Health Care Dilemma Research Articles

Healthcare influences today and tomorrow.

PacifiCare Health System’s (PHS) forward-thinking disease management programs and quality initiatives. He reviewed the company’s process for analyzing disease management opportunities, making the determination of buy versus build, and balancing social versus financial return on investment. Dr. Ho also presented an overview of PacifiCare’s consumer-directed provider evaluations that enable consumers to evaluate and compare providers on the basis of quality and cost. A Healthcare Panel accepted the challenge of assessing how healthcare must change in order to survive. Three diverse panelists offered their unique perspectives on how to reach what was revealed to be a common goal: the critical importance of achieving a customer focus. Targeted, appropriate consumer education and decision support are key. Dave Walters, of American Greetings Corporation, and Dr. Bill Yang, of The Coca-Cola Company, presented two different but effective approaches to the healthcare dilemma facing employers. Mr. Walters recounted American Greetings’ experience in dealing with double-digit healthcare inflation in a flat economy. Dr. Yang described The Coca-Cola Company’s initiative for employees with chronic conditions: helping them make the decision to come to work, and finding creative solutions to keep them productive at work until the end of the workday. An expert Pharmacy Panel addressed three aspects of the pharmacy business: the managed care perspective on specialty pharmaceuticals, carrier-based pharmacy benefits management, and one employer’s analysis of the cost/benefits of re-importation of pharmaceuticals. Susan Miller detailed Humana’s web-based health insurance “solutions.” In launching on-line products that enable consumers to assess their risk tolerances and make informed choices from a cafeteria of options, the company promotes its philosophy of providing members with tools to confidently take control of their own healthcare decisions. Dr. Peter Salgo entertained and educated us with his closing keynote presentation, providing an update on SARS—its pathogenesis, the prospect of a cure, and the implications for public health policies. He expounded on the discovery of a pathogen now suspected of being the root cause of heart attack, and left us confident of the prospect of eliminating the country’s number one fatal disease within the next five years. He closed with an intriguing question: As we discover how to control or eradicate the most life-threatening diseases, how do we continue to cover, care, and pay for living longer? As you review the highlights of the conference, I’m sure that you will be inspired to initiate similar discussions with your colleagues and to become an active partner in the continuing evolution of healthcare. HEALTH OF HEALTH CARE S-2

The ethics of life expectancy.

Some ethical dilemmas in health care, such as over the use of age as a criterion of patient selection, appeal to the notion of life expectancy. However, some features of this concept have not been discussed. Here I look in turn at two aspects: one positive--our expectation of further life--and the other negative--the loss of potential life brought about by death. The most common method of determining this loss, by counting only the period of time between death and some particular age, implies that those who die at ages not far from that one are regarded as losing very little potential life, while those who die at greater ages are regarded as losing none at all. This approach has methodological advantages but ethical disadvantages, in that it fails to correspond to our strong belief that anyone who dies is losing some period of life that he or she would otherwise have had. The normative role of life expectancy expressed in the 'fair innings' attitude arises from a particular historical situation: not the increase of life expectancy in modern societies, but a related narrowing in the distribution of projected life spans. Since life expectancy is really a representation of existing patterns of mortality, which in turn are determined by many influences, including the present allocation of health resources, it should not be taken as a prediction, and still less as a statement of entitlement.

Dilemmas in UK Health Care Dilemmas in UK Health Care

This is the seventh in a series of eight books by the Open University Press (OUP) on the subject of health and disease. Initially published in 1985, this full-colour, third edition has been completely revised.

Ethical reasoning observed: a longitudinal study of nursing students.

All nursing courses in the UK include ethics in the curriculum, although there is considerable variation in the content of ethics courses and the teaching methods used to assist the acquisition of ethical reasoning.The effectiveness of ethics courses continues to be disputed, even when the perceptions and needs of students are taken into account in their design. This longitudinal study, carried out in the UK, but with implications for nurse education in other developed countries, explored the ethical understanding of nursing students and changes in their understanding and approaches to practice over their four years of training (1995-1999). The data collection tools were a questionnaire originally piloted prior to the 1995 study, from which the present study developed, and five vignettes describing ethical dilemmas in health care also piloted in 1995. Students' thinking progressed as they became more mature as individuals and professionals, although this progress was not necessarily in the direction of greater certainty. Suggestions are made to help nurse educators to maximize the effectiveness of ethics courses in transmitting the skills of ethical reasoning.

