A growing body of research emphasises the role of ‘social determinants of health’ in generating inequalities in health outcomes. How, if at all, should primary care providers respond? In this paper, I want to shed light on this issue by focusing on the role that ‘big data’ might play in allowing primary care providers to respond to the social determinants that affect individual patients’ health. The general idea has been proposed and endorsed by the Institute of Medicine, and the idea (...) has been developed in more detail by Bazemore et al.. In Bazemore et al.’s proposal, patients’ addresses are used to generate information about the patients’ neighbourhood; this information is then included in patients’ health care records and made available to providers. This allows primary care providers to take this information into account when interacting with, and providing care to, patients. I explore three issues arising from this proposal. First, while questions of privacy have been central to discussions about big data, Bazemore et al.’s proposal also allows us to see that there might be costs to not making certain information available. Second, I consider some of the questions arising for primary care from the influence of social factors on health outcomes: given that we know these factors to be significant contributors to social inequalities in health, what precisely should be done about this in the primary care context? Finally, I address problems arising from the use of population level data when dealing with individuals. (shrink)

It is widely believed that implicit bias is common and that it contributes, in part, to the perpetuation of systemic injustice. Hence, the existence of implicit bias raises the question: can individuals be blameworthy for their implicit bias? Here, I consider what it is about implicit bias that renders agents blameworthy. I defend the claim that, when individuals omit to engage in activities that could prevent the influence of implicit bias on their behavior, they may be blamed for their implicit (...) bias. The plausibility of my proposal depends on whether individuals are able to engage freely in such activities and on whether there exists an obligation not to be biased (broadly put). I will answer positively to the former question and open the way for an answer to the latter, and tougher, question. (shrink)

Throughout the years, care ethicists have raised concerns that prevalent definitions of empathy fail to adequately address the problem of otherness. They have proposed alternative conceptualizations of empathy that aim to acknowledge individual differences, help to extend care beyond one’s inner circle, and develop a critical awareness of biases and prejudices. We explore three such alternatives: Noddings’ concept of engrossment, Meyers’ account of broad empathy, and Baart’s concept of perspective-shifting. Based on these accounts, we explain that care ethics promotes a (...) conceptualization of empathy that is radical in its commitment to engage otherness and that is characterized by being: (1) receptive and open, (2) broad and deep in scope, (3) relational and interactive, (4) mature and multifaceted, (5) critical and reflective, (6) disruptive and transformative. This type of empathy is both demanding and rewarding, as it may inspire health professionals to rethink empathy, its challenges, and its contribution to good care and as it may enrich empathy education and professional empathy practices in health care. (shrink)

The aim of this paper was to explore the experiences of perceived prejudices faced in England by Black African mental health nurses. Purposive sampling was used to identify five nurses from sub‐Saharan Africa. They were interviewed using face‐to‐face semi‐structured interviews. Data were analysed using interpretative phenomenological analysis (IPA). The findings were reported under two superordinate themes: Judging a book by its cover and opportunities. The findings showed that Black African nurses experience deep‐rooted discrimination and marginalisation. Aside from that, because of (...) their ethnicity and the fact that they speak English as a second language, they face discrimination and have difficulty achieving leadership roles. These findings provide key stakeholders, such as nursing trade unions and professional associations, as well as NHS employers, with the opportunity to act to counter hegemony in the NHS and recognise that discriminatory and racially related barriers hinder Black African nurses from reaching their full professional potential. (shrink)

It is commonly accepted that clinicians are ethically obligated to disclose their use of medical machine learning systems to patients, and that failure to do so would amount to a moral fault for which clinicians ought to be held accountable. Call this ‘the disclosure thesis.’ Four main arguments have been, or could be, given to support the disclosure thesis in the ethics literature: the risk-based argument, the rights-based argument, the materiality argument and the autonomy argument. In this article, I argue (...) that each of these four arguments are unconvincing, and therefore, that the disclosure thesis ought to be rejected. I suggest that mandating disclosure may also even risk harming patients by providing stakeholders with a way to avoid accountability for harm that results from improper applications or uses of these systems. (shrink)

