For a long time discussion about scarce health care resource allocation was limited to allocation of medical resources, with the paradigmatic case being kidney transplants. However, a narrow focus on medical resources prevents us from seeing that there are many cases-- perhaps the majority-- in which less dramatic but equally important issues of rationing occur. The allocation of nurses' time is one such issue.

How can we allocate scarce health care resources justly? In particular, are markets the most efficient way to deliver health services? Much blood, sweat and ink has been shed over this issue, but rarely has either faction challenged the unspoken assumption behind the claim made by advocates of markets: that efficiency advances the interests of both individuals and society. Whether markets actually do increase efficiency is arguably a matter for economists, but the deeper ethical question is (...) whether efficiency is the correct criterion, in terms of social justice and individual needs. (shrink)

Imagine you are the CEO of a hospital [. . .]. Decisions are constantly being made in your organization about how to spend the organization's money. The amount of money available to spend is never adequate to pay for everything you wish you could spend it on, therefore you must set spending priorities. There are two questions you need to be able to answer . . . How should we set priorities in this organization? How do we know when we (...) are doing it well? When people seek to achieve good public policy, the result will tend to be good public policy. In a collective choice process, public‐spirited individual participants produce good public policy by deliberating—talking with each other, listening to each other's arguments, and being willing to learn and change their minds based on such dialogue. –Steven Kelman (1992: 181) Public policy scholars agree that those persons (or agencies) vested with the authority to establish health care priorities should elicit public input before making rationing decisions. The two most common approaches are (i) consultation and (ii) deliberation. Though deliberation has obvious advantages over consultation, it falters in the face of the objection that ordinary citizens lack the cognitive resources for the extended, rigorous inquiry required of them in undertaking the priority‐setting task. To overcome this objection, I propose that deliberative forums for health care rationing should be designed so that they imitate the natural pattern of human experience. The experience of deliberation should encompass both prolonged periods of less‐demanding cognitive activity, in which citizens passively receive information, and briefer periods of more‐demanding cognitive activity, in which they engage in active problem‐solving. In arguing for this thesis, I rely on two theoretical sources and one practical case study, in the following order: (i) John Dewey's metaphysics of experience, (ii) cognitive science research on schemas and frames, and (iii) the Health Care Council in São Paulo, Brazil. (shrink)

One widely used method for allocating health care resources involves the use of cost-effectiveness analysis (CEA) to rank treatments in terms of quality-adjusted life-years (QALYs) gained. CEA has been criticized for discriminating against people with disabilities by valuing their lives less than those of non-disabled people. Avoiding discrimination seems to lead to the ’QALY trap’: we cannot value saving lives equally and still value raising quality of life. This paper reviews existing responses to the QALY trap and (...) argues that all are problematic. Instead, we argue that adopting a moderate form of prioritarianism avoids the QALY trap and disability discrimination. (shrink)

This book provides a survey of the ethical aspects of health care resources distribution. It first distinguishes health from health care in an effort to clear up the ethical landscape. After this, still with the same purpose, it makes a distinction between problems of macro-allocation and micro-allocation. In the rest of the book two questions of macro-allocation are treated in some detail. First, several approaches – in particular: utilitarian, egalitarian, communitarian, and libertarian – to (...) the question whether we have a right to health care are assessed. Second, it is discussed how best, if we have such a right, health care resources are allocated given obvious budget constraints. Here again the major theories discussed are utilitarian, communitarian, and egalitarian. Although it is not the aim of the book to propose a new theory of the ethics of health care resource distribution, the critical approach throughout is broadly egalitarian in spirit. (shrink)

Aims and Objectives. This article uses the concept of embodiment to demonstrate a conceptual approach to applied phenomenology. -/- Background. Traditionally, qualitative researchers and healthcare professionals have been taught phenomenological methods, such as the epoché, reduction, or bracketing. These methods are typically construed as a way of avoiding biases so that one may attend to the phenomena in an open and unprejudiced way. However, it has also been argued that qualitative researchers and healthcare professionals can benefit from phenomenology’s well-articulated theoretical (...) framework, which consists of core concepts, such as selfhood, empathy, temporality, spatiality, affectivity, and embodiment. -/- Design. This is a discursive article that demonstrates a conceptual approach to applied phenomenology. -/- Method. To outline and explain this approach to applied phenomenology, the Discussion section walks the reader through four stages of phenomenology, which progress incrementally from the most theoretical to the most practical. -/- Discussion. Part one introduces the philosophical concept of embodiment, which can be applied broadly to any human subject. Part two shows how philosophically trained phenomenologists use the concept of embodiment to describe general features of illness and disability. Part three illustrates how the phenomenological concept of embodiment can inform empirical qualitative studies and reflects on the challenges of integrating philosophy and qualitative research. Part four turns to phenomenology’s application in clinical practice and outlines a workshop model that guides clinicians through the process of using phenomenological concepts to better understand patient experience. -/- Conclusion and Relevance to Clinical Practice. A conceptual approach to applied phenomenology provides a valuable alternative to traditional methodological approaches. Phenomenological concepts provide a foundation for better understanding patient experience in both qualitative health research and clinical practice, and therefore provide resources for enhancing patient care. (shrink)

In this essay, we suggest practical ways to shift the framing of crisis standards of care toward disability justice. We elaborate on the vision statement provided in the 2010 Institute of Medicine (National Academy of Medicine) “Summary of Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations,” which emphasizes fairness; equitable processes; community and provider engagement, education, and communication; and the rule of law. We argue that interpreting these elements through disability justice entails a commitment (...) to both distributive and recognitive justice. The disability rights movement's demand “Nothing about us, without us” requires substantive inclusion of disabled people in decision‐making related to their interests, including in crisis planning before, during, and after a pandemic like Covid‐19. (shrink)

