Samia Hurst

Background Implicit prejudice can lead to disparities in treatment. The effects of specialty and experience on implicit obesity and mental illness prejudice had not been explored. The main objective was to examine how specializing in psychiatry/general medicine and years of experience moderated implicit obesity and mental illness prejudice among Swiss physicians. Secondary outcomes included examining the malleability of implicit bias via two video interventions and a condition of cognitive load, correlations of implicit bias with responses to a clinical vignette, and correlations with explicit prejudice. Methods In stage 1, participants completed an online questionnaire including a clinical vignette. In stage 2, implicit prejudice pre- and post- intervention was tested using a 4 x 4 between-subject design including a control group. In stage 3, explicit prejudice was tested with feeling thermometers and participants were debriefed. Participants were 133 psychiatrists and internists w...

As universal health coverage becomes the norm in many countries, it is important to determine public priorities regarding benefits to include in health insurance coverage. We report results of participation in a decision exercise among residents of Switzerland, a high-income country with a long history of universal health insurance and deliberative democracy. We adapted the Choosing Healthplans All Together (CHAT) tool, an exercise developed to transform complex healthcare allocation decisions into easily understandable choices, for use in Switzerland. We conducted CHAT exercises in twelve Swiss cities with recruitment from a range of socio-economic backgrounds, taking into account differences in language and culture. Compared to existing coverage, a majority of 175 participants accepted greater general practice gatekeeping (94%), exclusion of invasive life-sustaining measures in dying patients (80%), longer waiting times for non-urgent episodic care (78%), greater adherence to cost...

Gratitude is both expected and problematic in live organ donation. Are there grounds to require it, and to forbid access to live donor transplantation to a recipient who fails to signal that he feels any form of gratitude? Recipient gratitude is not currently required for organ donation, but it is expected and may be a moral requirement. Despite this, we argue that making it a condition for live organ transplantation would be unjustified. It would constitute a problematic and disproportionate punishment for perceived immoral behaviour on the part of the recipient. It would also bar the donor from positive aspects of organ donation that remain even in the absence of recipient gratitude. A potential recipient's lack of gratitude should be explored as a possible symptom of other morally problematic issues and integrated into the information provided to the potential donor. Recognition of the donor's gift and gratitude for it may also need to be expressed in part by others. This last aspect is relevant even in cases where the recipient feels and expresses gratitude.

Implicit biases involve associations outside conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender. This review examines the evidence that healthcare professionals display implicit biases towards patients. PubMed, PsychINFO, PsychARTICLE and CINAHL were searched for peer-reviewed articles published between 1st March 2003 and 31st March 2013. Two reviewers assessed the eligibility of the identified papers based on precise content and quality criteria. The references of eligible papers were examined to identify further eligible studies. Forty two articles were identified as eligible. Seventeen used an implicit measure (Implicit Association Test in fifteen and subliminal priming in two), to test the biases of healthcare professionals. Twenty five articles employed a between-subjects design, using vignettes to examine the influence of patient characteristics on healthcare professionals' attitudes, diagnos...

Responding to critical shortages of physicians, most sub-Saharan countries have scaled up training of non-physician clinicians (NPCs), resulting in a gradual but decisive shift to NPCs as the cornerstone of healthcare delivery. This development should unfold in parallel with strategic rethinking about the role of physicians and with innovations in physician education and in-service training. In important ways, a growing number of NPCs only renders physicians more necessary - for example, as specialized healthcare providers and as leaders, managers, mentors, and public health administrators. Physicians in sub-Saharan Africa ought to be trained in all of these capacities. This evolution in the role of physicians may also help address known challenges to the successful integration of NPCs in the health system.

... The ethics of research on pain and other symptoms for which effective treatments already exist Monica EscherandSamia Hurst The Case Dr ... investiga-tors can extend and impact on their relationship with their own physician, thus possibly jeopardizing rou-tine clinical care. 194 ...