Managed care, managed dollars, managed providers: ethical dilemmas in mental healthcare.

Managed care, managed dollars, managed providers: ethical dilemmas in mental healthcare.

Telepsychiatry: challenges in rural aging.

A significant health care dilemma for older individuals living in rural areas is that at a time in life when there is, predictably, a greater need for medical services, the ability to access those limited services is markedly reduced. Telepsychiatry presents an innovative and cost-effective strategy for the provision of improved local access to quality mental health services for the underserved rural elderly. Telepsychiatry has demonstrated the potential to improve access to mental health services, provide those services in an affordable and cost-effective manner and deliver those services at a quality nearly equal to traditional face-to-face services. Advances in telepsychiatry technology allow a core group of skilled mental health providers in a central location to provide timely local access to quality services for the rural elderly over a broad geographic area.

Age-based health care allocation as a wedge separating the person from the patient and commodifying medicine

Agism in the form of age-based health care allocation fosters the separation of the physiological part of a patient from the person who is the patient. It does so by ignoring the holistic best interests of the patient and instead focuses on providing certain procedures or therapies only when the patient’s age is less than or equal to a specified value (the allocation limit). Certainly not all forms of clinically relevant care and treatment are age-restricted in the scheme of aged-based health care allocation, but it is clear that this scheme functions on the arbitrary, and patients may miss out on optimal therapy presumably because it will be ranked as too expensive or too rare to provide to older people. Arbitrarily chosen age limits or those chosen based upon an estimation of humans’ natural lifespan have the effects of minimizing the patient’s clinical choices, devaluing the experiential skills and knowledge of the medical team, weakening the doctor-patient relationship, and commodifying medicine. Policies of this nature do not solve our current health care dilemma, rather they are an economic bandage over the still present (and unattended to) root cause.

Towards a public health approach to bioethics.

In this paper we examine the central commitments of bioethical enquiry and reasoning from a public health perspective. We argue that a core element of American national culture is individualism, which resonates in scholarly and popular debates. Our contention is that the habitus of bioethical debate is in large measure animated by an overriding concern with the individual, and the resulting social practice of the community has been to downplay the importance and legitimacy of group-level health care dilemmas. This paper calls for re-focusing of bioethics by employing a public health perspective, which would include a population focus, evidence-based research topics, and engagement of the ethical dilemmas that arise from decisions concerning prevention. Racial and ethnic health disparities throughout the life span of a population in central New York State are used to illustrate the need for a public health focus in bioethics.

Cancer and Pregnancy: A Health Care Dilemma

When cancer occurs during pregnancy, a conflict exists between the family's hopes and dreams for the future and the reality of the diagnosis of a potentially terminal illness. The nurse has a pivotal role in the assessment and management of the pregnant oncologic patient's physical and emotional health. The perinatal nurse must assure that the care experienced by the family balances the reality of a potentially life-threatening illness with the joy that accompanies the birth of a baby.

Book Review: Matters of Life and Death: Today's Healthcare Dilemmas in the Light of Christian Faith

Book Review: Matters of Life and Death: Today's Healthcare Dilemmas in the Light of Christian Faith

Book Review: No Cheap Solutions, Mailers of Life and Death: Today's Healthcare Dilemmas in the Light of Christian Faith

Book Review: No Cheap Solutions, Mailers of Life and Death: Today's Healthcare Dilemmas in the Light of Christian Faith

An Office on Main Street Health Care Dilemmas in Small Communities

The health care needs of rural populations often differ from those of their urban counterparts. And the ethical dilemmas that caregivers face are distinctively shaped in rural settings, not only by resource constraints, but by the nature of life in small, close-knit communities as well.

Frontier ethics: mental health care needs and ethical dilemmas in rural communities.

Roughly 15 million of the 62 million rural U.S. residents struggle with mental illness and substance abuse. These rural dwellers have significant health care needs but commonly experience obstacles to obtaining adequate psychiatric services. Important but little-recognized ethical dilemmas also affect rural mental health care delivery. Six attributes of isolated settings with limited resources appear to intensify these ethical dilemmas: overlapping relationships, conflicting roles, and altered therapeutic boundaries between caregivers, patients, and families; challenges in preserving patient confidentiality; heightened cultural dimensions of mental health care; "generalist" care and multidisciplinary team issues; limited resources for consultation about clinical ethics; and greater stresses experienced by rural caregivers. The authors describe these features of rural mental health care and provide vignettes illustrating dilemmas encountered in the predominantly rural and frontier states of Alaska and New Mexico. They also outline constructive approaches to rural ethical dilemmas in mental health care.

