Social Prescribing in National Health Service Primary Care: What Are the Ethical Considerations?

Policy Points Social prescribing is proposed as a way of improving patients' health and well-being by attending to their non-clinical needs. This is done by connecting patients with community assets (typically voluntary or charitable organizations) that provide social and personal support. In the United Kingdom, social prescribing is used to improve patient well-being and reduce use of National Health Service resources. Although social prescribing schemes hold promise, evidence of their effects and effectiveness is sparse. As more information on social prescribing is gathered, it will be important to consider the associated ethical issues for patients, clinicians, link workers, and community assets.

Ethics and Racial Equity in Social Welfare Policy: Social Work's Response to the COVID-19 Pandemic

The COVID-19 pandemic has been particularly overwhelming for communities of color in the United States. In addition to the higher levels of underlying health conditions, circumstances related to a history of oppression and unequal access to opportunities and services are apparent. Social service programs will need to be re-developed to accommodate a new reality, both in terms of how people connect with services and how social work professionals provide them. Professional social work organizations' codes of ethics are analyzed, along with the theoretical framework of structural competency. It is an ethical imperative that social welfare policy and practice advance as culturally competent, racial equity, and empowerment-based programs. Child welfare is portrayed as an example where the pandemic could provide an opportunity to learn from the past to construct a more compassionate, competent, and ethical future.

Deservingness put into practice: Constructing the (un)deservingness of migrants in four European countries

The increased comparative research on perceptions of public welfare deservingness studies the extent to which different subgroups of citizens are deemed worthy or unworthy of receiving help from the welfare state. The concept of deservingness criteria plays a crucial role in this research, as it theorizes a universal heuristic that citizens apply to rank people in terms of their welfare deservingness. Due to the mainly quantitative nature of the research and despite the indisputable progress it has made, the subjective existence and actual application of these deservingness criteria remain a bit of a black box. What criteria of deservingness do citizens actually apply, and how do they apply them? This article opens the black box of welfare deservingness and sheds light on the nature and practice of deservingness criteria. Empirically, the paper explores how the deservingness of immigrants is discussed and established within 20 focus groups conducted in Slovenia, Denmark, UK, and Norway in 2016 with a total of 160 participants. All 20 focus groups discussed the welfare deservingness of immigrants based on similar vignette stimuli. Our analysis shows that (1) deservingness criteria are used both to construct images of target groups and as normative yardsticks; (2) deservingness criteria do not work independently of each other, but rather co-function in specific hybridized discourses; and (3) the moral logic of deservingness is supplemented by alternative moral logics, at least in the case of migrants.

Universal Basic Income, Poverty, and Social Justice: A Moral and Economic Imperative for Social Workers

Modern technology threatens to dramatically alter the U.S. labor economy, but the crumbling social safety net may be insufficient for affected workers. Some advocates propose to address these converging problems through universal basic income (UBI). Authors conducted a preliminary review of social work perspectives on the topic of UBI. They found very little relevant literature, especially among American scholars. Existent social work literature frames UBI as an alternative to the neoliberal welfare state and mass unemployment. Social workers also contribute a critical social justice orientation to UBI scholarship in other disciplines. Grounded in the NASW Code of Ethics, authors argue that it is imperative for American social workers to seriously consider UBI as an answer to growing inequality and the unique expertise that social workers offer as allies of marginalized populations.

Stakeholder identities in Britain's neoliberal ethical community: Polish narratives of earned citizenship in the context of the UK's EU referendum

This article examines the narrative strategies through which Polish migrants in the UK challenge the formal rights of political membership and attempt to redefine the boundaries of 'citizenship' along notions of deservedness. The analysed qualitative data originate from an online survey conducted in the months before the 2016 EU referendum, and the narratives emerge from the open-text answers to two survey questions concerning attitudes towards the referendum and the exclusion of resident EU nationals from the electoral process. The analysis identifies and describes three narrative strategies in reaction to the public discourses surrounding the EU referendum - namely discursive complicity, intergroup hostility and defensive assertiveness - which attempt to redefine the conditions of membership in Britain's 'ethical community' in respect to welfare practices. Examining these processes simultaneously 'from below' and 'from outside' the national political community, the paper argues, can reveal more of the transformation taking place in conceptions of citizenship at the sociological level, and the article aims to identify the contours of a 'neoliberal communitarian citizenship' as internalized by mobile EU citizens.

