Is there an Aboriginal bioethic?

"The support has been brilliant": experiences of Aboriginal and Torres Strait Islander patients attending two high performing cancer services

Background

Improving health outcomes for Indigenous people by providing person-centred, culturally safe care is a crucial challenge for the health sector, both in Australia and internationally. Many cancer providers and support services are committed to providing high quality care, yet struggle with providing accessible, culturally safe cancer care to Indigenous Australians. Two Australian cancer services, one urban and one regional, were identified as particularly focused on providing culturally safe cancer care for Indigenous cancer patients and their families. The article explores the experiences of Indigenous cancer patients and their families within the cancer services and ascertains how their experiences of care matches with the cancer services’ strategies to improve care.

Methods

Services were identified as part of a national study designed to identify and assess innovative services for Indigenous cancer patients and their families. Case studies were conducted with a small number of identified services. In-depth interviews were conducted with Indigenous people affected by cancer and hospital staff. The interviews from two services, which stood out as particularly high performing, were analysed through the lens of the patient experience.

Results

Eight Indigenous people affected by cancer and 23 hospital staff (Indigenous and non-Indigenous) were interviewed. Three experiences were shared by the majority of Indigenous cancer patients and family members interviewed in this study: a positive experience while receiving treatment at the cancer service; a challenging time between receiving diagnosis and reaching the cancer centre; and the importance of family support, while acknowledging the burden on family and carers.

Conclusions

This article is significant because it demonstrates that with a culturally appropriate and person-centred approach, involving patients, family members, Indigenous and non-Indigenous staff, it is possible for Indigenous people to have positive experiences of cancer care in mainstream, tertiary health services. If we are to improve health outcomes for Indigenous people it is vital more cancer services and hospitals follow the lead of these two services and make a sustained and ongoing commitment to strengthening the cultural safety of their service.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06535-9.

Black bodies and Bioethics: Debunking Mythologies of Benevolence and Beneficence in Contemporary Indigenous Health Research in Colonial Australia

We seek to bring Black bodies and lives into full view within the enterprise of Indigenous health research to interrogate the unquestioned good that is taken to characterize contemporary Indigenous health research. We articulate a Black bioethics that is not premised upon a false logic of beneficence, rather we think through a Black bioethics premised upon an unconditional love for the Black body. We achieve this by examining the accounts of two Black mothers, fictional and factual rendering visible the racial violence Black bodies have been subjected to. We call for a Black bioethics that reimagines the Black body as beautiful and belonging-to both someone and somewhere.

The Whiteness of Bioethics

A discussion of whiteness as an "ethos" or "relational category" in bioethics, drawing on examples from medical and historical research.

Exploring Aboriginal patients' experiences of cardiac care at a major metropolitan hospital in Melbourne

Objectives The aim of the present study was to explore Aboriginal patients' lived experiences of cardiac care at a major metropolitan hospital in Melbourne. Methods The study was a qualitative study involving in-depth interviews with a purposive sample of 10 Aboriginal patients who had been treated in the cardiology unit at the study hospital during 2012-13. A phenomenological approach was used to analyse the data. Results Eight themes emerged from the data, each concerning various aspects of participants' experiences: 'dislike of hospitals', 'system failures', 'engagement with hospital staff', 'experiences of racism', 'health literacy and information needs', 'self-identifying as Aboriginal', 'family involvement in care' and 'going home and difficulties adapting'. Most participants had positive experiences of the cardiac care, but hospitalisation was often challenging because of a sense of dislocation and disorientation. The stress of hospitalisation was greatly mediated by positive engagements with staff, but at times exacerbated by system failures or negative experiences. Conclusion Cardiac crises are stressful and hospital stays were particularly disorienting for Aboriginal people dislocated from their home land and community. What is known about the topic? Aboriginal people have higher mortality rates due to cardiovascular diseases compared with other Australians. Along with different factors contributing to the life expectancy gap, Aboriginal people also face significant barriers in the use of the healthcare system. What does this paper add? Aboriginal patients' lived experience of cardiac care at a major metropolitan hospital in Melbourne is explored in this paper. Different issues were revealed during their interaction with the hospital staff and the hospital system in conjunction with their cultural aspect of patient care. What are the implications for practitioners? Positive interactions with staff, ongoing support from family and community, culturally appropriate cardiac rehabilitation programs can improve the cardiac care experiences of Aboriginal patients.