When allocating scarce healthcare resources, the expected benefits of alternative allocations matter. But, there are different kinds of benefits. Some are direct benefits to the recipient of the resource such as the health improvements of receiving treatment. Others are indirect benefits to third parties such as the economic gains from having a healthier workforce. This article considers whether only the direct benefits of alternative healthcare resource allocations are relevant to allocation decisions, or whether indirect benefits are relevant too. (...) First, we distinguish different conceptions of direct and indirect benefits and argue that only a recipient conception could be morally relevant. We analyze four arguments for thinking that indirect benefits should not count and argue that none is successful in showing that the indirectness of a benefit is a good reason not to count it. We conclude that direct and indirect benefits should be evaluated in the same way. (shrink)

We consider an ethical dilemma in global health: is it ethically acceptable to provide some patients cheaper treatments that are less effective or more toxic than the treatments other patients receive? We argue that it is ethical to consider local resource constraints when deciding what interventions to provide. The provision of cheaper, less effective health care is frequently the most effective way of promoting health and realizing the ethical values of utility, equality, and priority to the (...) worst off. (shrink)

Ontologies are being ever more commonly used in biomedical informatics and we provide a survey of some of these uses, and of the relations between ontologies and other terminology resources. In order for ontologies to become truly useful, two objectives must be met. First, ways must be found for the transparent evaluation of ontologies. Second, existing ontologies need to be harmonised. We argue that one key foundation for both ontology evaluation and harmonisation is the adoption of a realist paradigm (...) in ontology development. For science-based ontologies of the sort which concern us in the eHealth arena, it is reality that provides the common benchmark against which ontologies can be evaluated and aligned within larger frameworks. Given the current multitude of ontologies in the biomedical domain the need for harmonisation is becoming ever more urgent. We describe one example of such harmonisation within the ACGT project, which draws on ontology-based computing as a basis for sharing clinical and laboratory data on cancer research. (shrink)

Concerns of moral distress in health care have never been more relevant. In her book, Health Care Ethics Through the Lens of Moral Distress, Kristen Jones-Bonofiglio provides a comprehensive review of the effects of moral distress on providers and health care delivery, while highlighting the complexities of making ethical decisions in practice. Jones-Bonofiglio’s thoroughness and use of interdisciplinary, historical, and cultural scholarship makes this book an excellent introductory resource on moral distress for health (...) care providers and researchers alike. (shrink)

This thesis under the title “Public Health Policy in Resource Allocation: the Role of Ubuntu Ethics in Redressing Resource Disparity between Public and Private Healthcare in South Africa” explores health care disparities pertaining to resource allocation between public and private sector. It is of relevance and importance in South Africa where 54% of the population live on less than US$3 per day. Although the government has instituted certain changes aimed at transforming the public health care (...) system, the resource allocation gap between the two persists and remains wide. The research gives special attention to the role that Ubuntu ethics can play in redressing the resource allocation disparities between public and private health care sectors in South Africa, pointing out the existing gap in financing, as well as human resource between public and private health care sectors, which leads to poor health outcomes in public sector. Therefore, the problem is the prevalent inequality of resource allocation between private and public health care sectors. The analysis of policy gaps, as well as evaluating the cause of disparities in the health system is the goal of this research. The study endeavours to redress the disparities within the context of Ubuntu ethical principles and proposes a change in public policy so as to enhance healthcare for the benefit of the people. The study is philosophical and ethical, so the methodology used is discursive in nature, majorly focusing on critically reviewing existing literature, that is, the philosophical resources on Ubuntu ethics and justice theories as well as a range of government resources inclusive of public health policy documents. Social determinants of health and their impact in a South African context are discussed with the implication that health is not merely freedom from disease and or incapacity, but rather being well mentally, physically and socially. The attainment of a healthy status goes beyond ability to access healthcare services, and incorporates social determinants including but not limited to conditions in which people have been born into, stay, establish career and grow old in. It also includes the arrangements put in place to deal with illness and determine health. Issues of revenue, literacy, communal safety networks, vocation and conditions under-which vocation is undertaken, lack of work and vocation insecurity, early stages of human development, gender, cultural group, dietary insecurity, housing communal exclusion and disability all come into the picture as factors that determine health. But there is also discussion of the socio-economic status as contributors to health inequity wherein alcohol abuse, sugar intake, and smoking are identified as behavioural factors that complicate public health. One outstanding feature of this research is that it establishes a link between Ubuntu and public health policy. The researcher establishes that Ubuntu ethics is appropriate for not only discussing public morality, but also for formulating public policy that is morally tenable for South Africa, especially for the public health sector. This thesis calls for an application of Ubuntu in a proper context in order to enhance societal well-being for the benefit of many, if not all. The research proposes the fundamental principle of Ubuntu ethics in which the good of the community is as important as the good of every member of the community. Since Ubuntu ethics does not merely seek to fulfil what benefits the majority, as would be the case in a utilitarian society, the researcher advocates for the building of consensus on the common good, which should be understood to imply not just what is good for everyone in the community, but also what is good for the continued well-being of the community as a single unit. In this regard, the research finds it important that deliberate effort be made to integrate Ubuntu ethics into policies, citing the example of the National Health Insurance (NHI). The good health of all the members of a community is an assurance of the well-being and continuity of the whole national community. The research concludes that public health policy should integrate Ubuntu ethical values such as community, sharing, care, solidarity, identity, harmony, respect, and dignity into policy documents and legislation. (shrink)

In this commentary, I suggest expanding the deliberative aspects of critical care policy development in two ways. First, critical-care policy development should expand the scope of deliberation by leaving fewer issues up to expertise or private choice. For instance. it should allow deliberation about the relevance of age, disability, social position, and psychological well-being to allocation decisions. Second, it should broaden both the set of costs considered and the set of stakeholders represented in the deliberative process. In particular, (...) it should consider efforts to reduce the cost of end-of-life care and to redirect resources away from the provision of costly interventions, and should expand the set of individuals included in deliberation to include stakeholders outside the health-care system. (shrink)

