Background: Ambulance professionals often address conflicts between ethical values. As individuals’ values represent basic convictions of what is right or good and motivate behaviour, research is needed to understand their value profiles. Objectives: To translate and adapt the Managerial Values Profile to Spanish and Swedish, and measure the presence of utilitarianism, moral rights and/or social justice in ambulance professionals’ value profiles in Spain and Sweden. Methods: The instrument was translated and culturally adapted. A content validity index was calculated. Pilot tests (...) were carried out with 46 participants. Ethical considerations: This study conforms to the ethical principles for research involving human subjects and adheres to national laws and regulations concerning informed consent and confidentiality. Findings: Spanish professionals favoured justice and Swedish professionals’ rights in their ambulance organizations. Both countries favoured utilitarianism least. Gender differences across countries showed that males favoured rights. Spanish female professionals favoured justice most strongly of all. Discussion: Swedes favour rights while Spaniards favour justice. Both contexts scored low on utilitarianism focusing on total population effect, preferring the opposite, individualized approach of the rights and justice perspectives. Organizational investment in a utilitarian perspective might jeopardize ambulance professionals’ moral right to make individual assessments based on the needs of the patient at hand. Utilitarianism and a caring ethos appear as stark opposites. However, a caring ethos in its turn might well involve unreasonable demands on the individual carer’s professional role. Since both the justice and rights perspectives portrayed in the survey mainly concern relationship to the organization and peers within the organization, this relationship might at worst be given priority over the equal treatment and moral rights of the patient. Conclusion: A balanced view on ethical perspectives is needed to make professionals observant and ready to act optimally – especially if these perspectives are used in patient care. Research is needed to clarify how justice and rights are prioritized by ambulance services and whether or not these organization-related values are also implemented in patient care. (shrink)

Volume 19, Issue 10, October 2019, Page 105-107.

Volume 19, Issue 10, October 2019, Page 97-98.

Volume 19, Issue 10, October 2019, Page 99-101.

Emergency care providers regularly deal with ethical dilemmas that must be addressed. In comparison with in-hospital nurses, emergency medical service personnel are faced with more problems such as distance to resources including personnel, medico-technical aids, and information; the unpredictable atmosphere at the scene; arriving at the crime scene and providing emergency care for accident victims and patients at home. As a result of stressfulness, unpredictability, and often the life threatening nature of tasks that ambulance professionals have (...) to deal with every day, ethical decision-making has become an inevitable challenge. The content analysis approach was used to conduct the present qualitative study in Iran. The participants consisted of 14 EMS personnel selected through purposive sampling, which continued until the data became saturated. Data were collected using semi-structured interviews and analyzed concurrently with their collection through the constant comparison method. The process of data analysis resulted in the emergence of 3 main categories “respecting client’s values”, “performing tasks within the professional manner”, “personal characteristic”, and the emergence of eight sub-categories signifying participants’ experiences with regard to EDM. According to the results, when EMS personnel are faced with ethical dilemmas, they consider the client’s values and professional dignity, and perform the assigned tasks within the framework of the regulation. The findings also suggest that pre-hospital care providers assess legal consequences before making any decision. Further studies should be conducted regarding the experiences of the subordinates and other related parties. (shrink)

Michael Blake holds that liberal states are precluded from introducing compulsory medical service to improve access to health care under conditions of critical health worker shortage. "Emergency circumstances" are the only exception when the suspension of liberty may be justified. I argue that there are three problems with Blake's emergency justification of compulsory service. First, his concept of emergency is vague. Second, his account does not really rely on emergency as much as liberty. Third, his (...) conception of permissible restrictions of liberty is too narrow. I argue that liberties may be limited to some degree, temporarily, for the sake of attaining the capacities necessary for the exercise of liberties and for safeguarding the social conditions of the right to health. I conclude that in poor societies, temporarily delaying emigration through a highly qualified compulsory medical service can sometimes be justified. (shrink)

Background: In Hospital Emergency Department and Emergency Medical Services professionals experience situations in which they face difficulties or barriers to know patient’s advance directives and implement them. Objectives: To analyse the barriers, facilitators, and ethical conflicts perceived by health professionals derived from the management of advance directives in emergency services. Research design, participants, and context: This is a qualitative phenomenological study conducted with purposive sampling including a population of nursing and medical professionals linked (...) to Hospital Emergency Department and Emergency Medical Services. Three focus groups were formed, totalling 24 participants. We performed an inductive-type thematic discourse analysis. Ethical considerations: This study was approved by ethical committees of Ethical Commitee of Clínic Hospital (Barcelona) and Comittee of Emergency Medical Services (Barcelona). The participants received information about the purpose of the study. Patients’ anonymity and willingness to participate in the study were guaranteed. Findings: There were four types of barriers that hindered the proper management of patients’ advance directives in Hospital Emergency Department and Emergency Medical Services: personal and professional, family members, organisational and structural, and those derived from the health system. These barriers caused ethical conflicts and hindered professionals’ decision-making. Discussion: These results are in line with those of previous studies and indicate that factors such as gender, professional category, and years of experience, in addition to professionals’ beliefs and the opinions of colleagues and family members, can also influence the professionals’ final decisions. Conclusion: The different strategies described in this study can contribute to the development of health policies and action protocols to help reduce both the barriers that hinder the correct management and implementation of advance directives and the ethical conflicts generated. (shrink)

Medical assistance in dying (MAiD) in Canada is a complex, novel interprofessional practice governed by stringent legal criteria. Often, patients need assistance navigating the system, and MAiD providers/assessors struggle with the administrative challenges of MAiD. Resultantly, the role of the MAiD care coordinator has emerged across the country as a novel practice dedicated to supporting access to MAiD and ensuring compliance with regulatory requirements. However, variability in the roles and responsibilities of MAiD care coordinators across Canada has highlighted the (...) need for accountability and standardization for this practice. This manuscript constitutes a first attempt to describe this emerging role, through discussion of proposed standards of practice, as well as roles and responsibilities, and ethical duties of this emergent professional practice. We detail the core commitments of MAiD care coordinators to patients, providers/assessors and institutions involved in the MAiD process. We address the core competencies that inform the unique skillset required by MAiD care coordinators to facilitate high-quality care, while highlighting the moral and ethical considerations embedded in this work. To illustrate the complexity of the MAiD care coordinator role, case examples involving ethical dilemmas encountered in practice are included. Finally, a code of ethics is proposed to serve as a guide for appropriate professional practice and conduct. This manuscript is intended to illustrate the importance of transparency and accountability for this new role that provides service to vulnerable patients and families; this is especially critical as the ethical complexity of MAiD is likely to increase with future changes in legislation opening MAiD access to new populations. (shrink)

