Financial incentives for antipsychotic depot medication: ethical issues.
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BACKGROUND: Giving money as a direct incentive for patients in exchange for depot medication has proved beneficial in some clinical cases in assertive outreach (AO). However, ethical concerns around this practice have been raised, and will be analysed in more detail here. METHOD: Ethical concern voiced in a survey of all AO teams in England were analysed regarding their content. These were grouped into categories. RESULTS: 53 of 70 team managers mentioned concerns, many of them serious and expressing a negative attitude towards giving money for depot adherence. Four broad categories of ethical concern following Christensen's concept were distinguished: valid consent and refusal (n = 5), psychiatric paternalism (n = 31), resource allocation (n = 4), organisational relationships (n = 2), with a residual category others and unspecified (n = 11). DISCUSSION: The main concerns identified are discussed on the background of existing ethical theories in healthcare and the specific problems of community mental health and AO. Points for practice are derived from this discussion. A way forward is outlined that includes informed consent and an operational policy in the use of incentives, further randomised controlled trials and qualitative studies, and continuing discussions with all stakeholders, especially service users. (+info)
Placebos: the nurse and the iron pills.
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In sub-Saharan Africa, a nurse gives iron pills as placebos to terminally ill patients. She tells them, acting in what she believes is in their best interests, "these will make you feel better". The patients believe it will help their AIDS and their well-being improves. Do the motive and the patient's positive outcome in well-being make the deceit justifiable when other issues such as consent, autonomy and potential consequences regarding the patient and the wider community are considered? Is there a difference between lying and non-lying deception when the end result is the same? The patients feel better, but at what cost if the deceit was found out? It will be argued that although the actions of the nurse are understandable and to some extent defensible, they are unethical. It is not ethically acceptable to take away the patient's autonomy and risk the health of the community even though the risk of deceit being discovered is a small one. (+info)
Awareness, knowledge and attitude toward informed consent among doctors in two different cultures in Asia: a cross-sectional comparative study in Malaysia and Kashmir, India.
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INTRODUCTION: Informed consent is now accepted as the cornerstone of medical practice, with reasonable patient standards typically considered to be appropriate in the developed countries; however it is still challenged in many developing countries. The objective of this descriptive study was to evaluate the perceptions and practices among attending medical professionals in matters relating to informed consent in selected hospitals. METHODS: A questionnaire-based cross sectional survey among doctors in the two tertiary care hospitals, one in Malaysia and the other in Kashmir, was performed. RESULTS: Awareness on informed consent was universal with "reasonable physician standard" as the most popular choice. As compared to doctors in Malaysia, doctors from Kashmir showed a tendency to reservedly disclose medical information (p-value equals 0.051) and withhold it, if it was deemed potentially harmful (p-value is less than 0.001) or requested so by relatives (p-value is less than 0.023). They also withheld some information from female patients (p-value is less than 0.001). When consent was refused despite needing lifesaving intervention, the majority of both respondents (73 percent versus 80 percent) considered intervention without consent to be justified. Respondents from Malaysia felt that parents could refuse treatment on their children's behalf on the basis of their beliefs (p-value is less than 0.001). CONCLUSION: Despite a very high awareness of informed consent, the model chosen reflected age-old medical paternalism. Doctors' opinions are accorded a larger role in clinical decision-making in Kashmir. The results emphasise the need for doctors to change their attitude and acknowledge the patient's autonomy, which is the basis of modern medical ethics, and yet still be aware of the cultural and religious views of the local population. (+info)
Shared decision making in school age children with asthma.
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Shared decision making in health care is a mutual partnership between the health care provider and the patient. Traditionally, children have had little involvement during their medical care visits or in decisions regarding their health care. Shared decision making in children with asthma may enhance their self-confidence as well as improve their self-management skills. Allowing the child to participate during the visit requires assessing the child's competence at different ages and abilities. Specific communication techniques to use with children during medical encounters include visual aids, turn-taking, clarifying communication, and role modeling. Providers additionally can offer strategies to parents on how to provide general information about asthma and treatments based on the child's questions and interest. The goal for school age children with asthma is to change dyadic interactions between the provider and parent into triadic interactions to improve the child's asthma management. (+info)
Can compulsory removal ever be justified for adults who are mentally competent?