Solidarity and care as relational practices

Many working in bioethics today are engaging in forms of normative interpretation concerning the meaningful contexts of relational agency and institutional structures of power. Using the framework of relational bioethics, this article focuses on two significant social practices that are significant for health policy and public health: the practices of solidarity and the practices of care. The main argument is that the affirming recognition of, and caring attention paid to, persons as moral subjects can politically motivate a society in three respects. The recognition of solidarity and the attention of care can prompt progressive change toward a democratic willingness: (a) to provide for equal respect for rights and dignity; (b) to provide the social resources and services needed for just health and well-being; and (c) to focus its creativity and wealth on the actualization of potential flourishing of each and all. Solidarity is discussed as a morally developmental stance that moves from standing up for another, standing up with another, and standing up as another. Care is discussed as a morally developmental stance that moves from the attentive rehabilitation of another, attentive companionship with and for another, and attentive commitment to another.

Solidarity and the problem of structural injustice in healthcare

The concept of solidarity has recently come to prominence in the healthcare literature, addressing the motivation for taking seriously the shared vulnerabilities and medical needs of compatriots and for acting to help them meet these needs. In a recent book, Prainsack and Buyx take solidarity as a commitment to bear costs to assist others regarded as similar, with implications for governing health databases, personalized medicine, and organ donation. More broadly, solidarity has been understood normatively to call for 'standing with' or assisting fellow community members and possibly also distant others in regard to their needs, whether for its own sake or in order to realize the demands of justice. I argue here that the understanding of solidarity in the existing bioethics literature is unduly restricted by not sufficiently theorizing the notion of structural (or systemic) injustice and its import for understanding solidarity. Extending traditional conceptions of labor and social movement solidarity, I contrast unitary solidarity within a given group with 'networking solidarities' across groups. I analyze the meaning of structural injustice and its significance for solidarity, including countering institutionally entrenched inequalities and economic exploitation. I then apply this broadened conception to healthcare, discussing structural problems with the U.S. insurance system and the solidarity movements addressing its deficiencies. I analyze some natural disasters and global health challenges that were aggravated by structural injustices, along with the solidarity movements they engendered. Finally, I revisit the questions of governing health databases and of personalized medicine with the enlarged conception of solidarity in view.

The value of work: Addressing the future of work through the lens of solidarity

Designing the future of work is crucial to the health and well-being of people and societies. Experts predict that developments such as the advancement of digital technologies, automation, and the movement of manufacturing jobs to low-wage countries will lead to major transformations in the labour market, and some foresee significant job losses. Due to the close relationship between employment and health, major job losses would have significant negative impacts on the health and well-being of individuals and societies. Job losses would also pose a major challenge to solidaristic support within societies because they would negatively affect the recognition of similarities among people, which is vital for solidaristic practice and institutions. To prevent these negative effects, a fundamental redesign of the relationship between work and income is necessary. And for this project to succeed, we need to reconsider of the value of work. Building on definitions of flourishing people and societies, we argue that the value of work should not be determined by the labour market, but according to its importance for society. Using a solidarity-based framework we argue that such a re-valuation of work will help to ensure social cohesion and increase reciprocity in our societies. It will serve as a foundation upon which we can reconfigure the relationship between work and income without risking the loss of social cohesion and solidarity.