Background: Emergency care providers are frequently faces with situations in which they have to make decisions quickly in stressful situations. They face barriers to ethical decision-making and recognizing and finding solutions to these barriers helps them to make ethical decision. Objectives: The purpose of this study was to identify barriers of ethical decision-making in Iranian Emergency Medical Service personnel. Methods: In this qualitative research, the participants (n = 15) were selected using the purposive sampling method, and the (...) data were collected by deep and semi-structured interviews. Finally, the data are analyzed using the content analysis approach. Ethical considerations: Permission to conduct the study was obtained from the Ethics Committee of the Shahid Beheshti University of Medical Sciences. The objectives of the study were explained to the participants and written consent was received from them. Also, participants were assured that necessary measures were taken to protect their anonymity and confidentiality. Findings: The results of the analysis are classified in five main categories. It encompasses the following areas: perception of situation, patient-related factors, input and output imbalance, uncoordinated health system, and paradoxes. Conclusion: Emergency Medical Service personnel make ethical decisions every day. It is important that prehospital personnel know how to manage those decisions properly so that clients’ moral rights are respected. Hence, by identifying the dimensions and obstacles of ethical decision-making in Emergency Medical Service personnel, it is possible to enhance the moral judgment and ethical accountability of the personnel and develop the strategies necessary for ethical decision-making in them. (shrink)

Background The ambulance service provides emergency care to meet the patient’s medical and nursing needs. Based on professional nursing values, this should be done within a caring relationship with a holistic approach as the opposite would risk suffering related to disengagement from the patient’s emotional and existential needs. However, knowledge is sparse on how ambulance personnel can meet caring needs and avoid suffering, particularly in conjunction with urgent and emergency situations. Aim The aim of the study was (...) to explore ambulance nurses’ experiences of relationships with patients in urgent and emergency situations. Methods Data collection was performed using individual open-ended interviews with six ambulance nurses. The data were analyzed using a thematic analysis. Results Relationships with patients during urgent and emergency assignments emerged as three themes: “ Ambiguous silence,” “ Professional competence” and “ Challenging inadequacy” comprising eight sub-themes in total. The result shows that the ambulance nurses found it difficult to prioritize between medical care and establishing a caring relationship with the patient. However, sometimes a wordless relationship was perceived sufficient and considered a first step towards a verbal relationship. Conclusions Ambulance nurses experience that a caring relationship cannot and does not need to be prioritized in the acute stage. This uncovers a dichotomy approach to medical care versus caring relationships that exclude a holistic approach. Thus, patients’ emotional, existential and physical needs are not considered as equally important. Clinical relevance: It is important to stimulate reflection on core ethical nursing values, in training and simulation exercises among clinically active ambulance nurses. (shrink)

Crowdfunding websites allow users to post a public appeal for funding for a range of activities, including adoption, travel, research, participation in sports, and many others. One common form of crowdfunding is for expenses related to medical care. Medical crowdfunding appeals serve as a means of addressing gaps in medical and employment insurance, both in countries without universal health insurance, like the United States, and countries with universal coverage limited to essential medical needs, like Canada. For (...) example, as of 2012, the website Gofundme had been used to raise a total of 8.8 million dollars for seventy-six hundred campaigns, the majority of which were health related. This money can make an important difference in the lives of crowdfunding users, as the costs of unexpected or uninsured medical needs can be staggering. In this article, I offer an overview of the benefits of medical crowdfunding websites and the ethical concerns they raise. I argue that medical crowdfunding is a symptom and cause of, rather than a solution to, health system injustices and that policy-makers should work to address the injustices motivating the use of crowdfunding sites for essential medical services. Despite the sites’ ethical problems, individual users and donors need not refrain from using them, but they bear a political responsibility to address the inequities encouraged by these sites. I conclude by suggesting some responses to these concerns and future directions for research. (shrink)

BackgroundImplementing the routine consultation of patient advance directives in hospital emergency departments and emergency medical services has become essential, given that advance directives constitute the frame of reference for care personalisation and respect for patients’ values and preferences related to healthcare. The aim of this study was to assess the levels and relationship of knowledge and attitudes of nursing and medical professionals towards advance directives in hospital emergency departments and emergency medical (...) class='Hi'>services, and to determine the correlated and predictor variables of favourable attitudes towards advance directives.MethodsObservational, descriptive, and cross-sectional study. The study was conducted in the emergency department of a second-level hospital and in the emergency medical service. Data collection was performed from January 2019 to February 2020. The STROBE guidelines were followed for the preparation of the study.ResultsA total of 173 healthcare professionals responded to the questionnaire. Among them, 91.3% considered that they were not sufficiently informed about advance directives, and 74% acknowledged not having incorporated them into their usual practice. Multinomial analysis indicated a statistically significant relationship between the variable emergency medical service and having more favourable attitudes towards consulting the advance directives in their practical application (OR 2.49 [95% CI 1.06–5.88]; p = 0.037) and compliance in complex scenarios (OR 3.65 [95% CI 1.58 − 8.41]; p = 0.002). Working the afternoon and night shift was a predictor variable for obtaining a higher score with respect to attitudes in complex scenarios.ConclusionThere is an association between the level of knowledge that nursing and medical professionals have about advance directives and the scores obtained on the attitude scales at the time of practical implementation and in complex scenarios. This shows that the more knowledge professionals have, the more likely they are to consult patients' advance directives and to respect their wishes and preferences for care and/or treatment. (shrink)

Background: Decision-making and assessment in emergency situations are complex and result many times in ethical conflicts between different healthcare professionals. Aim: To analyse and describe situations that can generate ethical conflict among nurses working in emergency situations. Methods: Qualitative analysis. A total of 16 emergency nurses took part in interviews and a focus group. Ethical considerations: Organisational approval by the University Hospital, and informed consent and confidentiality were ensured before conducting the research. Result/conclusion: Two categories emerged: one (...) in ‘ethical issues’ and one in ‘emotions and feelings in caring’. The four ethical subcategories are presented: Autonomy, the first sub category: first, the nurse’s ability to practise care on an emergency ward and, second, to support the patient and/or relatives in terms of care and medical treatment. The conflicts arise when the nurse ends up in the middle between the patient and the physician responsible for the diagnosis and treatment from a nature scientific perspective. Reification of injured body: patient was often reified and fragmented, becoming just a leg or arm. Different factors contributed in this perspective. Pain: pain relief was often inadequate but more effectively treated in the emergency medical services than at the emergency department. The nurses highlighted the phenomenon of suffering because they felt that pain was only an object, forgetting the patients’ care need, like separating mind from body. Death: the nurses felt that the emergency services are only prepared to save lives and not to take care of the needs of patients with ‘end-of-life’ care. Another issue was the lack of ethical guidelines during a cardiac arrest. Resuscitation often continues without asking about the patient’s ‘previous wishes’ in terms of resuscitation or not. In these situations, the nurses describe an ethical conflict with the physician in performing their role as the patient’s advocate. The nurses express feelings of distress, suffering, anger and helplessness. (shrink)