Casuistry—Past and Present: A Search Engine for the Resolution of Ethical Dilemmas in Health Care

Ethical dilemmas within any system are created when moral principles are cited for opposing actions with neither side presenting the obvious right course to follow. Principle-driven decision making has its obvious limitations. Casuistry presents an alternative system for making ethical decisions. Principles in this approach are neither ignored nor discarded; rather they serve as general statements describing human behavior, out of which come “paradigm cases” illustrating the most manifest breaches of the general principle for the casuist. Scrutiny of a series of cases from the simplest most parsimonious to the most complex is undertaken to resolve the doubt inherent in ethical dilemmas; reasonable expectations are discovered in subsequent cases, driving the search until resolution is reached. The casuist sets out to join unique individual cases with general principles without discounting the validity of either, all the while determining how exactly to act in a particular situation.

Primary Health Care and partnerships: collaboration of a community agency, health department, and university nursing program.

Health care reform proposals emphasize health care that is essential, practical, scientifically sound, coordinated, accessible, appropriately delivered, and affordable. One route to achievement of improved health outcomes within these parameters is the formation of partnerships. Partnerships adopting the philosophy and five principles of Primary Health Care (PHC) focus on health promotion and prevention of illness and disability, maximum community participation, accessibility to health and health services, interdisciplinary and intersectoral collaboration, and use of appropriate technologies such as resources and strategies. A community service agency serving a multicultural population initiated a partnership with a health department and a university undergraduate nursing program. The result was a preschool health fair and there were benefits for each partner-benefits which could not have been realized without the collaboration. The health fair partnership planning, implementation, and evaluation process was guided by a framework shaped by the philosophy and five principles of PHC. The educational process described can be applied to other learning experiences where the goal is to help students understand and apply the concepts of PHC, develop myriad nursing competencies, and form collaborative relationships with the community and health agencies. Community health care dilemmas and nursing education challenges can be successfully addressed when various disciplines and sectors form effective partnerships.

Let's clear the air of that nocturnal miasma. Cigar anyone?

Ever since they could remember, Thaddeus and Alexandra enjoyed listening to their father’s accountings of mysterious illnesses —assembled stories that were meant to be enlightening and entertaining. Some were told them by their father, others by their grandfather; still others had been acquired from friends and acquaintances located throughout the world. And then there was their extensive reading of the medical literature. Now that Thaddeus was a junior in medical school and Alexandra hoped to soon follow in the family tradition, these stories took on an even greater fascination — each hoped to become a medical detective in real life. Home for the holidays on this cold winter’s evening, December 21, 1990. Thaddeus and Alexandra had earlier seen their younger sisters to bed. They now sat on the couch with their mother Elizabeth, a former nurse, who eagerly awaited tonight’s puzzle ready to add her own perspective to the health care dilemma that would unfold. As was so often the case when he told these stories, Theodore Conrad was nestled in a well worn armchair, his trusty pipe emitting a smokey tendril and distinctive fragrance in keeping with his long-time favorite cavendish tobacco. And then there were story titles laced with his own brand of humor. Tonight’s story, he suggested, with a twinkle in his eye, would be titled ‘‘Let’s Clear the Air of That Nocturnal Miasma. Cigar Anyone?’’. It began in Philadelphia, Pennsylvania, in August of 1793. August, 1793. Philadelphia, the Colonies’ capital, was in the midst of an epidemic similar to those of 1699, 1741, 1747 and 1762. This time, one tenth of the city’s population would die of the mysterious illness. Death was often preceded by black vomitus, considered a most deadly contagion. What caused this illness and from where did it arise? After a 30-year hiatus when had it arrived and by what means? Was it imported by vessel from ports in the West Indies? Why had it appeared so suddenly, so mysteriously, and killing so mercilessly? The origins of the scourge were obscure — contagion was considered most probable. Some thought it emanated from a nocturnal miasma that appeared in low marshy places borne by a swamp breeze, like the moist sultriness of a tropical jungle. Perhaps it came from morbid exhalations of organic decomposition found in gutters and wharves, like the putrid smell found along Water and Front Streets. The mayor ordered a purification of the atmosphere and cleansing of the city. Bonfires dotted streetcorners to eradicate fomites belonging to the ill; cannons were sounded periodically to clear the air. Warding off evil humors, women and men alike smoked cigars to the point of intoxication; they chewed garlic and carried vinegar or camphor-soaked sponges at their mouths when leaving their homes; tarred rope was worn at the neck or waist as a talisman. Dr. Benjamin Rush, one of 5 physicians to affix their signature to the Declaration of Independence, would chronicle the city’s epidemic. A majority of patients had fever, some to profound levels. In response to the miasmata, Rush divided cases into 3 categories: seOere, accompanied by coma, languor, a weak, slow pulse, and a disposition to syncope; moderate, with headache, delirium, vomiting, thirst, and quick pulse; and mild, often found in suburbs. In vivid and compassionate terms, Rush wrote of the devastation that affected entire families, rich and poor alike, and frenzied masses that crowded Philadelphia streets fleeing the city in every direction.This deadly malady had and would continue to ensnare other ports along the eastern seaboard, including New York, New Haven, Boston and Baltimore. The illness disappeared with October’s rain and frost; peace and tranquility were restored. Elsewhere in the Americas this illness would also claim many lives. In 1794, one half of the 12,000 man English army that occupied the West Indies would succumb. In 1798, 90% of the 24,000 member French army in Santo Domingo was lost. Spanish soldiers, who managed to survive the illness in the Caribbean, brought it home. Deadly epidemics followed in Barcelona and Seville. In the 19th century, ports along the Mississippi Valley and