Objective: This main aim of the study is to explore COVID-19 pandemic problems from the perspective of public health-clinical care ethics through online mediareports in Turkey. Method: This research was designed as a descriptive and qualitative study that assesses COVID-19 through online media reports on critics between the periods of March 11, 2020 and April 2 2020 as a quantitative as number of reports and qualitative study, across Turkey. Reports were from Turkish Medical Association websites which included newspaper (...) reports. Study data were presented as statistically and qualitative data case and headlines. No ethical or ofTicial permission was sought as the study was conducted through open access internet news sites. Results: This online reports analysis retrieved about 6723 articles about the COVID-19. According to study data, information about COVID-19 were themed as follows: general deTiciencies in taking action and isolation, lack of isolation, passengers and transport vehicles not quarantined ; insufTicient diagnostic tests, decision to test after healthcare professionals become infected, lack of equipment, lack of evaluation outbreak countries [Table 2]. Conclusion and Suggestions: COVID-19 is a pandemic and is a global public health problem that concerns every individual and needs to be handled carefully. This requires a multi-faceted preparation and education. In this context, healthcare professionals should be well trained in this aspect and have all the necessary equipment throughout the process. Additionally, it should work systematically with the cooperation of all health organizations, the Ministry of Health, local governments and of course the media, in order to inform society, fairly distribute the resources and to implement the safety measures effectively. BrieTly, lack of transparency, insufTicient information, limited resources, lack of public health protection measures such as partial quarantine decision, partial implementation of the scientiTic board's re c ommenda ti on s fo r e c on omi c rea s on s, and contradiction of the explanations are revealed as serious ethical problems. (shrink)

Politics, Philosophy & Economics, Volume 21, Issue 2, Page 165-189, May 2022. It is generally acknowledged that a certain amount of state intervention in health and health care is needed to address the significant market failures in these sectors; however, it is also thought that the primary rationale for state involvement in health must lie elsewhere, for example in an egalitarian commitment to equalizing access to health care for all citizens. This paper argues that (...) a complete theory of justice in health can be derived from a commitment to correcting market failure, or in other words promoting Pareto-efficiency, in the domain of health. This approach can address familiar problems around access to care, as well as problems related to resource allocation and rationing, the control of health care costs, and the foundations of public health. Egalitarian theories of justice in health cannot make sense of the depth and pervasiveness of state involvement in health and health care; only a theory rooted in the need to correct market failure can. (shrink)

According to the sufficiency theory of justice in health, justice requires that people have equal access to adequate health. In this article, I lay out the structure of this view and I assess its distributive implications for setting priority (i) between health needs across persons and (ii) between health care spending and other societal goods. I argue, first, that according to the sufficiency theory, deficiency in health cannot be completely offset by providing other societal (...) goods. And, second, that it can prevent the medicalization of societies by stressing that improvements beyond the level of adequate health have relatively little weight, if any, from the standpoint of justice. (shrink)

The resources and resource potential of the innovative component of nanoeconomics are analyzed. The factors of production – classical types of resources such as land, labor, capital and technology – are described. Ways of influencing the security resources of nanoeconomics within the innovation paradigm are evaluated. The purpose of the study is to identify the factor of nanoeconomics in the formation of resource security potential in the innovation paradigm. To achieve this goal, the following tasks were set: (...) to characterize the importance of the land resource as a factor in the potential of economic nanosystems; to highlight the importance of capital as a factor of nanoproduction and an indicator of the innovation paradigm; to determine the labor resource in the development of innovative nanosystems; to analyze the intellectual potential of nanoeconomic development of the innovation paradigm; to identify clusters of innovative nanopotential in the regions of countries with transition economies. Each resource is examined separately with the first analysis of a resource security assessment such as land. The other resource under consideration is labor. Demographic factors become decisive in describing the development of labor resources. The capital factor allows the formation of independent economic systems, when the state budget affects the possibility of developing science, education and health care. A number of methods were applied during the study: methods of induction and deduction (to assess the importance of the innovation paradigm for the development of nanoeconomics); system analysis and structural approach (to determine the aggregate state of production factors); method of comparing the quality of production factors in market economies and in developed countries; an observation method (for assessing the state of resources in different countries); method of cluster analysis (to determine the existence of innovation-territorial regions in countries with economies in transition). The analysis is carried out to identify the conditions of the impact of production factors on the innovative paradigm of nanoeconomics. It reveals theoretical approaches to the formation of nanoeconomics and its active development. As a result of the study of intellectual and resource potential of security, a cluster analysis was carried out to assess the conditions for the formation of innovation-territorial regions. This study allows to understand the role of production security factors in the formation of the innovation paradigm and the efficiency of the development of nanoeconomics. The way of providing the basis for the development of nanoeconomics in the form of efficient use of production factors is considered as a perspective. (shrink)

In the first wave of the COVID-19 pandemic, healthcare workers in some countries were forced to make distressing triaging decisions about which individual patients should receive potentially life-saving treatment. Much of the ethical discussion prompted by the pandemic has concerned which moral principles should ground our response to these individual triage questions. In this paper we aim to broaden the scope of this discussion by considering the ethics of broader structural allocation decisions raised by the COVID-19 pandemic. More specifically, we (...) consider how nations ought to distribute a scarce life-saving resource across healthcare regions in a public health emergency, particularly in view of regional differences in projected need and existing capacity. We call this the regional triage question. Using the case study of ventilators in the COVID-19 pandemic, we show how the moral frameworks that we might adopt in response to individual triage decisions do not translate straightforwardly to this regional-level triage question. Having outlined what we take to be a plausible egalitarian approach to the regional triage question, we go on to propose a novel way of operationalising the ‘save the most lives’ principle in this context. We claim that the latter principle ought to take some precedence in the regional triage question, but also note important limitations to the extent of the influence that it should have in regional allocation decisions. (shrink)

In this paper, I sound a warning note about the medicalization of risk conditions such as high cholesterol, especially in a health care climate of resource scarcity.

We offer a summary of the WHO Report "Making Fair Choices on the Path to Universal Health Coverage".