Progress in medicine and the subsequent extension of health coverage has meant that health expenditure has increased sharply in Western countries. In the United States, this rise was precipitated in the 1980s, compounded by an increase in drug consumption which prompted the government to re-examine its financial support to care delivery, most notably in hospital care and emergencies services. In California for example, 50 emergency service providers were closed between 1990 and 2000, and nine in 1999–2000 alone. In (...) that State, only 355 hospitals (out of 568) have maintained emergency services departments (Darves, WebMB, 2001). Reforming hospital Emergency Department (ED) operations requires caution not only because the media pay a lot of attention to ED operations, but also because it raises ethical issues: this became more apparent with the enactment of the EMTALA which stipulates that federally funded hospitals are required to give emergency aid in order to “stabilize” a patient suffering from an “emergency medical condition” before discharging or transferring that patient to another facility. While in essence the law aims to preserve patient access to care, physicians assert that the EMTALA leads to more patients seeking care for non-urgent conditions in EDs (GAO, Report to Congressional Committees, 2001), leading to overcrowding, delayed care for patients with true emergency needs, and forcing hospitals to divert ambulances to other facilities resulting in further delays in urgent care. Also, fewer physicians are willing to be on-call in emergency departments because the EMTALA law requires on-call physicians to provide uncompensated care. Thus there is a need to find a balance between appropriate care to be provided to ED patients, and low costs since uncompensated care is not covered by state or federal funds. This concerns, first and foremost, hospitals that provide a greater amount of uncompensated care (e.g. hospitals serving communities with a higher population of illegal immigrants). Looking at the intrinsic causes of high ED costs, the paper first explains why costs of care provided in EDs are high, and look at a major cause of high ED costs: overcrowding and ED users’ characteristics. This is followed by a discussion on a much-debated factor: the use of EDs for non-emergency conditions, a practice which has often been accused of disproportionately raising costs. We look at various mechanisms used either to divert or prevent the patient from using ED: these include triage services; and the role of HMOs in the ED chain of care: though the US government has increasingly relied on Managed Care organizations to contain costs (e.g. Medicaid and Medicare Managed Care), do HMOs make a difference when it comes to ED costs? Of particular interest is the family physician acting as a gatekeeper, and the legislation that was enacted to protect those who bypass the referral system. We then look at the other end of the ED chain (i.e. the recipient): the financial responsibility of ED users has increased. Alternative providers such as walk-in clinics are increasingly common. EDs also attempt to reengineer their operations to curb costs. While the data are mostly applicable to a private health care system (e.g. the US), the article, using a critical assessment of the existing literature, has implications for other EDs generally, wherever they operate, since every ED faces similar funding problems. (shrink)

Background: As a fundamental human right in healthcare, informational privacy creates the foundation for patient’s safety and the quality of care. However, its realization can be a challenge in prehospital emergency care, considering the nature of the work. Objectives: To describe patient’s informational privacy, its realization, and the factors related to the realization in prehospital emergency care from the perspective of paramedics. Research design: A descriptive questionnaire study was conducted. The data were analyzed with inductive content analysis. Participants (...) and research context: The participants (n = 26) were paramedics in one of the 22 rescue departments in Finland. Ethical considerations: The study received ethical approval from the ethics committee of the University of Turku (Finland). Permission for the study was given by the collaborating rescue department. Findings: Paramedics described patient’s informational privacy as patients’ right to their own health records, as protection of the patient’s health records, and as comprehensive respect of the patient’s privacy by the persons involved in the patient’s care. In general, informational privacy was described as being realized regarding confidentiality, reporting, and maintaining the patient’s health records. However, it was also described as being dependent on the context, and some areas in need of improvement were identified. Promoting and preventing factors related to the realization were also identified. The promoting factors were paramedics’ professional activity, environment, training, and guidelines. The preventing factors were the nature of the work, paramedics’ attitudes, and the lack of knowledge concerning informational privacy among paramedics, the collaborating authority, patients, and relatives. Discussion and conclusion: Paramedics had a multidimensional understanding of informational privacy and the factors related to its realization. However, its realization varies, and more research and education are therefore needed to enhance the realization and to provide equal and high-quality care for all the patients in prehospital emergency care. (shrink)

There has been a significant increase in the use of radiological services in the past 30 years. There are many reasons for this, but one has received little attention: the increased role of patient autonomy in healthcare. Patients demand x rays, CT scans, MRI, and positron emission tomography scans. The key question in this article is how a moral principle, such as respect for patient autonomy, can influence the extension of radiological services. A literature review reveals how patient (...) autonomy is acknowledged in radiology, and how it is used both to explain and to justify the increase in radiological examinations. Furthermore, it also shows how the premises favouring patients’ exercise of their autonomy are not always present, which makes patient autonomy subject to adverse side effects and even abuse. Patient autonomy can be used to reduce the professionals’ responsibility for radiological examinations , to increase the popularity of the profession , to increase the income of the professionals or their institutions, and to promote professional activity. Patient autonomy intended to reduce paternalism, to legitimise otherwise morally unjustifiable actions , and to protect patients, can easily be used as a moral means for opposite ends. These adverse effects are not peculiar to radiology. However, they emerge particularly clearly in explanations and justifications of the substantial increase in radiological services, as well as in debates on overuse of radiological services. (shrink)

With the ultrahigh-speed, large-scale development of tourism and the increasing frequency, intensity, and scope of extreme natural hazards in the context of climate warming, tourism has entered a high-risk era. Based on the central urban area within the outer ring of Shanghai as the research area and the tourism attraction as the research object, this paper takes the flood scenario simulation combined with GIS network analysis to evaluate the spatial accessibility of the emergency response of urban key public service (...) departments under current and future river flood scenarios in different return periods. The results of the study show that, under the current and future flood scenarios, the submergence range is mainly distributed within 2 ∼ 3 km along the banks of the Huangpu River, and it tends to increase from north to south; there are 6, 9, and 21 tourism attractions in the emergency blind area under the once-in-a-century floods in 2010, 2030, and 2050 and 98, 105, and 112 tourism attractions in the emergency blind area under the once-in-a-millennium floods in 2010, 2030, and 2050, respectively; in the flood scene, local road traffic in the inundation area is interrupted by water, and 120 first aid cannot get or be delayed to some tourist attraction ; and in 2030, under the normal and flooding scenarios, 120 first aid in the downtown area of Shanghai has the fastest route to tourism attractions according to the speed of S1, S2, S3, and S4. The flooding intensity, road traffic conditions, and the number and location of key public service departments jointly determine the service scope and response time of medical emergency in urban floods. Since the flood control area of the central city in Shanghai is mainly distributed in the 2 ∼ 3 km area on both banks of the Huangpu River, the impact of flood on the emergency medical service in the entire central city is limited, mainly in some hospitals in the riverside area, where 120 emergency vehicles are unable or delayed to reach some tourism attractions. The research indicates that the quantitative assessment method of spatial accessibility of the emergency response under flood scenario simulation has important scientific value and practical significance, which can provide decision-making basis for emergency management of tourism in China’s urban flood disaster. (shrink)