Physicians anecdotally report inquiring about incarcerated patients’ crimes and their length of sentence, which has potential implications for the quality of care these patients receive. However, there is minimal research on how a physician’s awareness of their patient’s crimes/length of sentence impacts physician behaviours and attitudes. We performed regression modelling on a 27-question survey to analyse physician attitudes and behaviours towards incarcerated patients. We found that, although most physicians did not usually try to learn of their patients’ crimes, they often (...) became aware of them. We observed associations between awareness of a patient’s crime and poor physician disposition towards their patients and between physicians’ poor dispositions and lower reported quality of care. These associations suggest that awareness of a patient’s crime may reduce quality of care by negatively impacting physicians’ dispositions towards their patients. Future quantitative and qualitative studies, for example, involving physician interviews and direct patient outcome assessments, are needed to confirm these findings and further uncover and address hurdles incarcerated patients face in seeking medical care. (shrink)

Background Though artificial intelligence holds great value for healthcare, it may also amplify health inequalities through risks of bias. In this paper, we explore bias risks in targeted medicines manufacturing. Targeted medicines manufacturing refers to the act of making medicines targeted to individual patients or to subpopulations of patients within a general group, which can be achieved, for example, by means of cell and gene therapies. These manufacturing processes are increasingly reliant on digitalised systems which can be controlled by artificial (...) intelligence algorithms. Whether and how bias might turn up in the process, however, is uncertain due to the novelty of the development. Methods Examining stakeholder views across bioethics, precision medicine, and artificial intelligence, we document a range of opinions from eleven semi-structured interviews about the possibility of bias in AI-driven targeted therapies manufacturing. Result Findings show that bias can emerge in upstream (research and development) and downstream (medicine production) processes when manufacturing targeted medicines. However, interviewees emphasized that downstream processes, particularly those not relying on patient or population data, may have lower bias risks. The study also identified a spectrum of bias meanings ranging from negative and ambivalent to positive and productive. Notably, some participants highlighted the potential for certain biases to have productive moral value in correcting health inequalities. This idea of “corrective bias” problematizes the conventional understanding of bias as primarily a negative concept defined by systematic error or unfair outcomes and suggests potential value in capitalizing on biases to help address health inequalities. Our analysis also indicates, however, that the concept of “corrective bias” requires further critical reflection before they can be used to this end. (shrink)

Bioethics has dedicated itself to exploring and defending both reasons for and against certain aspects of clinical care, biomedical research and health policy, including what decisions must be made, who should make them, and how they should be made. In pediatrics, it’s widely acknowledged that parents’ reasons may matter pragmatically; attending to parents’ reasons is important if we want to work with families. Yet the conventional view in pediatric ethics is that parents’ reasons are irrelevant to whether a decision is (...) permissible or impermissible according to accepted ethical standards. In this paper, we explore whether parents’ reasons matter ethically and, if so, in what way and for whom. First, we clarify what we mean by ‘reasons.’ Second, we provide an overview of how reasons are typically treated in medical decision-making and pediatric ethics. Third, we analyze a hypothetical pediatric case to illustrate how changing reasons can transform ethical analyses, including by contributing to where and how clinicians and ethicists draw the boundaries intrinsic to common pediatric ethical frameworks. We push back against the conventional view and argue that parents’ reasons matter ethically in several ways. We call for further research on the role of parents’ reasons in clinical ethics deliberation. (shrink)

Although clinical ethics scholarship and practice has largely avoided assuming an activist stance, the many health care crises of the last eighteen months motivated a distinct change: On listserves, in blog postings, and in published essays, activist language has permeated conversations over such issues as the impact of triage policies on persons with disabilities and of color, and how the health care system has historically failed African Americans. In this paper, I defend this turn, arguing that clinical ethicists should embrace (...) activism—generally, and with particular emphasis on institutional, mesolevel concerns. Ethicists are often uniquely situated to understand the structural factors that regularly motivate clinical ethics cases, and they are often in a privileged position to be effective change agents. In making this case, I also stress the need not to overstep one's skills and to be acutely cognizant of the political risks associated with such work. (shrink)