Heart Failure in Minority Populations - Impediments to Optimal Treatment in Australian Aborigines

Chronic heart failure (CHF) among Aboriginal/Indigenous Australians is endemic. There are also grave concerns for outcomes once acquired. This point is compounded by a lack of prospective and objective studies to plan care. To capture the essence of the presented topic it is essential to broadly understand Indigenous health. Key words such as ‘worsening’, ‘gaps’, ‘need to do more’, ‘poorly studied’, or ‘future studies should inform’ occur frequently in contrast to CHF research for almost all other groups. This narrative styled opinion piece attempts to discuss future directions for CHF care for Indigenous Australians. We provide a synopsis of the problem, highlight the treatment gaps, and define the impediments that present hurdles in optimising CHF care for Indigenous Australians.

Canadian residential schools and urban indigenous knowledge production about diabetes

The construction of illness as an inscription on the body of colonization figures importantly among Indigenous community-based service and health care providers. While residential schools and diabetes have both been characterized as products of colonization, little work has been done to examine how they are connected to and informative for health provider practice. The research data presented in this article come from a collaborative urban Indigenous community-based study examining the legacy of negative relationships with food that was instilled in residential schools and used in diabetes intervention. I illustrate how residential school disciplined eating, providing a context for understanding the contemporary production of Indigenous health knowledge and practice in the urban setting, and the diet-related management of diabetes.

Mental health of Australian Aboriginal women during pregnancy: identifying the gaps

Despite Australia's high standard of health care provision, Australian Aboriginal women continue to experience poor pregnancy outcomes in terms of maternal and foetal morbidity and mortality. In an attempt to improve these outcomes, health care providers have developed targeted antenatal programmes that aim to address identified health behaviours that are known to contribute to poor health during pregnancy. While some areas of improvement have been noted in rates of engagement with health services, the rates of premature births and low birth weight babies continue to be significantly higher than in the non-Aboriginal population. It appears that Australian researchers have been focused on the behaviour of the individual and have failed to fully consider the impact that social and emotional well-being has on both health behaviours and pregnancy outcomes. This review has highlighted the need for an approach to both research and clinical practice that acknowledges the Aboriginal view of health which encompasses mental, physical, cultural and spiritual health. Until clinicians and Aboriginal women have a shared understanding of how social and emotional well-being is experienced by Aboriginal women, in other words their explanatory model, it is unlikely that any meaningful improvements will be seen.

A cost-based equity weight for use in the economic evaluation of primary health care interventions: case study of the Australian Indigenous population

Background

Efficiency and equity are both important policy objectives in resource allocation. The discipline of health economics has traditionally focused on maximising efficiency, however addressing inequities in health also requires consideration. Methods to incorporate equity within economic evaluation techniques range from qualitative judgements to quantitative outcomes-based equity weights. Yet, due to definitional uncertainties and other inherent limitations, no method has been universally adopted to date. This paper proposes an alternative cost-based equity weight for use in the economic evaluation of interventions delivered from primary health care services.

Methods

Equity is defined in terms of 'access' to health services, with the vertical equity objective to achieve 'equitable access for unequal need'. Using the Australian Indigenous population as an illustrative case study, the magnitude of the equity weight is constructed using the ratio of the costs of providing specific interventions via Indigenous primary health care services compared with the costs of the same interventions delivered via mainstream services. Applying this weight to the costs of subsequent interventions deflates the costs of provision via Indigenous health services, and thus makes comparisons with mainstream more equitable when applied during economic evaluation.