Background Teamwork in emergency medical services is a very important factor in efforts to improve patient safety. The potential differences of staff gender on communication, patient safety, and teamwork were omitted. The aim of this study is to evaluate these inadequately examined areas. Methods A descriptive and anonymous study was conducted with an online questionnaire targeting emergency physicians and paramedics. The participants were asked about teamwork, communication, patient safety and handling of errors. Results Seven hundred fourteen (...) prehospital professionals from all over Germany participated. A total of 65.7% of the women harmed a patient (men 72.9%), and 52.6% were ashamed when mistakes were made (men 31.7%). 19.0% of the female participants considered their communication skills to be very good, compared to 81% of the men. More women than men did not want to appear incompetent (28.4%, 15.5%) and therefore did not speak openly about mistakes. Both genders saw the character of their colleagues as a reason for poor team communication (women 89.4%, men 84.9.%). Under high stress, communication decreased (women 35.9%, men 31.0%) and expression became inaccurate (women 18.7%, men 20.1%). Conclusions Team communication problems and teamwork in rescue services are independent of gender. Women seem to have more difficulty with open communication about mistakes because they seem to be subject to higher expectations. Work organization should be adapted to women’s needs to enable more effective error management. We conclude that it is necessary to promote a positive error and communication culture to increase patient safety. (shrink)

COVID-19 continues to dominate 2020 and is likely to be a feature of our lives for some time to come. Given this, how should health systems respond ethically to the persistent challenges of responding to the ongoing impact of the pandemic? Relatedly, what ethical values should underpin the resetting of health services after the initial wave, knowing that local spikes and further waves now seem inevitable? In this editorial, we outline some of the ethical challenges confronting those running health (...) services as they try to resume non-COVID-related services, and the downstream ethical implications these have for healthcare professionals’ day-to-day decision making. This is a phase of recovery, resumption and renewal; a form of reset for health services.1 This reset phase will define the ‘new normal' for healthcare delivery, and it offers an opportunity to reimagine and change services for the better. There are difficulties, however, healthcare systems are already weakened by austerity and the first wave of COVID-19 and remain under stress as the pandemic continues. The reset period is operating alongside, rather than at the end, of the pandemic and this creates difficult ethical choices. ### Balancing the greater good with individual care Pandemics—and public health emergencies more generally—reinforce approaches to ethics that emphasise or derive from the interests of communities, rather than those grounded in the claims of the autonomous individual. The response has been to draw on more public health focused ethics, ‘if demand outstrips the ability to deliver to existing standards, more strictly utilitarian considerations will have to be applied, and decisions about how to meet the individual's need will give way to decisions about how to maximise overall benefit’.2 Alongside this, effective …. (shrink)

Introduction: Prehospital emergency medicine is a specific field of emergency medicine. The basic approach of prehospital emergency medicine is to provide patients with medical intervention at the scene of the incident. This special environment causes health professionals to encounter various problems. One of the most important problems in this field is ethics, in particular questions involving refusal of treatment and the processes associated with it. Objective: The objective of this study is to identify emergency health (...) professionals’ views regarding refusal of treatment. Methods: This study was conducted with 356 health professionals who were on active duty in prehospital emergency health services. The data were collected through a form which included 10 statements. The participants were asked to indicate their level of agreement with the statements given by rating them between 0 and 10. Ethical considerations: Before conducting the research, permission was received from the local ethics committee. Participants were given written information about the purpose of the study. Participants were assured that their participation was voluntary. Results: The healthcare professionals with fewer years of experience in the profession and female participants adopted an attitude of giving priority to providing care. Young participants, in general, respected patient autonomy. However, paradoxically, when it comes to emergency medical cases, they expressed an opinion closer to paternalism. Conclusions: This study has found that prehospital emergency health professionals generally respect the patient’s right to refuse treatment; however, they do not prioritize this right when there is a life-threatening situation or when the person does not have decision-making capacity. In these cases, prehospital emergency health professionals tended to adopt a more paternalistic approach. (shrink)

It has been reported as an ethical problem within prehospital emergency care that ambulance professionals administer physiologically futile cardiopulmonary resuscitation (CPR) to patients having suffered cardiac arrest to benefit significant others. At the same time it is argued that, under certain circumstances, this is an acceptable moral practice by signalling that everything possible has been done, and enabling the grief of significant others to be properly addressed. Even more general moral reasons have been used to morally legitimize the use (...) of futile CPR: That significant others are a type of patient with medical or care needs that should be addressed, that the interest of significant others should be weighed into what to do and given an equal standing together with patient interests, and that significant others could be benefited by care professionals unless it goes against the explicit wants of the patient. In this article we explore these arguments and argue that the support for providing physiologically futile CPR in the prehospital context fails. Instead, the strategy of ambulance professionals in the case of a sudden death should be to focus on the relevant care needs of the significant others and provide support, arrange for a peaceful environment and administer acute grief counselling at the scene, which might call for a developed competency within this field. (shrink)

Law can greatly facilitate responses to public health emergencies, including naturally-occurring infectious disease outbreaks and intentional or accidental exposures to chemical, biological, radiological, or nuclear agents. At the federal level, the Secretary of the Department of Health and Human Services, as the lead for federal public health and medical responses to public health emergencies and incidents, has a range of authorities to support federal, state, tribal, local, and territorial responses. For example, under the Public Health Service Act, the (...) Secretary may provide temporary assistance to States to meet health emergency needs or deploy medicine and supplies from the Strategic National Stockpile. The Secretary also may determine that a disease or disorder presents a public health emergency, which may be the first step in triggering other critical legal authorities for response.Since the 2001 anthrax attacks, one focus of public health preparedness has been on developing, distributing, and rapidly dispensing medical countermeasures for CBRN emergencies and pandemics. (shrink)

Background Even though the traditional focus in emergency care is on life-threatening medical crisis, ambulance clinicians frequently encounter patients with mental illness, including suicidal ideation. A suicide is preceded by a complex process where most of the suicidal ideation is invisible to others. However, as most patients seek healthcare in the year before suicide, ambulance clinicians could have an important part to play in preventing suicide, as they encounter patients in different phases of the suicidal process. Aim The (...) aim of this study was to describe ambulance clinicians’ conceptions of responsibility when encountering patients in a suicidal process. Research design A qualitative inductive design using a phenomenographic approach was used. Participants and research context Twenty-seven ambulance clinicians from two regions in southern Sweden were interviewed. Ethical considerations The study was approved by the Swedish Ethical Review Authority. Findings Three categories of descriptions captured a movement from responding to a biological being to responding to a social being. Conventional responsibility was perceived as a primary responsibility for emergency care. In conditional responsibility, the patient’s mental illness was given only limited importance and only if certain conditions were met. Ethical responsibility was perceived to have its primary focus on the encounter with the patient and listening to the patient’s life story. Conclusions An ethical responsibility is favourable regarding suicide prevention in ambulance care, and competence development in mental illness and conversation skills could enable ambulance clinicians to have conversations with patients about suicidal ideation. (shrink)