Physician empathy is considered essential for good clinical care. Empirical evidence shows that it correlates with better patient satisfaction, compliance, and clinical outcomes. These data have nevertheless been criticized because of a lack of consistency and reliability. In this paper, we claim that these issues partly stem from the widespread idealization of empathy: we mistakenly assume that physician empathy always contributes to good care. This has prevented us from agreeing on a definition of empathy, from understanding the effects of its (...) different components and from exploring its limits. This is problematic because physicians’ ignorance of the risks of empathy and of strategies to manage them can impact their work and wellbeing negatively. To address this problem, we explore the effects of the potential components of empathy and argue that it should be conceived as a purely descriptive and wide term. We end by discussing implications for medical education. (shrink)

Happiness is an increasingly prominent topic of interest across academia. However, relatively little attention has been paid to how it is created, especially not in a multidimensional sense. By ‘created’ we do not mean its influencing factors, for which there is extensive research, but how it actually forms in the person. The work that has been done in this arena tends to focus on physiological dynamics, which are certainly part of the puzzle. But they are not the whole picture, with (...) psychological, phenomenological, and socio cultural processes also playing their part. As a result, this paper offers a multidimensional overview of scholarship on the ‘architecture’ of happiness, providing a stimulus for further work into this important topic. (shrink)

Bioethics has increasingly become a standard part of medical school education and the training of healthcare professionals more generally. This is a promising development, as it has the potential to help future practitioners become more attentive to moral concerns and, perhaps, better moral reasoners. At the same time, there is growing recognition within bioethics that nonideal theory can play an important role in formulating normative recommendations. In this chapter we discuss what this shift toward nonideal theory means for ethical curricula (...) within healthcare education. In particular, we contend that more attention to the particularities of historical and social context needs to be incorporated into bioethics training. To make this argument, we focus on two examples: teaching units on race and medicine and those that focus on stigma and coercion in mental health. For both, we show how a pedagogical approach in which educators focus on social injustice could influence how practitioners engage in ethics in the clinic. This chapter, then, demonstrates what a commitment to nonideal theory can mean practically when it comes to bioethics education. (shrink)

The purpose of this study was to examine the perceptions of Black African‐born nurses (BABN) with non‐native accents regarding their nursing career advancement in the United States. Data were collected using individual interviews. Fifteen nurses originally from three sub‐Saharan African countries were included in the study. The findings were reported under six themes: perceived low level of intelligence, not suitable to lead, making fun of/belittling, prejudging without evidence, downgrading, and accent modification. The finding indicated that participants believed that their race (...) and accent influenced their professional nursing opportunities. These results are relevant to BABNs, nurse educators, and healthcare organization leaders. BABNs are capable of participating in nursing leadership and education despite their non‐native accent. (shrink)

BackgroundImplicit prejudice can lead to disparities in treatment. The effects of specialty and experience on implicit obesity and mental illness prejudice had not been explored. The main objective was to examine how specializing in psychiatry/general medicine and years of experience moderated implicit obesity and mental illness prejudice among Swiss physicians. Secondary outcomes included examining the malleability of implicit bias via two video interventions and a condition of cognitive load, correlations of implicit bias with responses to a clinical vignette, and correlations (...) with explicit prejudice. MethodsIn stage 1, participants completed an online questionnaire including a clinical vignette. In stage 2, implicit prejudice pre- and post- intervention was tested using a 4 × 4 between-subject design including a control group. In stage 3, explicit prejudice was tested with feeling thermometers and participants were debriefed. Participants were 133 psychiatrists and internists working in Geneva, hospital-based and private practice. Implicit prejudice was assessed using a Weight IAT and a Mental Illness IAT. Explicit feelings towards the obese and the mentally ill were measured using Feeling Thermometers. A clinical vignette assessed the level of concern felt for a fictional patient under four conditions: control, obese, depression, obese and depression. Linear regression was conducted to test for association of gender, experience, and specialty with responses to vignettes, pre-intervention IATs and explicit attitudes, and to test for association of interventions with post-intervention IATs and explicit attitudes. Reported effect sizes were computed using Cohen’s d. Two-tailed p < 0.05 was selected as the significance threshold. ResultsCompared to internists, psychiatrists showed significantly less implicit bias against mentally vs. physically ill people than internists and warmer explicit feelings towards the mentally ill. More experienced physicians displayed warmer explicit feelings towards the mentally ill and a greater level of concern for the fictional patients in the vignette than the less experienced, except when the patient was described as obese. ConclusionsSpecialty moderates both implicit and explicit mental illness prejudice. Experience moderates explicit mental illness bias and concern for patients. The effect of specialty on implicit prejudice seems to be based principally on self-selection. (shrink)