As the quality movement in health care now enters its fourth decade, the language of quality is ubiquitous. Practitioners, organizations, and government agencies alike vociferously testify their commitments to quality and accept numerous forms of governance aimed at improving quality of care. Remarkably, the powerful phrase ‘‘quality of care’’ is rarely defined in the health care literature. Instead it operates as an accepted and assumed goal worth pursuing. The status of evidence-based medicine, for instance, (...) hinges on its ability to improve quality of care, and efforts are made by both proponents and detractors to unpack the contents and outcomes of evidence-based practice while the contents of ‘‘quality of care’’ are presumed to be understood. Because the goals of medicine are far from obvious, this paper investigates the neglected term, ‘‘quality of care,’’ in an effort to understand what it is that health care practices are so uncritically assumed to be striving for. Finding lack of consensus on the terminology in the quality literature, I propose that the term operates rhetorically by way of persuasive appeal (and lack of descriptive meaning). Unsatisfied that ‘‘quality of care’’ operates as a mere buzzword in morally contentious debates over resource allocation and duties of care, I implore health care communities to go beyond mere commitments to quality and, instead, to focus attention on the difficult task of specifying what counts as quality care within an economically constrained health care system. (shrink)

The COVID-19 pandemic has helped to clarify the fair and equitable allocation of scarce medical resources, both within and among countries. The ethical allocation of such resources entails a three-step process: (1) elucidating the fundamental ethical values for allocation, (2) using these values to delineate priority tiers for scarce resources, and (3) implementing the prioritisation to faithfully realise the fundamental values. Myriad reports and assessments have elucidated five core substantive values for ethical allocation: maximising benefits and minimising (...) harms, mitigating unfair disadvantage, equal moral concern, reciprocity, and instrumental value. These values are universal. None of the values are sufficient alone, and their relative weight and application will vary by context. In addition, there are procedural principles such as transparency, engagement, and evidence-responsiveness. Prioritising instrumental value and minimising harms during the COVID-19 pandemic led to widespread agreement on priority tiers to include health-care workers, first responders, people living in congregate housing, and people with an increased risk of death, such as older adults and individuals with medical conditions. However, the pandemic also revealed problems with the implementation of these values and priority tiers, such as allocation on the basis of population rather than COVID-19 burden, and passive allocation that exacerbated disparities by requiring recipients to spend time booking and travelling to appointments. This ethical framework should be the starting point for the allocation of scarce medical resources in future pandemics and other public health conditions. For instance, allocation of the new malaria vaccine among sub-Saharan African countries should be based not on reciprocity to countries that participated in research, but on maximally reducing serious illness and deaths, especially among infants and children. (shrink)

Disability Justice in Public Health Emergencies is the first book to highlight contributions from critical disability scholarship to the fields of public health ethics and disaster ethics. It takes up such contributions with the aim of charting a path forward for clinicians, bioethicists, public health experts, and anyone involved in emergency planning to better care for disabled people—and thereby for all people—in the future. Across 11 chapters, the contributors detail how existing public health emergency responses (...) have failed and still fail to address the multi-faceted needs of disabled people. They analyze complications in the context of epidemic and pandemic disease and emphasize that vulnerabilities imposed upon disabled people track and foster patterns of racial and class domination. -/- The central claim of the volume is that the ethical and political insights of disability theory and activism provide key resources for equitable disaster planning for all. The volume builds upon the existing efforts of disability communities to articulate emergency planning priorities and response measures that take into account the large body of qualitative and quantitative research on disabled people’s health, needs, and experiences. It is only by listening to disabled people’s voices that we will all fare better in future public health emergencies. (shrink)

Analysing the demands of global justice for the distribution of resources is a complex task and requires consideration of a broad range of issues. Of particular relevance is the effect that different distributions will have on global population growth and individual welfare. Since changes in the consumption and distribution of resources can have major effects on the welfare of the global population, and the rate at which it increases, it is important to establish meaningful principles to ensure a (...) just distribution of resources. In order to establish such principles we must consider the scope of any reproductive rights, and rights to other goods, such as food and health care, as well as examine the extent of duties correlating to those rights. In addition to the impact that distributions of global goods have on the welfare of current generations, it is also important to consider what duties we have, if any, to future generations. -/- The final version of this paper is available to download here: http://dx.doi.org/10.1002/9780470015902.a0024140. (shrink)

This dissertation aims to develop a program resource for helping and mental health professionals to foster proactive coping and diminish dysfunctional coping from work stressors. Professionals succumb to chronic stressors and secondary traumatic stress due to their vocation, often disregarding self-care. Should this type of resource be implemented, psychological and social resources would be required. The need for proactive coping is a generally accepted concept, but helping and mental health professionals often lack resources, limiting advocacy (...) and resilience. Self-help resources are frequently perceived as self-indulgence, in addition to the concept that professionals provide care, not the clients receiving care. Moreover, victimization by stigmas and emotional contagion surrounds helping and mental health professions. Addressing these concerns by implementing an accessible and advocate-heavy website may mitigate experienced ramifications by increasing retention, psychological well-being, resilience, and support. Most importantly, it may reduce maladaptive behaviors and standardize professional self-care. (shrink)

Non‐governmental aid programs are an important source of health care for many people in the developing world. Despite the central role non‐governmental organizations play in the delivery of these vital services, for the most part they either lack formal systems of accountability to their recipients altogether, or have only very weak requirements in this regard. This is because most NGOs are both self‐mandating and self‐regulating. What is needed in terms of accountability is some means by which all the (...) relevant stakeholders can have their interests represented and considered. An ideally accountable decision‐making process for NGOs should identify acceptable justifications and rule out unacceptable ones. Thus, the point of this paper is to evaluate three prominent types of justification given for decisions taken at the Dutch headquarters of Médecins sans Frontières. They are: population health justifications, mandate‐based justifications and advocacy‐based justifications. The central question at issue is whether these justifications are sufficiently robust to answer the concerns and objections that various stakeholders may have. I am particularly concerned with the legitimacy these justifications have in the eyes of project beneficiaries. I argue that special responsibilities to certain communities can arise out of long‐term engagement with them, but that this type of priority needs to be constrained such that it does not exclude other potential beneficiaries to an undesirable extent. Finally, I suggest several new institutional mechanisms that would enhance the overall equity of decisions and so would ultimately contribute to the legitimacy of the organization as a whole. (shrink)