Union's inspiration: Universal health care and the essential partiality of solidarity

Solidarity is commonly invoked in the justification of public health care. This is understandable, as calls for and appeals to solidarity are effective in the mobilization of unison action and the willingness to incur sacrifices for others. However, the reference to solidarity as a moral notion requires caution, as there is no agreement on the meaning of solidarity. The article argues that the reference to solidarity as a normative notion is relevant to health-related moral claims, but that it does not provide a convincing foundation of claims to universal health care. References to universal solidarity obliterate an important distinction between those moral demands that are founded on principles like justice, recognition, or humanity, and those demands that stem from partisan relations in communities. While there is no 'separate essence' of solidarity that could be referred to in order to argue for the conceptual necessity of solidarity's partiality, some features may reasonably be stipulated as being essential to solidarity with a view to its systematic function within moral philosophy. The normative and motivational force of the ties invoked by solidarity is particularly relevant when basic moral demands are not met, and societies are in need of significant forms of communal relatedness.

Displacement and solidarity: An ethic of place-making

Drawing on a conception of people as 'ecological subjects', creatures situated in specific social relations, locations, and material environments, I want to emphasize the importance of place and place-making for basing, demonstrating, and forging future solidarity. Solidarity, as I will define it here, involves reaching out through moral imagination and responsive action across social and/or geographic distance and asymmetry to assist other people who are vulnerable, and to advance justice. Contained in the practice of solidarity are two core 'enacted commitments', first, to engaging our moral imaginations and recognizing others in need and, second, to responsive action. Recognizing the suffering of displacement and responding through place-making should follow from even the most simplistic understanding of people as 'implaced'. Recognition, furthermore, that places are created and sustained, transformed, or neglected in ways that foster or perpetuate inequities, including health inequities, generates responsibilities concerning place-making. Place-based interventions, on either count, should be principal and, indeed, prioritized ways of showing solidarity for the vulnerable and promoting justice. Where solidaristic relations do not prevail, place-making can catalyze and nurture them, and over time advance justice. On the moral landscapes of bioethics, the terrain where care and health are or should be at the center of attention, an ethic of place and place-making for those who have been displaced - patients, the elderly, urban populations, and asylum-seekers, for instance - expresses and has rich potential for nurturing bonds of solidarity.

Welfare-to-work interventions and their effects on the mental and physical health of lone parents and their children

BACKGROUND

Lone parents in high-income countries have high rates of poverty (including in-work poverty) and poor health. Employment requirements for these parents are increasingly common. 'Welfare-to-work' (WtW) interventions involving financial sanctions and incentives, training, childcare subsidies and lifetime limits on benefit receipt have been used to support or mandate employment among lone parents. These and other interventions that affect employment and income may also affect people's health, and it is important to understand the available evidence on these effects in lone parents.

OBJECTIVES

To assess the effects of WtW interventions on mental and physical health in lone parents and their children living in high-income countries. The secondary objective is to assess the effects of welfare-to-work interventions on employment and income.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, PsycINFO EBSCO, ERIC EBSCO, SocINDEX EBSCO, CINAHL EBSCO, Econlit EBSCO, Web of Science ISI, Applied Social Sciences Index and Abstracts (ASSIA) via Proquest, International Bibliography of the Social Sciences (IBSS) via ProQuest, Social Services Abstracts via Proquest, Sociological Abstracts via Proquest, Campbell Library, NHS Economic Evaluation Database (NHS EED) (CRD York), Turning Research into Practice (TRIP), OpenGrey and Planex. We also searched bibliographies of included publications and relevant reviews, in addition to many relevant websites. We identified many included publications by handsearching. We performed the searches in 2011, 2013 and April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of mandatory or voluntary WtW interventions for lone parents in high-income countries, reporting impacts on parental mental health, parental physical health, child mental health or child physical health.

DATA COLLECTION AND ANALYSIS

One review author extracted data using a standardised extraction form, and another checked them. Two authors independently assessed risk of bias and the quality of the evidence. We contacted study authors to obtain measures of variance and conducted meta-analyses where possible. We synthesised data at three time points: 18 to 24 months (T1), 25 to 48 months (T2) and 49 to 72 months (T3).

