtained from the directors of the birth centers affiliated to Shahid Beheshti University of Medical Sciences. Then, after explaining the objectives of the study and assuring the confidentially of information, verbal consent of the participants was obtained. FINDINGS The total mean ± standard deviation of the severity and frequency of moral distress were 3.85 ± 0.75 and 3.03 ± 0.48, respectively. The highest severity and the lowest frequency of moral distress were obtained for the assistance for abortion and the lowest severity of moral distress was related to the organizational domain. However, the highest frequency of moral distress was related to futile care field. The mean of moral distress severity in the midwives with associate degree was significantly lower than other levels of education. Also, there was a significant relationship between age and moral distress frequency (p = 0.010). DISCUSSION The midwives' moral distress was relatively high as expected. This finding is consistent with the results of similar studies in intensive care unit nurses. CONCLUSION After identifying the level and most important factors of moral distress among midwives, the next step is empower them to prevent moral distress, in particular efforts to change structures.
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Affiliation(s)
- Shahrzad Zolala
- Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Almasi-Hashiani
- Department of Epidemiology and Reproductive Health, Reproductive Epidemiology Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Forouzan Akrami
- Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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21
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Innes SI, Leboeuf-Yde C, Walker BF. Comparing the old to the new: A comparison of similarities and differences of the accreditation standards of the chiropractic council on education-international from 2010 to 2016. Chiropr Man Therap 2018; 26:25. [PMID: 30128110 PMCID: PMC6092815 DOI: 10.1186/s12998-018-0196-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 05/30/2018] [Indexed: 01/14/2023] Open
Abstract
Background Chiropractic programs are accredited and monitored by regional Councils on Chiropractic Education (CCE). The CCE-International has historically been a federation of regional CCEs charged with harmonising world standards to produce quality chiropractic educational programs. The standards for accreditation periodically undergo revision. We conducted a comparison of the CCE-International 2016 Accreditation Standards with the previous version, looking for similarities and differences, expecting to see some improvements. Method The CCE-International current (2016) and previous versions (2010) were located and downloaded. Word counts were conducted for words thought to reflect content and differences between standards. These were tabulated to identify similarities and differences. Interpretation was made independently followed by discussion between two researchers. Results The 2016 standards were nearly 3 times larger than the previous standards. The 2016 standards were created by mapping and selection of common themes from member CCEs' accreditation standards and not through an evidence-based approach to the development and trialling of accreditation standards before implementation. In 2010 chiropractors were expected to provide attention to the relationship between the structural and neurological aspects of the body in health and disease. In 2016 they should manage mechanical disorders of the musculoskeletal system. Many similarities between the old and the new standards were found. Additions in 2016 included a hybrid model of accreditation founded on outcomes-based assessment of education and quality improvement. Both include comprehensive competencies for a broader role in public health. Omissions included minimal faculty qualifications and the requirement that students should be able to critically appraise scientific and clinical knowledge. Another omission was the requirement for chiropractic programs to be part of a not-for-profit educational entity. There was no mention of evidence-based practice in either standards but the word 'evidence-informed' appeared once in the 2016 standards. Conclusions Some positive changes have taken place, such as having bravely moved towards the musculoskeletal model, but on the negative side, the requirement to produce graduates skilled at dealing with scientific texts has been removed. A more robust development approach including better transparency is needed before implementation of CCE standards and evidence-based concepts should be integrated in the programs. The CCE-International should consider the creation of a recognition of excellence in educational programs and not merely propose minimal standards.
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Affiliation(s)
- Stanley I Innes
- 1School of Health Professions, Murdoch University, Murdoch, Australia
| | - Charlotte Leboeuf-Yde
- 1School of Health Professions, Murdoch University, Murdoch, Australia.,Institut Franco-Européen de Chiropraxie, Ivry sur Seine, France.,3CIAMS, Université Paris-Sud, Université Paris-Saclay, 91405 Orsay Cedex, France.,4CIAMS, Université d'Orléans, 45067 Orléans, France.,5Institute for Regional Health Research, University of Southern Denmark, DK-5000 Odense, Denmark
| | - Bruce F Walker
- 1School of Health Professions, Murdoch University, Murdoch, Australia
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Greiner AM, Kaldjian LC. Rethinking medical oaths using the Physician Charter and ethical virtues. MEDICAL EDUCATION 2018; 52:826-837. [PMID: 29700846 DOI: 10.1111/medu.13581] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/12/2017] [Accepted: 02/08/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Medical oaths express ethical values that are essential to the trust within the patient-physician relationship and medicine's commitment to society. However, the contents of oaths vary between medical schools and therefore raise questions about which ethical values should be included in a medical oath. More than a decade has passed since this variability was last analysed in North America, and since that time the Physician Charter on Medical Professionalism has gained considerable attention, raising the possibility that the Charter may be influencing medical oaths and making them more consistent. METHODS The authors conducted a content analysis of 84 oaths available in 2015 from medical schools in the USA and Canada affiliated with the Association of American Medical Colleges, organising the content into three categories: (i) ethical values, (ii) principles and commitments in the Physician Charter, and (iii) ethical virtues. RESULTS Only five ethical values were expressed in the majority of oaths (confidentiality, obligation to the profession, beneficence, avoiding discrimination, and honour and integrity), and respect for patient autonomy was uncommon. Only three of the Physician Charter's principles and commitments (primacy of patient welfare, social justice and confidentiality) and one virtue (honour and integrity) were reflected in the majority of oaths. CONCLUSIONS Medical oaths in North America appear to be highly variable in content. Greater attention to resources like the Physician Charter can help improve the ethical content and consistency of oaths across different institutions, and throughout their education medical students should be encouraged to discuss and reflect on the principles and virtues they will profess when they graduate.
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Affiliation(s)
- Alexander M Greiner
- Medical Scientist Training Program, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Lauris C Kaldjian
- Program in Bioethics and Humanities, Carver College of Medicine, Iowa City, Iowa, USA
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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