We discuss the role of prior authorization (PA) in supporting patient-centered care (PCC) by directing health system resources and thus the ability to better meet the needs of individual patients. We begin with an account of PCC as a standard that should be aimed for in patient care. In order to achieve widespread PCC, appropriate resource management is essential in a healthcare system. This brings us to PA, and we present an idealized view of PA in (...) order to argue how at its best, it can contribute to the provision of PCC. PA is a means of cost saving and as such it has mixed success. The example of the US demonstrates how implementation of PA has increased health inequalities whereas best practice has the potential to reduce them. In contrast, systems of universal coverage, like those in Europe, may use the cost savings of PA to better address individuals' care and PCC. The conclusion we offer therefore is an optimistic one, pointing towards areas of supportive overlap between PCC and PA where usually the incongruities are most evident. (shrink)

Women constituting almost half of the population of a country are the major human resource and accordingly the involvment of women in every sphere - economic, social, political is urgently felt for the development of a country. Health is one of the major infrastructures to constitute a strong human resource and is emerging as a significant element of human capital and a vital indicator of human development. Improvement in the health status of women plays a very important role (...) in the improvement of socio-economic condition of an economy. In India nearly 70% of the population are coming from rural areas and are suffering and dying from preventable diseases due to unavailability and inaccessibility of health care services. Among the rural population women are the most sufferer. They are trapped in poverty, malnutrition, low level of literacy, and are facing high rate of infant and maternal mortality rate with low expectancy of life at birth etc. Providing sound health care to these rural women is the urgent need and accordingly the Government of India has launched National Rural Health Mission to improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, and women. ASHA – one of the stakeholders of NRHM play a very important role in smoothening the delivery of health care services to the rural population specially the woman. A female from a village acts as an ASHA in improvising the health condition of the rural women. The present paper is prepared with the following objectives: 1. To study how ASHA is functioning in providing health care services. Methodology and data base: The study will be based on both primary and secondary data. The primary data will be collected by using multistage sampling. In the first stage of sample selection 2 Community Blocks of Karimganj will be selected at random. From the selected 2(two) Community Blocks 1 Gaon Panchayat from each Blocks will be selected on the basis of simple random sampling. From each of 2 selected Gaon Panchayat 2 villages will be selected by using simple random sampling. From each village 10% of total household will be surveyed and the ASHA workers will be directly interviewed. The main sources of secondary data are the official publication of governments. (shrink)

This study analyzed the monitoring and evaluation of HIV/AIDS prevention programs in Southern Senatorial District of Cross River State, Nigeria. The study considered different levels of care/support and tested for locational variations in the monitoring/evaluation of HIV/AIDs prevention programs. A descriptive survey research design was utilized. This study covered 596 public health employees (doctors, nurses, pharmacists, and laboratory employees) in the study area. A sample of 239 respondents was chosen using the proportional stratified random sampling procedure. Data was (...) collected using a questionnaire constructed by the researchers and validated by specialists. Data gathered were analyzed using descriptive and inferential statistics. Results indicated that HIV/AIDs programs have been successfully monitored/evaluated to a high extent. High rates of success in the monitoring/evaluation of HIV/AIDs prevention programs are attributable to high rates of care/support provided to people living with HIV/AIDs. There was a significant variation in the monitoring/evaluation of HIV/AIDs prevention programs based on the location of health facilities, with higher rates recorded for urban areas. Based on the findings, it was concluded that the monitoring/evaluation of HIV/AIDs prevention programs in the Southern Senatorial District of Cross River State had recorded a significant level of success. The study recommended, among others, that there should be even distribution of medical facilities, resources and personnel to both urban and rural areas to promote equity and access to materials needed to contain or mitigate the spread of the pandemic across all locations. (shrink)

Coronavirus disease 2019 can lead to respiratory failure. Some patients require extracorporeal membrane oxygenation support. During the current pandemic, health care resources in some cities have been overwhelmed, and doctors have faced complex decisions about resource allocation. We present a case in which a pediatric hospital caring for both children and adults seeks to establish guidelines for the use of extracorporeal membrane oxygenation if there are not enough resources to treat every patient. Experts in critical (...) class='Hi'>care, end-of-life care, bioethics, and health policy discuss if age should guide rationing decisions. (shrink)

In a context of imperfect risk protection, households may protect against the impact of a health shock by employing various financial and non-financial coping mechanisms, such as foregoing or reducing needed medical care, labor substitution, consumption reduction, borrowing money, dissaving, and selling assets. However, leveraging certain coping mechanisms may reduce future productivity, potentially trapping households in chronic or persistent poverty. Resources and risk are not necessarily shared equitably within a household; the ability and willingness of the household (...) to leverage coping mechanisms, or the choice of coping mechanism may depend on the social protection policy context, household socioeconomic status, and type of intrahousehold risk sharing. Vietnam has been making policy changes aimed towards achieving Universal Health Coverage for the past several decades, culminating in a 2015 change mandating universal insurance coverage. This can potentially influence both providers in making decisions around service delivery and households around financing care. This research aims to contribute to the literature exploring the relationships among direct and indirect health care costs, potentially maladaptive coping mechanisms, and household living standards, within the particular health financing and social protection environment in Vietnam. (shrink)

Background The health care sector is experiencing a drastic transition all over the world. This has an impact not only on the way hospitals, clinics, special-care homes etc. are organized, but also on patients, personnel and other stakeholders involved. The consequences of changes for both physicians and patients are investigated using a comprehensive health care reform in Ukraine as an example. -/- Methods The analysis is based on empirical data collected from general physicians in 2 (...) Ukrainian cities. Based on the Job Demands-Resources Model, we developed a set of hypotheses and tested them using the structural equation modelling technique. A total of 178 general physicians (81% of the approached population) participated in the study. -/- Results Our investigation reveals a clear relationship between the organizational job demands (additional tasks, structural changes, new processes) and their psychological effects (e. g., burnout). The latter have a negative impact on cooperation of physicians in hospitals leading to lower patient satisfaction. -/- Discussion and Conclusions Change in health care is inevitable. The example of Ukraine shows that openness of hospitals towards change reduces the probability of physicians’ burnout and, eventually, increases patient satisfaction. We strongly suggest applying the process management approach in order to increase openness to change, especially in turbulent times. (shrink)