MAIN RESULTS

Twelve studies involving 27,482 participants met the inclusion criteria. Interventions were either mandatory or voluntary and included up to 10 discrete components in varying combinations. All but one study took place in North America. Although we searched for parental health outcomes, the vast majority of the sample in all included studies were female. Therefore, we describe adult health outcomes as 'maternal' throughout the results section. We downgraded the quality of all evidence at least one level because outcome assessors were not blinded. Follow-up ranged from 18 months to six years. The effects of welfare-to-work interventions on health were generally positive but of a magnitude unlikely to have any tangible effects.At T1 there was moderate-quality evidence of a very small negative impact on maternal mental health (standardised mean difference (SMD) 0.07, 95% Confidence Interval (CI) 0.00 to 0.14; N = 3352; studies = 2)); at T2, moderate-quality evidence of no effect (SMD 0.00, 95% CI 0.05 to 0.05; N = 7091; studies = 3); and at T3, low-quality evidence of a very small positive effect (SMD -0.07, 95% CI -0.15 to 0.00; N = 8873; studies = 4). There was evidence of very small positive effects on maternal physical health at T1 (risk ratio (RR) 0.85, 95% CI 0.54 to 1.36; N = 311; 1 study, low quality) and T2 (RR 1.06, 95% CI 0.95 to 1.18; N = 2551; 2 studies, moderate quality), and of a very small negative effect at T3 (RR 0.97, 95% CI 0.91 to 1.04; N = 1854; 1 study, low quality).At T1, there was moderate-quality evidence of a very small negative impact on child mental health (SMD 0.01, 95% CI -0.06 to 0.09; N = 2762; studies = 1); at T2, of a very small positive effect (SMD -0.04, 95% CI -0.08 to 0.01; N = 7560; studies = 5), and at T3, there was low-quality evidence of a very small positive effect (SMD -0.05, 95% CI -0.16 to 0.05; N = 3643; studies = 3). Moderate-quality evidence for effects on child physical health showed a very small negative effect at T1 (SMD -0.05, 95% CI -0.12 to 0.03; N = 2762; studies = 1), a very small positive effect at T2 (SMD 0.07, 95% CI 0.01 to 0.12; N = 7195; studies = 3), and a very small positive effect at T3 (SMD 0.01, 95% CI -0.04 to 0.06; N = 8083; studies = 5). There was some evidence of larger negative effects on health, but this was of low or very low quality.There were small positive effects on employment and income at 18 to 48 months (moderate-quality evidence), but these were largely absent at 49 to 72 months (very low to moderate-quality evidence), often due to control group members moving into work independently. Since the majority of the studies were conducted in North America before the year 2000, generalisabilty may be limited. However, all study sites were similar in that they were high-income countries with developed social welfare systems.

AUTHORS' CONCLUSIONS

The effects of WtW on health are largely of a magnitude that is unlikely to have tangible impacts. Since income and employment are hypothesised to mediate effects on health, it is possible that these negligible health impacts result from the small effects on economic outcomes. Even where employment and income were higher for the lone parents in WtW, poverty was still high for the majority of the lone parents in many of the studies. Perhaps because of this, depression also remained very high for lone parents whether they were in WtW or not. There is a lack of robust evidence on the health effects of WtW for lone parents outside North America.

23rd Gordon Arthur Ransome Oration: Law and Medicine: Professions of Honour, Service and Excellence

Amidst dramatic global change, there is a greater need than ever for principled and committed professionals. The sibling professions of law and medicine, in particular, serve crucial functions in contemporary society. To meet the challenges of the future, members of both professions must appreciate and commit to their shared calling to public service, and ensure that it is not overridden by the profit motive. Three further commitments follow from this: first, to nurture and mentor new entrants to the professions to ensure the continuance of that mission of public service; second, to improve accessibility and affordability through pro bono work and by other means, so that all who need professional assistance can receive it; and, thirdly, to serve with excellence in ethics as well as competence, so as not to betray the trust of the laypersons who rely on professionals to safeguard their interests and welfare. The medical and legal professions have much to learn and gain from working with each other toward those shared goals.