Background: Since 2010, the United States has experienced 228 disasters, affecting over 86 million people. Because of population shifts, the growing number of people living with chronic conditions or disabilities, and the growing number of older citizens living independently, access and service gaps often exist for those without money or other transferable resources. There is a lack of evidence regarding individual community members’ capacity to prepare for emergencies. Research objective: The purpose of this study is to highlight participant experiences in (...) becoming better prepared for emergencies and provide insight from a social justice perspective. Research design: This is a descriptive qualitative study, staying very close to the data as an end product rather than a beginning for interpretation. Participants and research context: A total of 13 low-income, uninsured, or under-insured attendees at a medical outreach clinic were interviewed. Ethical considerations: Institutional Review Board approval was obtained from the University of Texas at Tyler. Findings: Four themes emerged from the interview data: (a) evaluation of the emergency-preparedness education, (b) making emergency plans, (c) challenges in preparing for emergencies, and (d) facilitators of emergency preparedness. Discussion: Identifying the potential challenges to individual emergency preparedness among vulnerable populations is the first step in overcoming them. The capacity to comply with such measures, especially the ability of those with limited incomes and other vulnerable populations, must be considered. Conclusion: Synchronized, well-ordered assistance will close gaps in recovery and enhance efficiency in pre- and post-event aid. Theoretically, doing so will promote engaged and resilient members of society who are better able to withstand adverse events. The importance of the relationship between individual preparedness levels and the resiliency of nations supports the social justice imperative to address the needs of vulnerable populations in the mitigation and planning phase of the emergency management cycle. (shrink)

AbstractBackgroundEthical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. In prehospital emergency medicine, decision-making commonly takes place in everyday life, under time pressure, with limited information about a patient and with few possibilities of consultation with colleagues. This paper explores the ethical challenges experienced by prehospital emergency personnel. MethodsThe study was grounded in the tradition of action research related to interventions in health care. Ethical challenges were explored in three focus groups, each (...) attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. The participants, 15 in total, were recruited through an internal information network of the emergency services. Focus groups were audio-recorded and transcribed verbatim.ResultsThe participants described ethical challenges arising when clinical guidelines, legal requirements, and clinicians’ professional and personal value systems conflicted and complicated decision-making processes. The challenges centred around treatment at the end of life, intoxicated and non-compliant patients, children as patients—and their guardians, and the collaboration with relatives in various capacities. Other challenges concerned guarding the safety of oneself, colleagues and bystanders, prioritising scarce resources, and staying loyal to colleagues with different value systems. Finally, challenges arose when summoned to situations where other professionals had failed to make a decision or take action when attending to patients whose legitimate needs were not met by the appropriate medical or social services, and when working alongside representatives of authorities with different roles, responsibilities and tasks.ConclusionFrom the perspective of the prehospital emergency personnel, ethical challenges arise in three interrelated contexts: when caring for patients, in the prehospital emergency unit, and during external collaboration. Value conflicts may be identified within these contexts as well as across them. A proposed model of analysis integrating the above contexts can assist in shedding light on ethical challenges and value conflicts in other health care settings. The model emphasises that ethical challenges are experienced from a particular professional perspective, in the context of the task at hand, and in a particular, the organisational setting that includes work schedules, medical guidelines, legal requirements, as well as professional and personal value systems. (shrink)

This article examines the Emergency Medical Treatment and Labor Act in a public health emergency context. Congress enacted EMTALA in 1986 to prohibit the practice of “patient clumping,” which involved hospitals’ refusal to undertake emergency screening and stabilization services for individual patients who sought emergency room care, typically because of insurance status, inability to pay, or other grounds unrelated to the patient’s need for the services or the hospital’s ability to provide them. But (...) in fact EMTALA, whose conceptual roots can be found in the Hospital Survey and Construction Act of 1946 as well as an evolution in both the common law and state statutes related to hospital licensure, can be viewed as having a far broader purpose than protection of individuals, and indeed, one that is related to the protection of communities and the public health. (shrink)

“Recognizing that prisons disproportionately confine sick people, with mental illness, substance abuse, HIV disease among other illnesses; and that prisoners are subject to further morbidity and mortality in these institutions, due to lack of access and/or resources for health care, overcrowding, violence, emotional deprivation, and suicide.… condemns the social practice of mass imprisonment.”After decades of steady decline, tuberculosis has emerged as a significant public health threat in the United States. The rising rates of tuberculosis cases, an increasing proportion of which (...) are resistant to standard chemotherapies, are linked to the many scourges threatening our communities: the explosion of poverty, drug use, violence, the HIV epidemic, and the concomitant rise in congregate housing including homeless shelters, residential drug treatment programs and incarceration facilities. Jails and prisons have disproportionately high rates of tuberculosis infection and have been implicated as points of tuberculosis spread and, as such, are a critical point for tuberculosis control interventions. (shrink)

Drawing on philosophy, law and political science, and on a wealth of practical experience delivering emergency medical services in conflict-ridden settings, Lepora and Goodin untangle the complexities surrounding compromise and complicity.

Respecting privacy and patients’ satisfaction are amongst the main indicators of quality of care and one of the basic goals of health services. This study, carried out in 2007, aimed to investigate the extent to which patient privacy is observed and its correlation with patient satisfaction in three emergency departments of Tehran University of Medical Science, Iran. Questionnaire data were collected from a convenience sample of 360 patients admitted to emergency departments and analysed using SPSS software. (...) The results indicated that, according to 50.6% of the patients, the extent to which their privacy was respected was described as either ‘weak’ or ‘average’. Spearman’s coefficient indicated a significant correlation between respecting privacy and the patients’ satisfaction about the various aspects of privacy studied. Considering the levels of privacy observed together with the patients’ degree of satisfaction, it is imperative that clinical professionals address both aspects from conceptual and practical viewpoints. (shrink)