Donors to global health programs and policymakers within national health systems have to make difficult decisions about how to allocate scarce health care resources. Principled ways to make these decisions all make some use of summary measures of health, which provide a common measure of the value (or disvalue) of morbidity and mortality. They thereby allow comparisons between health interventions with different effects on the patterns of death and ill health within a (...) population. The construction of a summary measure of health requires that a number be assigned to the harm of death. But the harm of death is currently a matter of debate: different philosophical theories assign very different values to the harm of death at different ages. This chapter considers how we should assign numbers to the harm of deaths at different ages in the face of uncertainty and disagreement. (shrink)

Population obesity and associated morbidities pose significant public health and economic burdens in the United Kingdom, United States, and globally. As a response, public health initiatives often seek to change individuals’ unhealthy behavior, with the dual aims of improving their health and conserving health care resources. One such initiative—taxes on sugar‐sweetened beverages (SSB)—has sparked considerable ethical debate. Prominent in the debate are arguments seeking to demonstrate the supposed impermissibility of SSB taxes and similar policies (...) on the grounds that they interfere with individuals’ freedom and autonomy. Commentators have often assumed that a policy intended to restrict or change private individuals’ consumption behavior will necessarily curtail freedom and, as a corollary, will undermine individuals’ autonomy with respect to their consumption choices. Yet this assumption involves a conceptual mistake. To address the misunderstanding, it’s necessary to attend to the differences between negative liberty, freedom of options, and autonomy. Ultimately, concerns about negative liberty, freedom, and autonomy do not provide strong grounds for opposing SSB taxes. (shrink)

Common principles for resource allocation in health care can prioritize the alleviation of small health burdens over lifesaving treatment. I argue that there is some evidence that these principles are at odds with a sizable share of public opinion, which holds that saving a life should take priority over any number of cures for minor ailments. I propose two possible explanations for this opinion, one debunking and one vindicatory. I also outline how well-designed surveys and moral inquiry (...) could help decide between them. Finally, I consider how priority-setting principles could be adjusted if the view that saving a life always trumps alleviating small burdens were vindicated. (shrink)

When many people think of bioethics, they think of gripping issues in clinical medicine such as end-of-life decision-making, controversies in biomedical research such as that over work with stem cells, or issues in allocating scarce health-care resources such as organs or money. The term “bioethics” may evoke images of moral controversies being discussed on news programs and talk shows. But this “controversy of the day” focus often treats ethical issues in medicine superficially, for it addresses them as (...) if they could be examined and discussed in isolation from the context in which they are situated. Such a focus on the latest controversies fails to take into account that medicine is a social institution and that the controversies in bioethics often reflect deeper social and moral issues that transcend the boundaries of medicine and ethics. If one moves beyond the issue-of-the-day approach to bioethics, one can see that the field must address these deeper issues. (shrink)

When hospitals face surges of patients with COVID-19, fair allocation of scarce medical resources remains a challenge. Scarcity has at times encompassed not only hospital and intensive care unit beds—often reflecting staffing shortages—but also therapies and intensive treatments. Safe, highly effective COVID-19 vaccines have been free and widely available since mid-2021, yet many Americans remain unvaccinated by choice. Should their decision to forgo vaccination be considered when allocating scarce resources? Some have suggested it should, while others disagree. (...) We offer a framework for evaluating when it is ethical and briefly discuss its legality in American law. (shrink)

COVID-19 demonstrated a global catastrophe that touched everybody, including the scientific community. As we respond and recover rapidly from this pandemic, there is an opportunity to guarantee that the fabric of our society includes sustainability, fairness, and care. However, approaches to environmental health attempt to decrease the population burden of COVID-19, toward saving patients from becoming ill along with preserving the allocation of clinical resources and public safety standards. This paper explores environmental and public health evidence-based (...) practices toward responding to Covid-19. A literature review tried to do a deep dive through the use of various search engines such as Mendeley, Research Gate, CAB Abstract, Google Scholar, Summon, PubMed, Scopus, Hinari, Dimension, OARE Abstract, SSRN, Academia search strategy toward reretrieving research publications, “grey literature” as well as reports from expert working groups. To achieve enhanced population health, it is recommended to adopt widespread evidence-based strategies, particularly in this uncertain time. As only together can evidence-informed decision-making (EIDM) can become a reality which includes effective policies and practices, transparency and accountability of decisions, and equity outcomes; these are all more relevant in resource-constrained contexts, such as Nigeria. Effective and ethical EIDM though requires the production as well as use of high-quality evidence that are timely, appropriate and structured. One way to do so is through co-production. Co-production (or co-creation or co-design) of environmental/public health evidence considered as a key tool for addressing complex global crises such as the high risk of severe COVID-19 in different nations. A significant evidence-based component of environmental/public health (EBEPH) consist of decisions making based on best accessible, evidence that is peer-reviewed; using data as well as systematic information systems; community engagement in policy making; conducting sound evaluation; do thorough program-planning frameworks; as well as disseminating what is being learned. As researchers, scientists, statisticians, journal editors, practitioners, as well as decision-makers strive to improve population health, having a natural tendency toward scrutinizing the scientific literature aimed at novel research findings serving as the foundation for intervention as well as prevention programs. The main inspiration behind conducting research ought to be toward stimulating and collaborating appropriately on public/environmental health action. Hence, there is need for a “Plan B” of effective behavioural, environmental, social as well as systems interventions (BESSI) toward reducing transmission. (shrink)