Welfare-to-work interventions and their effects on the mental and physical health of lone parents and their children

BACKGROUND

Lone parents in high-income countries have high rates of poverty (including in-work poverty) and poor health. Employment requirements for these parents are increasingly common. 'Welfare-to-work' (WtW) interventions involving financial sanctions and incentives, training, childcare subsidies and lifetime limits on benefit receipt have been used to support or mandate employment among lone parents. These and other interventions that affect employment and income may also affect people's health, and it is important to understand the available evidence on these effects in lone parents.

OBJECTIVES

To assess the effects of WtW interventions on mental and physical health in lone parents and their children living in high-income countries. The secondary objective is to assess the effects of welfare-to-work interventions on employment and income.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, PsycINFO EBSCO, ERIC EBSCO, SocINDEX EBSCO, CINAHL EBSCO, Econlit EBSCO, Web of Science ISI, Applied Social Sciences Index and Abstracts (ASSIA) via Proquest, International Bibliography of the Social Sciences (IBSS) via ProQuest, Social Services Abstracts via Proquest, Sociological Abstracts via Proquest, Campbell Library, NHS Economic Evaluation Database (NHS EED) (CRD York), Turning Research into Practice (TRIP), OpenGrey and Planex. We also searched bibliographies of included publications and relevant reviews, in addition to many relevant websites. We identified many included publications by handsearching. We performed the searches in 2011, 2013 and April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of mandatory or voluntary WtW interventions for lone parents in high-income countries, reporting impacts on parental mental health, parental physical health, child mental health or child physical health.

DATA COLLECTION AND ANALYSIS

One review author extracted data using a standardised extraction form, and another checked them. Two authors independently assessed risk of bias and the quality of the evidence. We contacted study authors to obtain measures of variance and conducted meta-analyses where possible. We synthesised data at three time points: 18 to 24 months (T1), 25 to 48 months (T2) and 49 to 72 months (T3).

MAIN RESULTS

Twelve studies involving 27,482 participants met the inclusion criteria. Interventions were either mandatory or voluntary and included up to 10 discrete components in varying combinations. All but one study took place in North America. Although we searched for parental health outcomes, the vast majority of the sample in all included studies were female. Therefore, we describe adult health outcomes as 'maternal' throughout the results section. We downgraded the quality of all evidence at least one level because outcome assessors were not blinded. Follow-up ranged from 18 months to six years. The effects of welfare-to-work interventions on health were generally positive but of a magnitude unlikely to have any tangible effects.At T1 there was moderate-quality evidence of a very small negative impact on maternal mental health (standardised mean difference (SMD) 0.07, 95% Confidence Interval (CI) 0.00 to 0.14; N = 3352; studies = 2)); at T2, moderate-quality evidence of no effect (SMD 0.00, 95% CI 0.05 to 0.05; N = 7091; studies = 3); and at T3, low-quality evidence of a very small positive effect (SMD -0.07, 95% CI -0.15 to 0.00; N = 8873; studies = 4). There was evidence of very small positive effects on maternal physical health at T1 (risk ratio (RR) 0.85, 95% CI 0.54 to 1.36; N = 311; 1 study, low quality) and T2 (RR 1.06, 95% CI 0.95 to 1.18; N = 2551; 2 studies, moderate quality), and of a very small negative effect at T3 (RR 0.97, 95% CI 0.91 to 1.04; N = 1854; 1 study, low quality).At T1, there was moderate-quality evidence of a very small negative impact on child mental health (SMD 0.01, 95% CI -0.06 to 0.09; N = 2762; studies = 1); at T2, of a very small positive effect (SMD -0.04, 95% CI -0.08 to 0.01; N = 7560; studies = 5), and at T3, there was low-quality evidence of a very small positive effect (SMD -0.05, 95% CI -0.16 to 0.05; N = 3643; studies = 3). Moderate-quality evidence for effects on child physical health showed a very small negative effect at T1 (SMD -0.05, 95% CI -0.12 to 0.03; N = 2762; studies = 1), a very small positive effect at T2 (SMD 0.07, 95% CI 0.01 to 0.12; N = 7195; studies = 3), and a very small positive effect at T3 (SMD 0.01, 95% CI -0.04 to 0.06; N = 8083; studies = 5). There was some evidence of larger negative effects on health, but this was of low or very low quality.There were small positive effects on employment and income at 18 to 48 months (moderate-quality evidence), but these were largely absent at 49 to 72 months (very low to moderate-quality evidence), often due to control group members moving into work independently. Since the majority of the studies were conducted in North America before the year 2000, generalisabilty may be limited. However, all study sites were similar in that they were high-income countries with developed social welfare systems.