The Emergency Department is a crucial medical treatment unit of hospital specializing in emergency medicine. EDs are responsible for providing immediate healthcare facilities to patients arriving without prior appointment. Thus, evaluating patient satisfaction is of immense importance for efficient service delivery. Very few studies are found in Pakistan, related to patients’ satisfaction and utilization of ED services both from demand and supply perspective of ED-Services Supply Chains. Data was collected to assess 200 patient’s satisfaction towards (...) quality of healthcare services of ED of Sindh Government Qatar Hospital, Orangi town-a tertiary care hospital in Karachi. Structured questionnaire was developed to interview patients and their attendants. Results of SPSS analysis revealed that 55% of patients were transferred to ED within 5 minutes, which shows efficient patient queues and flow management. 64.5% patient’s average LOS was between 40-60 minutes. 71% get the availability of basic facilities in ED. Majority of patients i.e. 96.5% and 90.5%, showed satisfaction with the time spent and treatment given by the doctor. Majority of the patients are satisfied with the services and performance of ED of a tertiary care hospital and 76% patients showed willingness to recommend ED of Government Qatar Hospital, Karachi to others. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Medical Tourism:Crossing Borders to Access Health CareHarriet Hutson Gray (bio) and Susan Cartier Poland (bio)Traveling abroad for one's health has a long history for the upper social classes who sought spas, mineral baths, innovative therapies, and the fair climate of the Mediterranean as destinations to improve their health. The newest trend in the first decade of the twenty-first century has the middle class traveling from developed countries to (...) those with emerging economies to avoid treatment delays, prohibitive costs for life-saving procedures, or simply high costs for elective surgery. Others leave to have access to assisted suicide in countries that have legalized it: Belgium, The Netherlands, and Switzerland. This new era of globalization in health care has arrived without the benefit of international standards, government oversight, or ethical and legal review.Howard Staab, a self-employed carpenter from North Carolina, flew to India for his medically necessary heart surgery, scheduled a side trip to the Taj Mahal, and returned home to work in North Carolina. He spent a total of less than $10,000, instead of the $200,000 required from the local hospital (I, Milstein and Smith 2006).At first blush, the outsourcing of medical care to India seems to be a particular solution for a particular problem. However, the particularity of Mr. Staab is not unique. His experience is emblematic of those patients in the United States with a medical need for major and elective procedures, but who also must bear the total cost of these procedures. These middle-class, under-insured Americans go abroad.In tandem with increasingly aggressive marketing campaigns, American hospitals and companies have begun to leverage their connections in Asia to grow the medical tourism business into a major economic force. What are the consequences of this?Several authors point to the effect on the host country's population, particularly the poor, to be pushed farther down the queue to receive adequate, affordable care. Resources are applied to the foreign trade instead of building the local [End Page 193] medical infrastructure. Another potential problem is the obligation of the home-country physician to provide follow-up care. What are the legal ramifications when the procedure was illegal to begin with? Are there opportunities for redress for medical errors?These factors may be converging into a "perfect storm" for health care in the U.S., in which the potential participation of the major insurance companies in promoting offshore care will be the tipping point in the precarious structure that represents the economic currents in health care. Third-party administrators and self-funded employers may be on the cutting edge in 2009 by providing incentives to employees to travel overseas for care.I. Economic ConsiderationsConnell, John. Medical Tourism: Sea, Sun, Sand and... Surgery. Tourism Management 27: 1093–1100, 2006.As evidence of the interest of traditional tour operators in this newer twist on the industry, the author explores medical tourism as an element of the growth of world tourism. In promoting medical tourism, he urges consideration of such issues as the privatization of health care, the foundational role of technology, and uneven access to health resources.Dunn, Philip. Medical Tourism Takes Flight. H and HN: Hospitals and Health Networks: 40–44, November 2007.Writing for U.S. health care executives, Dunn emphasizes that the reality of medical tourism competes with the local medical center for patients and their insurance dollars in a significant way. He examines the possibility that U.S. insurance plans soon may offer to pay for what is currently a cash only business and that the economic impact to the local medical center could be significant or even devastating.Frontiers of Health Services Management [Selected Articles] 24 (2), Winter 2007.In "Managing Healthcare Services in the Global Marketplace" (pp. 3–18), Bruce J. Fried and Dean M. Harris consider legal, ethical, and financial implications of the international workforce. In "Globalization of Health Care" (pp. 19–30), Lynn Schroth and Ruthy Khawahja point out that the transfer of comprehensive management expertise and intellectual property from U.S. medical centers to international sites is driving the success of collaboration between U.S. and foreign health care centers. In "Is... (shrink)

Machine generated contents note: Introduction. -- Acknowledgments. -- The Author. -- 1 Ethical Theories and Bioethics in a Global Perspective. -- Theories of Ethics. -- Are Theories of Ethics Global? -- Can Theories of Ethics Encourage People to Do the Right Thing? -- 2 Autonomy and Informed Consent in Global Perspective. -- Ethical Principles and Practical Issues of Informed Consent. -- Does Informed Consent Really Matter to Patients? -- Is Informed Consent a Universal Principle or a Cultural Value? -- 3 (...) Withholding or Withdrawing Treatment and Physician-Assisted Suicide. -- Withholding or Withdrawing Treatment at the End of Life. -- Assisting Patients in Committing Suicide. -- 4 Ethical Issues in Reproductive Health. -- Ethics of Abortion in Different Times, Places, and Cultures. -- Current Ethical Issues in Abortion. -- Assisted Reproductive Technology and Stem Cell Research. -- Emergency Contraception. -- Ethics of Imposing Conditions on Funding. -- 5 Ethical Issues of Female Genital Mutilation. -- The Facts About FGM. -- FGM as a Challenge to Ethical Relativism. -- Ethics of FGM for Adult Women. -- 6 Ethical Issues of Research with Human Subjects. -- Background Information and the Belmont Report. -- Autonomy and Voluntary Informed Consent. -- Beneficence and Cost-Benefit Analysis. -- Issues of Justice and Fairness for Human Subjects. -- 7 The Right to Health Care, and Ethical Obligations to Provide Care. -- Is There an Ethical Right to Health Care? -- Ethical Obligations of Health Care Professionals. -- Ethical Obligations of for-Profit Health Care Providers. -- 8 Ethical Issues in Rationing and Allocation of Limited Resources. -- Levels of Allocating Resources. -- Methods of Rationing Health Resources. -- Comparative Effectiveness Research and Cost-Effectiveness Analysis. -- 9 Ethical Issues of Health Insurance and Health System Reform. -- Ethical Issues in Financing Health Services and Designing Insurance Systems. -- Fundamental Values of Health Systems. -- 10 Ethical Issues in the Movement of Patients Across National Borders. -- Ethical Duties to Provide Health Care to Undocumented Aliens. -- Ethical Issues in Medical Tourism. -- 11 Ethical Issues in the Movement of Health Care Professionals Across National Borders. -- Ethical Issues in the Migration of Health Professionals. -- Proposed Solutions and Their Ethical Implications. -- Fair Treatment of Health Care Workers from Other Countries. -- 12 Corruption and Informal Payments in Health Systems. -- Payment of Informal Fees by Patients and Their Families. -- Is Corruption Bad for Your (and Other People's) Health? -- References. -- Index. (shrink)

Medically unexplained symptoms (MUS) are common and costly in both primary and secondary health care. It is gradually being acknowledged that there needs to be a variety of interventions for patients with medically unexplained symptoms to meet the needs of different groups of patients with such chronic long-term symptoms. The proposed intervention described herewith is called The BodyMind Approach (TBMA) and promotes learning for self-management through establishing a dynamic and continuous process of emotional self-regulation. The problem is the mismatch between (...) the patient’s mind-set and profile and current interventions. This theoretical article, based on practice-based evidence, takes forward the idea that different approaches (other than cognitive behaviour therapy) are required for people with MUS. The mind-set and characteristics of patents with MUS are reflected upon to shape the rationale and design of this novel approach. Improving services for this population in primary care is crucial to prevent the iterative spiralling downwards of frequent GP visits, hospital appointments, and Accident and Emergency attendance, all of which are common for these patients. The approach derives from embodied psychotherapy (authentic movement in dance movement psychotherapy) and adult models of learning for self-management. It has been developed from research and practice-based evidence. In this article the problem of MUS in primary care is introduced and the importance of the reluctance of patients to accept a psychological/mental health referral in the first instance is drawn out. A description of the theoretical underpinnings and philosophy of the proposed alternative to current interventions is then presented related to the design, delivery, facilitation and educational content of the programme. The unique intervention is also described to give the reader a flavour. (shrink)