Given that biases can distort bioethics work, it has received surprisingly little and fragmented attention compared to in other fields of research. This article provides an overview of potentially relevant biases in bioethics, such as cognitive biases, affective biases, imperatives, and moral biases. Special attention is given to moral biases, which are discussed in terms of (1) Framings, (2) Moral theory bias, (3) Analysis bias, (4) Argumentation bias, and (5) Decision bias. While the overview is not exhaustive and the taxonomy (...) by no means is absolute, it provides initial guidance with respect to assessing the relevance of various biases for specific kinds of bioethics work. One reason why we should identify and address biases in bioethics is that it can help us assess and improve the quality of bioethics work. (shrink)

Definition of the problem Few concepts in recent ethical debates have enjoyed as much popularity as the concept of discrimination. However, a comparative discussion of the concept, including its conceptual nuances and its ethical significance for health care, has so far been lacking. The aim of this paper is to develop a nuanced understanding of discrimination based on the philosophical and sociological literature against the background of ethically relevant medical and nursing scenarios. Methods Using practical examples from health care, we (...) discuss direct, indirect, and statistical discrimination; we examine the importance of intentions and the role of collective actors. In addition, we analyze which social groups may experience discrimination and the respective importance of forms of epistemic injustice. Conclusions We argue that despite its complexity, the concept offers significant added value because it allows us to highlight forms of disadvantage that go beyond the violation of individual specific rights or interests. As a knowledge-based system of great societal influence, health care exhibits some characteristics that can foster discrimination. Acknowledging this fact is essential in order to effectively address discrimination. (shrink)

Kaum ein Begriff der ethischen Debatten der letzten Jahre hat eine solche Konjunktur erlebt wie der Begriff der Diskriminierung. Eine vergleichende Erörterung des Konzepts einschließlich seiner begrifflichen Nuancen und seiner ethischen Bedeutung für das Gesundheitswesen fehlte jedoch bislang. Ziel dieses Beitrags ist die Entwicklung eines differenzierten Verständnisses von Diskriminierung auf der Basis der philosophischen und soziologischen Literatur vor dem Hintergrund ethisch relevanter medizinischer und pflegerischer Szenarios. Anhand von praktischen Beispielen aus dem Gesundheitswesen erörtern wir die Besonderheiten direkter, indirekter und statistischer (...) Diskriminierung, wir untersuchen die Bedeutung von Absichten und die Rolle von kollektiven Akteuren. Zudem diskutieren wir, welche sozialen Gruppen diskriminiert werden können und welche Rolle Formen epistemischer Ungerechtigkeit dabei spielen. Argumentiert wird, dass das Konzept trotz seiner Komplexität einen signifikanten Mehrwert bietet, weil es erlaubt, Formen der Benachteiligung aufzuzeigen, die über die Verletzung einzelner spezifischer Rechte oder Interessen hinausgehen. Als wissensbasiertes System von großem gesellschaftlichen Einfluss weist das Gesundheitswesen einige Eigenschaften auf, die Diskriminierung begünstigen können. Dies zu erkennen ist unerlässlich, um Diskriminierung wirksam entgegentreten zu können. (shrink)

ObjectivesTo examine implicit and explicit attitudes toward gay men and lesbian women among heterosexual undergraduate and graduate psychology and nursing students.MethodsImplicit attitudes were measured via the Implicit Association Test and explicit attitudes via the Attitudes Toward Lesbian Women and Gay questionnaire.Main resultsAll groups held negative implicit attitudes toward gay men and lesbian women. Among undergraduates, nursing students reported holding more negative explicit attitudes toward gay men and lesbian women than psychology students.ConclusionThe curricula in both nursing and psychology studies need to (...) address the medical and paramedical needs and issues of sexual minorities. (shrink)