Results

Based on achieving 'equitable access', existing measures of health inequity are suitable for establishing 'need', however the magnitude of health inequity is not necessarily proportional to the magnitude of resources required to redress it. Rather, equitable access may be better measured using appropriate methods of health service delivery for the target group. 'Equity of access' also suggests a focus on the processes of providing equitable health care rather than on outcomes, and therefore supports application of equity weights to the cost side rather than the outcomes side of the economic equation.

Conclusion

Cost-based weights have the potential to provide a pragmatic method of equity weight construction which is both understandable to policy makers and sensitive to the needs of target groups. It could improve the evidence base for resource allocation decisions, and be generalised to other disadvantaged groups who share similar concepts of equity. Development of this decision-making tool represents a potentially important avenue for further health economics research.

Exploring aboriginal views of health using fuzzy cognitive maps and transitive closure. A case study of the determinants of diabetes

OBJECTIVES

To demonstrate how fuzzy cognitive maps may be used to extract, present and compare Aboriginal perspectives, using the determinants of diabetes as a case study.

METHODS

Participants from the Mohawk Community of Akwesasne and the Miawpukek First Nation in Conne River created fuzzy cognitive maps (FCMs) (N=3) detailing their views of "the causes of diabetes in their community", through a facilitated, group mapping session. For each FCM, the net causal effect of every determinant (direct or indirect) on diabetes was calculated from its transitive closure. The net causal effects were then compared across the set of FCMs to identify strong, weak and controversial determinants.

RESULTS

Comparison of FCMs revealed significant heterogeneity in the perspectives of diabetes. The Akwesasne participants focused heavily on social, traditional and spiritual factors, while Conne River participants placed more importance on direct personal and lifestyle factors. There was, however, a core of strong, validated determinants related primarily to healthy diet and physical activity.

CONCLUSIONS

This work demonstrates how FCM may be used to extract and represent different perspectives of complex issues allowing for comparisons among stakeholders or knowledge groups. Comparison of multiple FCM employing the transitive closure may then be used to identify areas of agreement and controversy.

Aspects of informed consent in medical practice in the eastern Mediterranean region during the 17th and 18th centuries

Informed consent is a question of central importance in contemporary medical ethics, and clinical practice is inconceivable without considering the issues it raises. Although it is often vigorously argued that consent, informed or otherwise, is a recent phenomenon and that no sources testify to its existence before the 20th century, it is difficult to accept that a process for regulating the common and fundamental parameters in the relationship between doctor and patient and the planning of treatment had not concerned previous eras. A review of the Registers of the Islamic Court of Candia (Heraklion) in Crete, a series of records that touches on, among other things, matters of medical interest, reveals that the concept of informed consent was not only known during a period that stretched from the mid-17th to the early 19th century, but it was concerned with the same principles that prevail or have been a point of contention today. An extension of this study into other periods may thus provide contemporary researchers with material and information valuable in the discussion of today's bioethical issues.

Cultural awareness of Inuit patients' experiences with emergency nursing care

Around 1500 Inuit patients fly annually from Nunavik to hospital centres in Montreal. This is a tense experience for many Inuit, due to cultural differences, and task-driven nursing practices often inadequately meeting their holistic health beliefs. In this qualitative study, we explored the experiences of Inuit patients with emergency nursing (EN) in the McGill University Health Centre, to inform on the best holistic nursing practices to meet culturally specific needs. Data analysis from semi-structured interviews with four participants generated a single theme: "rationalizing the care". While staying in the emergency department (ED), Inuit patients progressed through three steps in this rationalization process: first impressions of EN, perceiving the realities of EN, and appreciating EN care. "Being away from home" emerged as a stressor, and "other Inuit support", acted as a mediator. The participants in this study felt they had been shown culturally sensitive treatment through being kept informed, and skills of the nurses. As instruments of healing, therefore, the nurses in this study were able to apply a holistic approach to provide culturally sensitive care. Participants also highlighted speaking the same language and having direct access to an interpreter as key to improving ED experiences.