AUTHORS' CONCLUSIONS

The effects of WtW on health are largely of a magnitude that is unlikely to have tangible impacts. Since income and employment are hypothesised to mediate effects on health, it is possible that these negligible health impacts result from the small effects on economic outcomes. Even where employment and income were higher for the lone parents in WtW, poverty was still high for the majority of the lone parents in many of the studies. Perhaps because of this, depression also remained very high for lone parents whether they were in WtW or not. There is a lack of robust evidence on the health effects of WtW for lone parents outside North America.

The moral economy of austerity: analysing UK welfare reform

This paper notes the contemporary emergence of 'morality' in both sociological argument and political rhetoric, and analyses its significance in relation to ongoing UK welfare reforms. It revisits the idea of 'moral economy' and identifies two strands in its contemporary application; that all economies depend on an internal moral schema, and that some external moral evaluation is desirable. UK welfare reform is analysed as an example of the former, with reference to three distinct orientations advanced in the work of Freeden (1996), Laclau (2014), and Lockwood (1996). In this light, the paper then considers challenges to the reform agenda, drawn from third sector and other public sources. It outlines the forms of argument present in these challenges, based respectively on rationality, legality, and morality, which together provide a basis for evaluation of the welfare reforms and for an alternative 'moral economy'.

Global justice, capabilities approach and commercial surrogacy in India

Inequalities, ineffective governance, unclear surrogacy regulations and unethical practices make India an ideal environment for global injustice in the process of commercial surrogacy. This article aims to apply the 'capabilities approach' to find possibilities of global justice through human fellowship in the context of commercial surrogacy. I draw primarily on my research findings supplemented by other relevant empirical research and documentary films on surrogacy. The paper reveals inequalities and inadequate basic entitlements among surrogate mothers as a consequence of which they are engaged in unjust contracts. Their limited entitlements also limit their opportunities to engage in enriching goals. It is the role of the state to provide all its citizens with basic entitlements and protect their basic human rights. Individuals in India evading their basic duty also contribute to the existing inequalities. Individual responsibilities of the medical practitioners and the intended parents are in question here as they are more inclined towards self-interest rather than commitment towards human fellowship. At the global level, the injustice in transnational commercial surrogacy practices in developing countries calls for an international declaration of women and child rights in third party reproduction with a normative vision of mutual fellowship and human dignity.