Everyday Ethics and Home Health Care Challenges

This article reviews the common ethical principles, values, and duties that are at the core of any ethical dilemma in health care and presents a simple model for ethical decision making that can be used in the types of daily ethical challenges confronted by home health care organizations. Principles such as autonomy, beneficence, nonmaleficence, and veracity, or truthfulness, are presented with practical application in the home care setting. A case study format is used to analyze the variety of principles and conflicts that home care staff often face in their daily practice, and the model for ethical inquiry is used to arrive at practical alternatives.

Moral orientation of elderly persons: considering ethical dilemmas in health care.

Knowledge about moral development and elderly persons is very limited. A hermeneutical interpretative study was conducted with healthy elderly persons (n = 20) in order to explore and describe their moral orientation based on the paradigms of justice (Kohlberg) and care (Gilligan). The types of moral reasoning, dominance, alignment and orientation were determined. All but one participant included both types of reasoning when discussing an ethical conflict. None of the men's moral reasoning was dominated by caring, but justice dominated the reasoning of four women. The implications for ethical decision-making and future research are discussed.

Moral Orientation of Elderly Persons:: considering ethical dilemmas in health care

Knowledge about moral development and elderly persons is very limited. A hermeneutical interpretative study was conducted with healthy elderly persons (n = 20) in order to explore and describe their moral orientation based on the paradigms of justice (Kohlberg) and care (Gilligan). The types of moral reasoning, dominance, alignment and orientation were determined. All but one participant included both types of reasoning when discussing an ethical conflict. None of the men’s moral reasoning was dominated by caring, but justice dominated the reasoning of four women. The implications for ethical decision-making and future research are discussed.

The Evolution of Caring Within Bioethics: Provision for Relationship and Context

Given the complexity of modern health care, there exists an urgent need to discover how best to resolve complex bioethical issues. Traditionally, principle based ethics provided the benchmark for guiding ethical decision-making. More recently, however, it has become apparent that this traditional approach is often inadequate in dealing with current health care dilemmas. The notion of caring was advanced initially as an alternative to, then as a complement to, principle based ethics. In this article, caring is conceptualized as an attitude and is viewed as integral to the advancement of a coherent and integrated moral approach to ethical decision-making. First, a brief historical description of bioethics is presented. Next, an evolutionary account of caring within bioethics is described. Four fundamental problems associated with the use of caring within bioethics are then outlined. Finally, caring as an attitude is delineated and a case study is used to illustrate the proposed conceptualization of caring. The case study demonstrates that a caring attitude provides for relationship and context, which are elements often neglected by traditional approaches.