I argue that despite criticism from some disability rights organizations, aid in dying is morally permissible. First, I suggest that disability-related concerns can be classified as emerging from one of two kinds of harm: person affecting, and personhood affecting. Second, I examine whether person affecting harm has occurred within those jurisdictions that have legalized aid in dying. I conclude that despite suggestions to the contrary, there is no evidence to demonstrate that people with disabilities have been adversely impacted by legalized (...) medical aid in dying. Third, I entertain these same arguments as a matter of principle and conclude the principled objections should not give us reason for concern. Fourth, I explore whether we have evidence to suggest the presence of increased personhood affecting harm where aid in dying is permissible. I suggest, through a focus on disability support services, that no evidence of social attitudes that diminish the moral worth of disabled people is present. Fifth, I examine whether we ought to have a principled concern with personhood affecting harm emerging from medical aid in dying. I conclude that to the contrary, to deny people with disabilities access to aid in dying constitutes a morally egregious form of personhood affecting harm. (shrink)

Rambam Medical Center, the only tertiary care center and largest hospital in northern Israel, was subjected to continuous rocket attacks in 2006. This extreme situation posed serious and unprecedented ethical dilemmas to the hospital management. An ambiguous situation arose that required routine patient care in a tertiary modern hospital together with implementation of emergency measures while under direct fire. The physicians responsible for hospital management at that time share some of the moral dilemmas faced, the policy they chose (...) to follow, and offer a retrospective critical reflection in this paper. The hospital’s first priority was defined as delivery of emergency surgical and medical services to the wounded from the battlefields and home front, while concomitantly providing the civilian population with all elective medical and surgical services. The need for acute medical service was even more apparent as the situation of conflict led to closure of many ambulatory clinics, while urgent or planned medical care such as open heart surgery and chemotherapy continued. The hospital management took actions to minimize risks to patients, staff, and visitors during the ongoing attacks. Wards were relocated to unused underground spaces and corridors. However due to the shortage of shielded spaces, not all wards and patients could be relocated to safer areas. Modern warfare will most likely continue to involve civilian populations and institutes, blurring the division between peaceful high-tech medicine and the rough battlefront. Hospitals in high war-risk areas must be prepared to function and deliver treatment while under fire or facing similar threats. (shrink)

Although medical providers rely on similar tools to “treat” intersex and trans individuals, their enactment of medicalization practices varies. To deconstruct these complexities, we employ a comparative analysis of providers who specialize in intersex and trans medicine. While both sets of providers tend to hold essentialist ideologies about sex, gender, and sexuality, we argue they medicalize intersex and trans embodiments in different ways. Providers for intersex people are inclined to approach intersex as an emergency that necessitates medical (...) attention, whereas providers for trans people attempt to slow down their patients’ urgent requests for transitioning services. Building on conceptualizations of “giving gender,” we contend both sets of providers “give gender” by “giving sex.” In both cases too, providers shift their own responsibility for their medicalization practices onto others: parents in the case of intersex, or adult recipients of care in the case of trans. According to the accounts of most providers, successful medical interventions are achieved when a person adheres to heteronormative gender practices. (shrink)

Medical tourism (MT) can be conceptualized as the intentional pursuit of non-emergency surgical interventions by patients outside their nation of residence. Despite increasing popular interest in MT, the ethical issues associated with the practice have thus far been under-examined. MT has been associated with a range of both positive and negative effects for medical tourists' home and host countries, and for the medical tourists themselves. Absent from previous explorations of MT is a clear argument of how (...) responsibility for the harms of this practice should be assigned. This paper addresses this gap by describing both backward looking liability and forward looking political responsibility for stakeholders in MT. We use a political responsibility model to develop a decision-making process for individual medical tourists and conclude that more information on the effects of MT must be developed to help patients engage in ethical MT. (shrink)

Mr. C is a twenty‐two‐year‐old who was flown to a level‐1 trauma center after diving headfirst into shallow water. Prior to this accident, he was in excellent health. At the scene, he had been conscious but was paralyzed and had no sensation below his neck. The emergency medical services team immobilized Mr. C's neck with a cervical collar and intubated him for airway protection before transport. As Mr. C's medical care proceeds, he expresses a desire for (...) extubation, although it was not clear that he had the capacity to make this (or any other) decision. It also was unclear whether this desire reflected his authentic wishes to be allowed to die or stemmed from feelings of discomfort and agitation. Over a period of several days, Mr. C's sedation was lightened, and the psychiatry service conducted a formal decision‐making capacity assessment. Mr. C continues to express a desire to withdraw life‐sustaining medical treatment. However, the psychiatry service is concerned that Mr. C seems to lack adequate insight into what it would mean to die.What does it mean to respect Mr. C's autonomy? (shrink)

This book addresses the moral, social and political problems emerging from the practice of healing and caring, biomedical research and the provision of health care services. The primary aim of many professional bioethicists is, of late, to solve as efficiently as possible, the problems encountered by health care providers and scientists in clinical, laboratory and administrative settings. Seen from the viewpoint of applied philosophy, however, this is a dangerous tendency if the grounds for the suggested solutions are not properly (...) examined. Even choices which are harmless and seem to involve no immoralities can be indirectly hazardous if those making choices appeal to dubious ethical principles or inaccurate data. This is why this book is dedicated to the examination of the reasons that people can and should have for their health care related decisions as well as to the formulation of good solutions to difficult problems. It covers criterial in life and death decisions, voluntary euthanasia and medical paternalism, wrongful medical authoritarianism, health education, preventive medicine and the welfare of the population, AIDS, discrimination and legal restrictions, and health care policy-making. (shrink)

Senior physicians of modern medicine in India play a key role in shaping policies and public opinion and institutional management. This paper explores their perceptions of medical tourism (MT) within India which is a complex process involving international demands and policy shifts from service to commercialisation of health care for trade, gross domestic profit, and foreign exchange. Through interviews of 91 physicians in tertiary care hospitals in three cities of India, this paper explores four areas of concern: their understanding (...) of MT, their views of the hospitals they work in, perceptions of the value and place of MT in their hospital and their views on the implications of MT for medical care in the country. An overwhelming majority (90%) of physicians in the private tertiary sector and 74.3 percent in the public tertiary sector see huge scope for MT in the private tertiary sector in India. The private tertiary sector physicians were concerned about their patients alone and felt that health of the poor was the responsibility of the state. The public tertiary sector physicians’ however, were sensitive to the problems of the common man and felt responsible. Even though the glamour of hi-tech associated with MT dazzled them, only 35.8 percent wanted MT in their hospitals and a total of 56 percent of them said MT cannot be a public sector priority. 10 percent in the private sector expressed reservations towards MT while the rest demanded state subsidies for MT. The disconnect between their concern for the common man and professionals views on MT was due to the lack of appreciation of the continuum between commercialisation, the denial of resources to public hospitals and shift of subsidies to the private sector. The paper highlights the differences and similarities in the perceptions and context of the two sets of physicians, presents evidence, that questions the support for MT and finally analyzes some key implications of MT on Indian health services, ethical issues emerging out of that and the need for understanding the linkages between public and private sectors for a more effective intervention for an equitable medical care policy. (shrink)