Distributive justice and cognitive enhancement in lower, normal intelligence

There exists a significant disparity within society between individuals in terms of intelligence. While intelligence varies naturally throughout society, the extent to which this impacts on the life opportunities it affords to each individual is greatly undervalued. Intelligence appears to have a prominent effect over a broad range of social and economic life outcomes. Many key determinants of well-being correlate highly with the results of IQ tests, and other measures of intelligence, and an IQ of 75 is generally accepted as the most important threshold in modern life. The ability to enhance our cognitive capacities offers an exciting opportunity to correct disabling natural variation and inequality in intelligence. Pharmaceutical cognitive enhancers, such as modafinil and methylphenidate, have been shown to have the capacity to enhance cognition in normal, healthy individuals. Perhaps of most relevance is the presence of an 'inverted U effect' for most pharmaceutical cognitive enhancers, whereby the degree of enhancement increases as intelligence levels deviate further below the mean. Although enhancement, including cognitive enhancement, has been much debated recently, we argue that there are egalitarian reasons to enhance individuals with low but normal intelligence. Under egalitarianism, cognitive enhancement has the potential to reduce opportunity inequality and contribute to relative income and welfare equality in the lower, normal intelligence subgroup. Cognitive enhancement use is justifiable under prioritarianism through various means of distribution; selective access to the lower, normal intelligence subgroup, universal access, or paradoxically through access primarily to the average and above average intelligence subgroups. Similarly, an aggregate increase in social well-being is achieved through similar means of distribution under utilitarianism. In addition, the use of cognitive enhancement within the lower, normal intelligence subgroup negates, or at the very least minimises, several common objections to cognitive enhancement. Subsequently, this paper demonstrates that there is a compelling case for cognitive enhancement use in individuals with lower, normal intelligence.

Ethical challenges with welfare technology: a review of the literature

Demographical changes in high income counties will increase the need of health care services but reduce the number of people to provide them. Welfare technology is launched as an important measure to meet this challenge. As with all types of technologies we must explore its ethical challenges. A literature review reveals that welfare technology is a generic term for a heterogeneous group of technologies and there are few studies documenting their efficacy, effectiveness and efficiency. Many kinds of welfare technology break with the traditional organization of health care. It introduces technology in new areas, such as in private homes, and it provides new functions, e.g. offering social stimuli and entertainment. At the same time welfare technology is developed for groups that traditionally have not been extensive technology users. This raises a series of ethical questions with regard to the development and use of welfare technologies, which are presented in this review. The main challenges identified are: (1) Alienation when advanced technology is used at home, (2) conflicting goals, as welfare technologies have many stakeholders with several ends, (3) respecting confidentiality and privacy when third-party actors are involved, (4) guaranteeing equal access and just distribution, and (5) handling conflicts between instrumental rationality and care in terms of respecting dignity and vulnerability. Addressing these issues is important for developing and implementing welfare technologies in a morally acceptable manner.

Solidarity in contemporary bioethics--towards a new approach

This paper, which is based on an extensive analysis of the literature, gives a brief overview of the main ways in which solidarity has been employed in bioethical writings in the last two decades. As the vagueness of the term has been one of the main targets of critique, we propose a new approach to defining solidarity, identifying it primarily as a practice enacted at the interpersonal, communal, and contractual/legal levels. Our three-tier model of solidarity can also help to explain the way in which crises of solidarity can occur, notably when formal solidaristic arrangements continue to exist despite 'lower tiers' of solidarity practices at inter-personal and communal levels having 'broken away'. We hope that this contribution to the growing debate on the potential for the value of solidarity to help tackle issues in bioethics and beyond, will stimulate further discussion involving both conceptual and empirically informed perspectives.

A dialectic of cooperation and competition: solidarity and universal health care provision

The concept of solidarity has achieved relatively little attention from philosophers, in spite of its signal importance in a variety of social movements over the past 150 years. This means that there is a certain amount of preliminary philosophical work concerning the concept itself that must be undertaken before one can ask about its potential use in arguments concerning the provision of health care. In this paper, I begin with this work through a survey of some of the most prominent bioethical, political philosophical and intellectual historical literature concerned with the project of determining a philosophically specific and historically perspicacious meaning of the term 'solidarity'. This provides a conceptual foundation for a sketch of a four-tiered picture of social competition and cooperation within the nation-state. Corresponding to this picture is a four-tiered account of health care provision. These two models, taken together, provide a framework for articulating the conclusion that, while there are myriad examples of solidarity in claiming health care for some, or even many, the concept does not provide a basis for claiming health care for all.