Mental health challenges can be described via the application of multiple lenses, from clinical-medical perspectives, to social and community-based, to further understandings in the context of public health. While these challenges can represent multiple issues to the scientific community at-large, especially because of the translational issues attached to the application of research and practice to the sphere of community services, it is useful to understand that the triad ethics, evidence, and experience can be instrumental in navigating the complexity (...) of the issue-at-hand. Furthermore, the work of researchers and practitioners is rooted in a solid understanding of the specific needs of psychiatric patients, particularly from the perspective of possible misunderstandings, ostracization, and stigmatization of psychiatric issues and related presentation, affect, and behaviours. Years of research have indicated how a proper interaction between resources at the level of scientific research and the community is a fundamental cornerstone for a practice rooted in both science and true care for individuals affected by mental health disorders. In this presentation we will discuss the case of the Centro Salute Mentale (Mental Health Centre, CSM) of Verona. (shrink)

One of the most unpredictable things the pandemic brought to our societies was the closure of hospitals and other health services to visitors. Preventing the spread of infection was the main reason for these decisions in the early days of the pandemic when there was no clarity about the means of transmission and the origin of the virus. However, in view of the persistence of the restrictions to date and the numerous negative consequences they have had on the professional (...) and personal quality of life of doctors, nurses, patients and carers, the aim of this article is to analyse in depth the reasons why these decisions have been and, above all, are still being applied, also considering the hypothesis that the choices made so far in the training of health professionals should be questioned. The persistence of restrictions, the constant reduction of human and economic resources in the face of an increase in the demand for care have exacerbated the distance between health professionals and users, to the point of escalating into actual acts of violence and aggression. According to the Critical Pedagogy approach, educators can play a central role in activating formative and collaborative strategies, such as maieutic groups, to rebuild an alliance between those who today find themselves on opposite sides: health professionals on the one hand, and patients and families on the other. (shrink)

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s (...) severity criteria in Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda. (shrink)

William Smith’s recent article criticises the so-called orthodox approaches to the normative analysis of healthcare resource allocation, associated to the requirement that decision-makers should abide by strictly procedural principles of legitimacy defining a deliberative democratic process. Much of the appeal of Smith’s argument goes down to his awareness of real-world processes and, in particular, to the large gap he identifies between well-led democratic deliberation and the messiness of the process through which the intuitively legitimate Affordable Care Act (ACA) was (...) created. This reply aims to demonstrate that the ACA provides no counterexample to orthodox views, seizing this opportunity to explore the specific space that the procedural principles populating orthodox accounts are meant to regulate. Neither general questions of healthcare justice concerning, for example, universal access nor, relatedly, the activity of elected politicians falls within the natural scope of application of such principles, revealing a much more complex picture of the interactions between justice and legitimacy as well as substantive and procedural considerations than acknowledged by Smith. In the end, orthodox accounts of healthcare resource allocation turn out to provide a precious fund of theoretical resources for the normative study of administrators, which might be useful well beyond bioethics and health policy. (shrink)

The COVID-19 pandemic has been overwhelming public health-care systems around the world. With demand exceeding the availability of medical resources in several regions, hospitals have been forced to invoke triage. To ensure that this difficult task proceeds in a fair and organised manner, governments scrambled experts to draft triage guidelines under enormous time pressure. Although there are similarities between the documents, they vary considerably in how much weight their respective authors place on the different criteria that they (...) propose. Since most of the recommendations do not come with ethical justifications, analysing them requires that one traces back these criteria to their underlying theories of distributive justice. In the literature, COVID-19 triage has been portrayed as a value conflict solely between utilitarian and egalitarian elements. While these two accounts are indeed the main antipodes, I shall show that in fact all four classic theories of distributive justice are involved: utilitarianism, egalitarianism, libertarianism, and communitarianism. Detecting these in the documents and classifying the suggested criteria accordingly enables one to understand the balancing between the different approaches to distributive justice—which is crucial for both managing the current pandemic and in preparation for the next global health crisis. (shrink)

Despite negative effects on their health and social lives, many informal carers of people living with dementia claim to be acting in accordance with a moral obligation. Indeed, feelings of failure and shame are commonly reported by those who later give up their caring responsibilities, suggesting a widespread belief that professional dementia care, whether delivered in the person's own home or in an institutional setting, ought always to be a last resort. In this paper, however, I suggest that (...) this common intuition gets things the wrong way around. Adopting a relational egalitarian framework, I argue that the most serious injustices engendered by present‐day dementia care services are contingent on broader societal structures—they can thus be ameliorated relatively easily (if resource intensively) by changing those structures. Informal dementia care, on the other hand, carries similar risks of injustice and is much more resistant to structural reform. While there may be moral obligations to provide informal dementia care in present‐day societies, then, they arise because of the deficiencies of professional care, not the virtues of its informal counterpart. Though we may be far from achieving just care arrangements in most of our societies, we must never lose sight of the fact that, when we engage in morally permitted informal dementia care, we are exercising our last resort. (shrink)

Animal rights activists are often accused of caring more about animals than about human beings. How, it is asked, can activists condemn the use of animals in biomedical research—research that improves human health and saves human lives? In this article, I argue that even if animal experimentation might eventually provide cures for many serious diseases, given the present state of the world, we are not justified supporting this research; rather, we ought to devote our limited resources to other (...) forms of humanitarian assistance. (shrink)