Since the 19th century, innocence has been a hallmark of childhood. The innocence of children is seen as both a sanctity worth defending and a feature that excuses the unavoidable mistakes of adolescence. While beneficial in many settings, notions of childhood innocence are often entangled with values judgements. Inherent in innocence is the notion that that which we are innocent of is undesirable. Further, attributing innocence to some implies the tolerability of blame for others. This has unique implications in a (...) medical setting. This essay explores the implications of espousing the innocence of paediatric patients. Ultimately, because attribution of innocence is both prone to bias and rooted in the same framework as blame, it degrades patient-centred care and compromises the patient–provider relationship. I argue that avoiding such characterisations may allow providers to more effectively promote paediatric health. (shrink)

While a significant body of bioethical literature considers how the placebo effect might introduce a conflict between autonomy and beneficence, the link between justice and the placebo effect has been neglected. Here, we bring together disparate evidence from the field of placebo studies and research on health inequalities related to race and ethnicity, and argue that, collectively, this evidence may provide the basis for an unacknowledged route by which health disparities are exacerbated. This route is constituted by an uneven distribution (...) of placebo effects, resulting from differences in expressions of physician warmth and empathy, as well as support and patient engagement, across racial and ethnic lines. In a discussion of the ethical implications of this connection, we argue that this contribution to health disparities is a source of injustice, consider ways in which these disparities might be ameliorated and suggest that this conclusion is likely to extend to other realms of inequality as well. (shrink)

Respect for patient autonomy is paramount in resolving ethical tensions in end-of-life care. The concept of relational autonomy has contributed to this debate; however, scholars often use this concept in a fragmented manner. This leads to partial answers on ascertaining patients’ true wishes, meaningfully engaging patients’ significant others, balancing interests among patients and significant others, and determining clinicians’ obligations to change patients’ unconventional convictions to enhance patient autonomy. A satisfactory solution based on relational autonomy must incorporate patients’ competence (apart from (...) decisional capacity), authenticity (their true desires or beliefs) and the involvement level of their significant others. To that end, we argue that John Christman’s procedural approach to relational autonomy provides critical insights, such as the diachronic or socio-historical personhood, sustained critical reflection and his recent explication of the nature of asymmetrical relationships and helpful interlocutors. This study reviews Christman’s account, proposes minor modifications and advocates for an integrated three-dimensional model for medical decision-making. Clarifying the relationship among the three elements promotes an ethical framework with a coherent understanding of relational autonomy. This model not only provides a descriptive and normative framework for end-of-life care practice but also reconsiders the nature of the clinician–patient relationship and its normative implications. We further present a case study to illustrate the merits of our proposed model. Altogether, our proposal will help navigate complex medical decision-making, foster trust and negotiate shared values between patients and their significant others, particularly in end-of-life care. (shrink)

Menschen mit psychischer Erkrankung sterben statistisch gesehen früher als die Allgemeinbevölkerung. Ein Grund hierfür ist, dass sie eine schlechtere somatische Gesundheitsversorgung erhalten. Wir argumentieren, dass ableistische Netzwerke sozialer Bedeutung zu einer Abwertung der epistemischen Kompetenz von Menschen mit psychischer Erkrankung führen. Diese Abwertung kann mit dem Konzept der testimonialen Ungerechtigkeit erfasst werden. Testimoniale Ungerechtigkeit bezeichnet das ungerechtfertigte Herabstufen der Glaubwürdigkeit einer*s Sprecher*in aufgrund eines Vorurteils gegen ihre*seine soziale Identität. Wir analysieren ethische und epistemische Folgen testimonialer Ungerechtigkeit als wichtige Ursachen der (...) schlechteren Gesundheitsversorgung von Menschen mit psychischer Erkrankung. Testimoniale Ungerechtigkeit kann zu medizinischen Behandlungsfehlern führen und für Betroffene schwerwiegende gesundheitliche Folgen nach sich ziehen. Zudem kann sie zu einem Vertrauensverlust von Menschen mit psychischer Erkrankung in das Gesundheitssystem führen. Daher trägt testimoniale Ungerechtigkeit zur strukturellen Diskriminierung von Menschen mit psychischer Erkrankung bei. Vor diesem Hintergrund diskutieren wir, wie die somatische Gesundheitsversorgung unter ethischen Gesichtspunkten verbessert werden kann. (shrink)