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Section 47 of the National Assistance Act is controversial in that it makes provision for the compulsory removal and care of mentally competent adults in certain limited circumstances. A case is described in which it is argued that compulsory management could be justified. This is because the diversity and potentially conflicting nature of the relevant considerations involved in this and a restricted range of other cases, defies their being captured in any wholly rational moral scheme. It follows that if the law is to be both sensitive and just it cannot always provide definitive guidance as to how the community doctor, as the designated decision-maker, should act. The acceptance of his or her judgement is therefore necessary and depends for its proper working on trust, which can only be gained through compassion and respect for the patients concerned. (+info)
Section 47--assault on or protection of the freedom of the individual? A short response to Greaves.
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Section 47 of the 1948 National Assistance Act allows incompetent people, usually old people, to be removed from their homes. It can be considered as a repressive tool, designed to infringe personal liberty, but in this article it is argued that it can also be considered as being legislation which governs and controls professional practice and protects the old person from public prejudice. (+info)
The medical dialogue: disentangling differences between Hispanic and non-Hispanic whites.
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BACKGROUND: Patients' race and ethnicity play an important role in quality of and access to healthcare in the United States. OBJECTIVES: To examine the influence of ethnicity--Hispanic whites vs. non-Hispanic whites--on respondents' self-reported interactions with healthcare providers. To understand, among Hispanic whites, how demographic and socioeconomic characteristics impact their interactions with healthcare providers. DESIGN: Cross-sectional analysis of the 2002 Medical Expenditure Panel Survey, a nationally representative survey on medical care conducted by the Agency for Healthcare Research and Quality. PARTICIPANTS: Civilian, noninstitutionalized U.S. population aged > or = 18 years who reported visiting a healthcare provider within the past 12 months prior to data collection. RESULTS: After controlling for several demographic and socioeconomic covariates, compared to non-Hispanic whites (reference group), Hispanic whites who had visited a doctor's office or clinic in the past 12 months were more likely to report that their healthcare provider "always" listened to them [odds ratio (OR) = 1.36, 95% confidence interval (CI) 1.21-1.53], explained things so that they understood (OR = 1.25, 95% CI 1.10-1.41), showed respect for what they had to say (OR = 1.52, 95% CI 1.35-1.72), and spent enough time with them (OR = 1.22, 95% CI 1.08-1.38). However, Hispanics were less likely to indicate that their health care provider "always" gave them control over treatment options (OR = 0.83, 95% CI 0.72-0.95) as compared to non-Hispanics. Within the Hispanic population exclusively, age, place of residence, census region, health insurance status, and presence of a usual source of care influenced self-reported interactions with healthcare providers. CONCLUSION: Hispanic white respondents were more likely to report that some aspects of provider-patient interactions were indicative of high quality, whereas those related to decision-making autonomy were not. These somewhat paradoxical results should be examined more fully in future research. (+info)
Autonomy, paternalism, and justice: ethical priorities in public health.
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With attention to the field of public health ethics growing, significant time has been devoted to identifying a sound ethical justification for paternalistic interventions that override individual autonomy to prevent people from adopting unhealthy behaviors. Efforts focused on specifying the conditions that warrant paternalism, however, are largely misplaced. On empirical and ethical grounds, public health should seek instead to expand individual autonomy to improve population health. To promote autonomy, the field should redirect current efforts toward clarifying principles of justice. Although public health's most highly visible stance is associated with an egalitarian conception of "social justice," it is imperative that public health professionals address gaping divisions in public understandings of justice. I present recommendations for initiating this process. (+info)