To practise ‘fairly and justly’ a clinician must balance the needs of both the many and the few: the individual patient in front of them, and the many unseen patients in the waiting room, and in the county. They must consider the immediate clinical needs of those in the present, and how their actions will impact on future patients. The good medical practice guidance ‘Make the care of your patient your first concern’ provides no guidance on how doctors should (...) act when they care for multiple patients with conflicting needs. Moreover, conflicting needs extend far past simply those between different patients. At an organisational level, financial obligations must be balanced with clinical ones; the system must support those who work within it in a variety of roles; and, finally, in order for a healthcare service to be sustainable, the demands of current and future generations must be balanced.The central problem, we propose, is that there is no shared philosophical framework on which the provision of care or the development of health policy is based, nor is there a practical, fair and transparent process to ensure that the service is equipped to deal justly with new challenges as they emerge. Many philosophers have grappled with constructing a set of principles which would lead to a ‘good’ society which is just to different users; prominent among them is Rawls.Four important principles can be derived using a Rawlsian approach: equity of access, distributive justice, sustainability and openness. However, Rawls’ approach is sometimes considered too abstract to be applied readily to policymaking; it does not provide clear guidance for how individuals working within existing institutions can enact the principles of justice. We therefore combine the principles derived from Rawls with Scanlonian contractualism: by demanding that decisions are made in a way which cannot be ‘reasonably rejected’ by different stakeholders, we ensure that conflicting needs are considered robustly.We demonstrate how embedding this framework would ensure just policies and fair practice. We illustrate this by using examples of how it would help prevent injustice among different socioeconomic groups, prevent intergenerational injustice and prevent injustice in a crisis, for example, as we respond to new challenges such as COVID-19.Attempts to help individual doctors practise fairly and justly throughout their professional lives are best focused at an institutional or systemic level. We propose a practical framework: combining Scanlonian contractualism with a Rawlsian approach. Adopting this framework would equip the workforce and population to contribute to fair policymaking, and would ultimately result in a healthcare system whose practice and policies—at their core—were just. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Whisper Before You GoJohn K PettyDavid came with a bang.1A momentary prelude from a dysphonic chorus of pagers announce “Level 1 Pediatric Trauma—MVC ejected” before the abrupt crescendo of the trauma bay doors opening. He is maybe two. Maybe three–years–old. It is hard to tell when a child is strapped in, strapped down, nonverbal, intubated, and alone.The flight team speaks for him, “Four–year–old boy improperly restrained in a single–vehicle (...) crash into a ditch. He was partially ejected. He was unresponsive and pulseless at the scene. He got CPR and code drugs, and they got a pulse back. Emergency medical service (EMS) took him to the nearest hospital where they needled his chest, called for air transport, and scanned him up. He has been shocky for us since we picked him up. Glasgow Coma Scale (GCS) has been three the whole time. They said his head scan showed subarachnoid hemorrhage.”With the words of the flight team as background narrative, we get about doing our thing—hopefully more method and less madness. Bang, bang, bang! Check the tube. Vital signs. IV fluids. Place a chest tube. Hang the blood. Quick X–ray. Neuro exam—nothing. Get him off the board. Warm him up. Place the orogastric (OG) tube. Bang, bang, bang!The neurosurgery resident opens the CT scans from the other hospital. The brain and cervical spine scans show a disaster: some swelling and bleeding in the higher brain, but the worst damage is in the lower brain, brainstem, and top of the spinal cord. I have heard a neurosurgeon describe this pattern before as “internal decapitation.” Such language never makes it into the patient’s chart. For David the last two words of the neurosurgery consult note will eventually read, “Prognosis grim.”He remains unstable in the trauma bay. Inaction is death. We ultrasound his heart, abdomen, and pelvis. He has fluid that shouldn’t be around his heart. He is dying of the neuro injury we cannot control, but the pericardial fluid might be giving him shock, and we can control that. We can’t ignore the fluid. Shouldn’t ignore it. At least, wouldn’t ignore it. So, we bang up to the operating room. Squeezing blood. Spiking fluid. Oxygen tank and crash cart. Up we go.In the operating room, we do much and we do well. We release the fluid around the heart and find it was CPR, not heart injury that put it there. In the pericardial flash we get a view of the cardiac athlete, pounding like the 26th mile of the marathon. We explore the abdomen and find it swollen but innocent of an injury that would take his life. We place our lines and tubes as the neurosurgeons place theirs. If nothing else, we will be able to measure what lies ahead.“Good work, team,” and we bump the door on the way to the pediatric intensive care unit (PICU).The care in the PICU is more Apache brave than Gaelic knight—more bottles, fewer scissors. The curtains and carpets mute the tones. Our efforts continue, but I get a word that David’s father has arrived. He is sitting in a small, private waiting room off of the main PICU waiting room. The PICU staff colloquially refer to this as “the bad news room.” I take a seat next to a solitary man who is having the worst day of his life. His worst day so far.“I am Dr. Petty, and I am one of the doctors who is taking care of your son. I am very sorry about what has happened. Maybe you can tell me a little bit about what you understand is going on, and I’ll tell you what I know.” [End Page 17]He tells me that his wife was driving David back from her sister’s house, just the two of them. He doesn’t know what happened, but he got a call from the other hospital about the crash. His wife was badly hurt. He heard that David had died, but they got him back. Both were transferred up to the... (shrink)

The Physician Orders for Life-Sustaining Treatment Paradigm is designed to improve end-of-life care by converting patients’ treatment preferences into medical orders that are transferable throughout the health care system. It was initially developed in Oregon, but is now implemented in multiple states with many others considering its use. Accordingly, an observational study was conducted in order to identify potential legal barriers to the implementation of a POLST Paradigm. Information was obtained from experts at state emergency medical (...) class='Hi'>services and long-term care organizations/agencies in combination with a review of relevant state law. Legal analysis of survey responses and existing laws identified several potential state legal barriers to a POLST Paradigm implementation. The most potentially problematic barriers are detailed statutory specifications for out-of-hospital DNR protocols. Other potential barriers include limitations on the authority to consent to forgo life-sustaining treatments, medical preconditions, and witnessing requirements for out-of-hospital DNR protocols. (shrink)