In mental health ethics, it is generally assumed that coercive measures are sometimes justified when persons with mental illness endanger themselves or others. Coercive measures are regarded as ethically justified only when certain criteria are fulfilled: for example, the intervention must be proportional in relation to the potential harm. In this paper, we demonstrate shortcomings of this established ethical framework in cases where people with mental illness experience structural racism. By drawing on a case example from mental healthcare, we first (...) demonstrate that biases in assessing whether the coercive intervention is proportional are likely, for example, due to an overestimation of dangerousness. We then show that even if proportionality is assessed correctly, and the specific coercive intervention would thus be regarded as ethically justified according to the standard framework, coercion may still be ethically problematic. This is because the standard framework does not consider how situations in which coercive measures are applied arise. If structural racism causally contributes to such situations, the use of coercion can compound the prior injustice of racist discrimination. We conclude that the ethical analysis of coercion in mental healthcare should consider the possibility of discriminatory biases and practices and systematically take the influence of structural discrimination into account. (shrink)

In pediatric emergency rooms (ERs), social workers must navigate diverse responsibilities including acting as advocates and liaisons between families and multidisciplinary treatment teams, providing compassionate support to families in crisis, and assessing for and reporting any suspicions of child abuse or neglect. These potentially contrasting roles can place social workers at the center of dealing with ethical dilemmas and advocating against ethical violations, such as bias and discrimination toward families. This qualitative study seeks to gain insight into ethical issues commonly (...) encountered in pediatric ERs by exploring the perspectives of 23 social workers at Level 1 trauma centers in the United States. Thematic analysis was used to develop major themes and subthemes related to ethical violations, dilemmas, and best practices in pediatric ERs. Major themes emerged related to unfair treatment of families (with subthemes of bias, discrimination, and compassion fatigue), ethical dilemmas (with subthemes of cultural issues, safety and system issues), and promoting ethical practices (with subthemes of self-awareness, advocacy, and efforts to change the system). This study provides important insights into ethical issues in pediatric ERs as experienced by social workers and can inform efforts to improve the quality and equity of care for all families in pediatric ERs. (shrink)

This paper reconsiders Tommie Shelby's (2016) analysis of procreation in poor black communities. I identify three conceptual frames within which Shelby situates his analysis—feminization, choice-as-control, and moralization. I argue that these frames should be rejected on conceptual, empirical, and moral grounds. As I show, this framing engenders a flawed understanding of poor black women's procreative lives. I propose an alternative framework for reconceiving the relationship between poverty and procreative justice, one oriented around reproductive flourishing instead of reproductive responsibility. More generally, (...) the paper develops a methodological challenge for nonideal moral and political philosophy, especially concerning the obligations of the oppressed. Specifically, I argue that in the absence of descriptive and conceptual accountability, the moral gaze of the philosopher risks preserving, rather than destabilizing, oppressive ideologies. (shrink)

How should we respond to patients who do not wish to take on the responsibility and burdens of making decisions about their own care? In this paper, we argue that existing models of decision-making in modern healthcare are ill-equipped to cope with such patients and should be supplemented by an “appointed fiduciary” model where decision-making authority is formally transferred to a medical professional. Healthcare decisions are often complex and for patients can come at time of vulnerability. While this does not (...) undermine their capacity, it can be excessively burdensome. Most existing models of decision-making mandate that patients with capacity must retain ultimate responsibility for decisions. An appointed fiduciary model provides a formalized mechanism through which those few patients who wish to defer responsibility can hand over decision-making authority. By providing a formal structure for deferring to an appointed fiduciary, the confusions and risks of the informal transfers that can occur in practice are avoided. Finally, we note how appropriate governance and law can provide safeguards against risks to the welfare of patients and medical professionals. -/- . (shrink)