Given the unprecedented novel nature and scale of coronavirus and the global nature of this public health crisis, which upended many public/environmental research norms almost overnight. However, with further waves of the virus expected and more pandemics anticipated. The COVID-19 pandemic of 2020 opened our eyes to the ever-changing conditions and uncertainty that exists in our world today, particularly with regards to environmental and public health practices disruption. This paper explores environmental and public health evidence-based practices toward (...) responding to Covid-19. A literature review tried to do a deep dive through the use of various search engines such as Mendeley, Research Gate, CAB Abstract, Google Scholar, Summon, PubMed, Scopus, Hinari, Dimension, OARE Abstract, SSRN, Academia search strategy toward retrieving research publications, “gray literature” as well as reports from expert working groups. To achieve enhanced population health, it is recommended to adopt widespread evidence-based strategies, particularly in this uncertain time. As only together can evidence-informed decision-making (EIDM) can become a reality which include effective policies and practices, transparency and accountability of decisions, and equity outcomes; these are all more relevant in resource-constrained contexts, such as Nigeria. Effective and ethical EIDM though requires the production as well as use of high-quality evidence that are timely, appropriate and structured. One way to do so is through co-production. Co-production (or co-creation or co-design) of environmental/public health evidence considered as a key tool for addressing complex global crises such as the high risk of severe COVID-19 in different nations. A significant evidence-based component of environmental/public health (EBEPH) consist of decisions making based on best accessible, evidence that is peer-reviewed; using data as well as systematic information systems; community engagement in policy-making; conducting sound evaluation; do a thorough program-planning frameworks; as well as disseminating what is being learned. As researchers, scientists, statisticians, journal editors, practitioners, as well as decision makers strive to improve population health, having a natural tendency toward scrutinizing the scientific literature aimed at novel research findings serving as the foundation for intervention as well as prevention programs. The main inspiration behind conducting research ought to be toward stimulating and collaborating appropriately on public/environmental health action. Hence, there is need for a “Plan B” of effective behavioral, environmental, social as well as systems interventions (BESSI) toward reducing transmission. (shrink)

Artificial intelligence (AI) systems are increasingly adopted to make decisions in domains such as business, education, health care, and criminal justice. However, such algorithmic decision systems can have prevalent biases against marginalized social groups and undermine social justice. Explainable artificial intelligence (XAI) is a recent development aiming to make an AI system’s decision processes less opaque and to expose its problematic biases. This paper argues against technical XAI, according to which the detection and interpretation of algorithmic bias can (...) be handled more or less independently by technical experts who specialize in XAI methods. Drawing on resources from feminist epistemology, we show why technical XAI is mistaken. Specifically, we demonstrate that the proper detection of algorithmic bias requires relevant interpretive resources, which can only be made available, in practice, by actively involving a diverse group of stakeholders. Finally, we suggest how feminist theories can help shape integrated XAI: an inclusive social-epistemic process that facilitates the amelioration of algorithmic bias. (shrink)

In times of crises, public health leaders may claim that trials of public health interventions are unethical. One reason for this claim can be that equipoise—i.e. a situation of uncertainty and/or disagreement among experts about the evidence regarding an intervention—has been disturbed by a change of collective expert views. Some might claim that equipoise is disturbed if the majority of experts believe that emergency public health interventions are likely to be more beneficial than harmful. However, such beliefs (...) are not always justified: where high quality research has not been conducted, there is often considerable residual uncertainty about whether interventions offer net benefits. In this essay we argue that high-quality research, namely by means of well-designed randomized trials, is ethically obligatory before, during, and after implementing policies in public health emergencies (PHEs). We contend that this standard applies to both pharmaceutical and non-pharmaceutical interventions, and we elaborate an account of equipoise that captures key features of debates in the recent pandemic. We build our case by analyzing research strategies employed during the COVID-19 pandemic regarding drugs, vaccines, and non-pharmaceutical interventions; and by providing responses to possible objections. Finally, we propose a public health policy reform: whenever a policy implemented during a PHE is not grounded in high-quality evidence that expected benefits outweigh harms, there should be a planned approach to generate high-quality evidence, with review of emerging data at preset time points. These preset timepoints guarantee that policymakers pause to review emerging evidence and consider ceasing ineffective or even harmful policies, thereby improving transparency and accountability, as well as permitting the redirection of resources to more effective or beneficial interventions. (shrink)

Background: Dengue Disease is a mosquito-borne tropical disease caused by the dengue virus, symptoms typically begin three to fourteen days after infection. This may include a high fever, headache, vomiting, muscle and joint pains, and a characteristic skin rash. Dengue serology is applied in different settings, such as for surveillance, in health care facilities in endemic areas and in travel clinics in non-endemic areas. The applicability and quality of serological tests in dengue endemic regions has to be judged (...) against a background of potential cross reactivity with other flavi-viruses, difficulties in distinguishing primary from secondary infections and technological problems related to the fact that most dengue endemic regions are relatively poor of resources .Objectives: to help doctors and patients in diagnosing Dengue Disease and give them the information of how to prevent Dengue Disease and to be able to understand the signs and symptoms of Dengue Disease. Methods: We collected all relevant material for Dengue Disease. Then we designed and implemented a knowledge based system for diagnosing Dengue Disease using SL5 Object Language. Results: The knowledge based system was evaluated by a group of Patients and specialized doctors and they found it very friendly and easy to use. (shrink)

This project considers whether and how research ethics can contribute to the provision of cost-effective medical interventions. Clinical research ethics represents an underexplored context for the promotion of cost-effectiveness. In particular, although scholars have recently argued that research on less-expensive, less-effective interventions can be ethical, there has been little or no discussion of whether ethical considerations justify curtailing research on more expensive, more effective interventions. Yet considering cost-effectiveness at the research stage can help ensure that scarce resources such as (...) tissue samples or limited subject popula- tions are employed where they do the most good; can support parallel efforts by providers and insurers to promote cost-effectiveness; and can ensure that research has social value and benefits subjects. I discuss and rebut potential objections to the consideration of cost-effectiveness in research, including the difficulty of predicting effectiveness and cost at the research stage, concerns about limitations in cost-effectiveness analysis, and worries about overly limiting researchers’ freedom. I then consider the advantages and disadvantages of having certain participants in the research enterprise, including IRBs, advisory committees, sponsors, investigators, and subjects, consider cost-effectiveness. The project concludes by qualifiedly endorsing the consideration of cost-effectiveness at the research stage. While incorporating cost-effectiveness considerations into the ethical evaluation of human subjects research will not on its own ensure that the health care system realizes cost-effectiveness goals, doing so nonetheless represents an important part of a broader effort to control rising medical costs. (shrink)