Global solidarity, migration and global health inequity

The grounds for global solidarity have been theorized and conceptualized in recent years, and many have argued that we need a global concept of solidarity. But the question remains: what can motivate efforts of the international community and nation-states? Our focus is the grounding of solidarity with respect to global inequities in health. We explore what considerations could motivate acts of global solidarity in the specific context of health migration, and sketch briefly what form this kind of solidarity could take. First, we argue that the only plausible conceptualization of persons highlights their interdependence. We draw upon a conception of persons as 'ecological subjects' and from there illustrate what such a conception implies with the example of nurses migrating from low and middle-income countries to more affluent ones. Next, we address potential critics who might counter any such understanding of current international politics with a reference to real-politik and the insights of realist international political theory. We argue that national governments--while not always or even often motivated by moral reasons alone--may nevertheless be motivated to acts of global solidarity by prudential arguments. Solidarity then need not be, as many argue, a function of charitable inclination, or emergent from an acknowledgment of injustice suffered, but may in fact serve national and transnational interests. We conclude on a positive note: global solidarity may be conceptualized to helpfully address global health inequity, to the extent that personal and transnational interdependence are enough to motivate national governments into action.

Family solidarity and informal care: the case of care for people with dementia

According to Bayertz the core meaning of solidarity is the perception of mutual obligations between the members of a community. This definition leaves open the various ways solidarity is perceived by individuals in different communities and how it manifests itself in a particular community. This paper explores solidarity as manifested in the context of families in respect of caregiving for a family member who has become dependent because of disease or illness. Though family caregiving is based on the same perception of mutual obligation as the solidarity that supports welfare arrangements in society, the manifestation of solidarity in families is different. Solidarity that underpins welfare arrangements is based on a perception of mutual obligation towards an anonymous dependent other and is enforced by the government. Solidarity in families is directed towards a concrete other and is based on free choice, albeit often accompanied by a strong sense of personal duty. In this paper we try to distinguish between solidarity as a sociological concept and as a moral concept. An important moral element of solidarity, as expressed in families, is the need for recognition of family caregivers, not only of their concrete practical efforts, but also of their own identity as caregivers and as individuals. We illustrate this argument by referring to examples in the Nuffield Council on Bioethics report Dementia: ethical issues, about the experiences of family caregivers in dementia care and the importance for them of recognition of their role.

Ethics education in undergraduate pre-health programs. The contribution of undergraduate colleges and universities to the ethical and moral development of future doctors in the medical and dental professions

There are many barriers to ethics education of students attending medical and dental schools. The question is asked, "Should more attention be given to addressing students' ethics education during their undergraduate years of preparation for professional healthcare programs?" This qualitative study utilizes digitally recorded personal interviews with two undergraduate pre-healthcare students, one medical student, one recently matriculated dental student, one undergraduate pre-healthcare faculty member, three dental school faculty members, and three medical school faculty members. Interview participants discuss areas of personal knowledge and experience concerning: the admissions process and screening of potential medical/dental students for ethical traits and behaviors, influences on student ethical development, undergraduate pre-healthcare ethics training, and preferred college major for pre-healthcare students. The study concludes that undergraduate pre-healthcare programs should take the initiative to be proactive and deliberate in strengthening the positive influences on students. Strategies include: 1) humanities curricula to broaden perspectives and increase non-prejudice; 2) mentoring and modeling by older students, faculty, and community and professional volunteers; 3) ethical case study discussions in class or extracurricular activities; and 4) volunteer/service learning activities. Additionally, curriculum learning is enhanced by the use of reflection and writing, discussions, and media.

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.