Sharply in focus in the United States right now is the disproportionate COVID‐19 infection, hospitalization, and mortality rates of Black, Indigenous, Hispanic, and Pacific Islanders living in the United States in contrast to White people. These COVID‐19 disparities are but one example of how systemic racism filters into health outcomes for many Black, Indigenous, and other People of Color (BIPOC). With these issues front and center, more attention is being given to the ways that White medical professionals contribute to these (...) disparities, including their socialization to ignore or deny inequities. As such, the present study sought to understand how educating White health‐care pre‐professionals about systemic racism might influence their understanding of and responsibility for disrupting White supremacy. Data were drawn from 49 White‐identified nursing students who participated in a mapping project that uncovered instantiations of systemic racism in the United States. Participant written reflections were analyzed using thematic analysis. Findings revealed that mapping projects can develop White people's knowledge and understanding of systemic racism. We introduce the construct, transformative dissonant encounters, to describe how this project precipitated shifts in world view necessary for White people to confront systemic racism. Implications for nursing educators, psychological researchers, and antiracist activists are discussed. (shrink)

Background Paramedicine is a newly regulated profession in Australia and with the introduction of regulation in 2018 for this profession came increased responsibilities – including the introduction of a professional code of conduct. Several countries now have regulation of paramedicine and associated professional codes to guide ethical and professional behaviour. Despite this, there has been no published research into paramedic understanding and use of their professional codes. Objectives To explore Australian paramedics’ use and understanding of their professional code of conduct. (...) Research design: This study used a qualitative descriptive design, underpinned by hermeneutic theory. Reflexive thematic analysis was used to analyse the interview data and identify Australian paramedic perceptions surrounding the use of their code of conduct. Results 11 Registered Paramedics from several states and territories were interviewed. Participants were invited to interview by advertisement on social media and the Australasian College of Paramedicine Web site. Participants had varied professional backgrounds including clinical work, education providers and policymakers/managers. Four themes were identified as follows: Theme 1 – ‘You don’t know, what you can’t know’; Theme 2 – ‘I don’t need the code – the code is for others’; Theme 3 – ‘It’s about time’; Theme 4 – ‘Navigating the new profession’. Ethical considerations: Ethics approval was granted by the Monash University Human Research Ethics Committee (MUHREC) Project ID: 28921. All participants provided informed consent. Conclusions The results of this study suggest that paramedics’ knowledge and use of their code is limited, and participants appeared to mostly rely instead on ‘common sense’ morals. Participants did appear to want to understand the broad concepts of the code more and have this better integrated into the profession. The code was also interpreted as important to the paramedic profession and its new professional status, helping to legitimise it as a health profession in Australia. (shrink)

In this paper we propose that our understanding of pathocentric epistemic injustices can be enriched if they are theorised in terms of predicaments. These are the wider socially scaffolded structures of epistemic challenges, dangers, needs, and threats experienced by ill persons due to their particular emplacement within material, social, and epistemic structures. In previous work we have described certain aspects of these predicaments - pathocentric epistemic injustices, pathophobia, and so on. We argue that thinking predicamentally helps us integrate the various (...) social, epistemic, and practical obstacles experienced by ill persons and also unify the many concepts available for theorising them (microaggessions, epistemic injustices, and so on). (shrink)

Patients in around 20 countries worldwide are now offered online access to at least some of their medical records. Access includes test results, medication lists, referral information, and/or the very words written by clinicians (so-called ‘open notes’). In this paper, I discuss the possibility of one unintended negative consequence of patient access to their clinical notes—the potential to increase ‘nocebo effects’. A growing body of research shows that nocebo effects arise by engaging perceptual and cognitive processes that influence negative expectancies, (...) and as a consequence, adverse health effects. Studies show that increased awareness about the side effects of medications, the framing of information and the socioemotional context of care can increase the risk of nocebo effects. Connecting research into the nocebo effect with open notes provides preliminary support for the hypothesis that patient access to clinical notes might be a forum for facilitating unwanted nocebo effects. Furthermore, current findings indicate that we might expect to see systematic differences in how nocebo effects are experienced among different patient populations. The ethical implications of the tension between transparency and the potential for harm are discussed, with an emphasis on what open notes might mean for justice and equity in clinical care for a range of already marginalised patient populations. I argue that to resolve these challenges does not thereby justify ‘closed notes’, and conclude with suggestions for how health systems and clinicians might adapt to this innovation to reduce the risk of potential nocebo effects arising via this novel route. (shrink)

In many countries, including patients are legally entitled to request copies of their clinical notes. However, this process remains time-consuming and burdensome, and it remains unclear how much of the medical record must be made available. Online access to notes offers a way to overcome these challenges and in around 10 countries worldwide, via secure web-based portals, many patients are now able to read at least some of the narrative reports written by clinicians (‘open notes’). However, even in countries that (...) have implemented the practice many clinicians have resisted the idea remaining doubtful of the value of opening notes, and anticipating patients will be confused or anxious by what they read. Against this scepticism, a growing body of qualitative and quantitative research reveals that patients derive multiple benefits from reading their notes. We address the contrasting perceptions of this practice innovation, and claim that the divergent views of patients and clinicians can be explained as a case of epistemic injustice. Using a range of evidence, we argue that patients are vulnerable to (oftentimes, non-intentional) epistemic injustice. Nonetheless, we conclude that the marginalisation of patients’ access to their health information exemplifies a form of epistemic exclusion, one with practical and ethical consequences including for patient safety. (shrink)

The increasing use of opioid treatment agreements has prompted debate within the medical community about ethical challenges with respect to their implementation. The focus of debate is usually on the efficacy of OTAs at reducing opioid misuse, how OTAs may undermine trust between physicians and patients and the potential coercive nature of requiring patients to sign such agreements as a condition for receiving pain care. An important consideration missing from these conversations is the potential for racial bias in the current (...) way that OTAs are incorporated into clinical practice and in the amount of physician discretion that current opioid guidelines support. While the use of OTAs has become mandatory in some states for certain classes of patients, physicians are still afforded great leeway in how these OTAs are implemented in clinical practice and how their terms should be enforced. This paper uses the guidelines provided for OTA implementation by the states of Indiana and Pennsylvania as case studies in order to argue that giving physicians certain kinds of discretion may exacerbate racial health disparities. This problem cannot simply be addressed by minimising physician discretion in general, but rather by providing mechanisms to hold physicians accountable for how they treat patients on long-term opioid therapy to ensure that such treatment is equitable. There are no data in this work. (shrink)

The presence of stigmatizing language in the electronic health record (EHR) has been used to measure implicit biases that underlie health inequities. The purpose of this study was to identify the presence of stigmatizing language in the clinical notes of pregnant people during the birth admission. We conducted a qualitative analysis on N = 1117 birth admission EHR notes from two urban hospitals in 2017. We identified stigmatizing language categories, such as Disapproval (39.3%), Questioning patient credibility (37.7%), Difficult patient (21.3%), (...) Stereotyping (1.6%), and Unilateral decisions (1.6%) in 61 notes (5.4%). We also defined a new stigmatizing language category indicating Power/privilege. This was present in 37 notes (3.3%) and signaled approval of social status, upholding a hierarchy of bias. The stigmatizing language was most frequently identified in birth admission triage notes (16%) and least frequently in social work initial assessments (13.7%). We found that clinicians from various disciplines recorded stigmatizing language in the medical records of birthing people. This language was used to question birthing people's credibility and convey disapproval of decision‐making abilities for themselves or their newborns. We reported a Power/privilege language bias in the inconsistent documentation of traits considered favorable for patient outcomes (e.g., employment status). Future work on stigmatizing language may inform tailored interventions to improve perinatal outcomes for all birthing people and their families. (shrink)

During public health crises including the COVID-19 pandemic, resource scarcity and contagion risks may require health systems to shift—to some degree—from a usual clinical ethic, focused on the well-being of individual patients, to a public health ethic, focused on population health. Many triage policies exist that fall under the legal protections afforded by “crisis standards of care,” but they have key differences. We critically appraise one of the most fundamental differences among policies, namely the use of criteria to categorically exclude (...) certain patients from eligibility for otherwise standard medical services. We examine these categorical exclusion criteria from ethical, legal, disability, and implementation perspectives. Focusing our analysis on the most common type of exclusion criteria, which are disease-specific, we conclude that optimal policies for critical care resource allocation and the use of cardiopulmonary resuscitation (CPR) should not use categorical exclusions. We argue that the avoidance of categorical exclusions is often practically feasible, consistent with public health norms, and mitigates discrimination against persons with disabilities. (shrink)