Diaries are written for critically ill patients, to help them understand their intensive care stay and come to terms with their illness. The aim of this content analysis of eight such diaries is to understand the potential benefits for patients and families of this care intervention. A main category emerged: Sharing throughout the ICU time. Four themes were identified: (a) Sharing the story, (b) Sharing the presence, (c) Sharing feelings, and (d) Sharing through support. The first theme reflects the narration of daily events. The second is the perceived presence of health professionals and family at the patient's bedside and the presence of the patient as a person through the diary entries. The third theme describes the expression of feelings as written throughout the text. The last theme refers to the support offered to the patient. The diaries reflect the commitment and care of contributors to the patients' welfare.

Abstract Fair resource allocation in humanitarian medicine is gaining in importance and complexity, but remains insufficiently explored. It raises specific issues regarding non-ideal fairness, global solidarity, legitimacy in non-governmental institutions and conflicts of interest. All would benefit from further exploration. We propose that some headway could be made by adapting existing frameworks of procedural fairness for use in humanitarian organizations. Despite the difficulties in applying it to humanitarian medicine, it is possible ...

Abstract Clinical cases of frontal lobe lesions have been significantly associated with acquired aggressive behaviour. Restoring neuronal and cognitive faculties of aggressive individuals through invasive brain intervention raises ethical questions in general. However, more questions have to be addressed in cases where individuals refuse surgical treatment. The ethical desirability and permissibility of using intrusive surgical brain interventions for involuntary or voluntary treatment of acquired aggressiveness is highly questionable. This ...

In an international survey of rationing we have found that European physicians encounter scarcity-related ethical difficulties, and are dissatified with the resolution of many of these cases. Here we further examine survey results to explore whether ethics support services would be potentially useful in addressing scarcity related ethical dilemmas. Results indicate that while the type of help offered by ethics support services was considered helpful by physicians, they rarely referred difficulties regarding scarcity to ethics consultation. We propose that ethics consultants could assist physicians by making the process less difficult, and by contributing to decisions being more ethically justifiable. Expertise in bringing considerations of justice to bear on real cases could also be useful in recognising an unjust limit, as opposed to a merely frustrating limit. Though these situations are unlikely to be among the most frequently referred to ethics support services, ethics consultants should be prepared to address them.

In the literature on medical ethics, it is generally admitted that vulnerable persons or groups deserve special attention, care or protection. One can define vulnerable persons as those having a greater likelihood of being wronged - that is, of being denied adequate satisfaction of certain legitimate claims. The conjunction of these two points entails what we call the Special Protection Thesis. It asserts that persons with a greater likelihood of being denied adequate satisfaction of their legitimate claims deserve special attention, care or protection. Such a thesis remains vague, however, as long as we do not know what legitimate claims are. This article aims at dispelling this vagueness by exploring what claims we have in relation to health care - thus fleshing out a claim-based conception of vulnerability. We argue that the Special Protection Thesis must be enriched as follows: If individual or group X has a greater likelihood of being denied adequate satisfaction of some of their legitimate claims to (i) physical integrity, (ii) autonomy, (iii) freedom, (iv) social provision, (v) impartial quality of government, (vi) social bases of self-respect or (vii) communal belonging, then X deserves special attention, care or protection. With this improved understanding of vulnerability, vulnerability talk in healthcare ethics can escape vagueness and serve as an adequate basis for practice.

ABSTRACT Background: Understanding of informed consent forms (ICFs) for clinical research remains insufficient despite attempts to simplify them. Through linguistic discourse analysis, we sought to identify pitfalls within the text of ICFs that could hinder readers’ understanding of participation in research. Methods: We conducted a linguistic discourse analysis on a qualitative sample of 19 ICFs approved by research ethics committees (RECs) for oncology protocols and explored whether our findings also applied to standard U.S. documents available online. Results: We identified five major categories of language patterns that were problematic with respect to ensuring informed consent. We categorized them as follows: “bypassing consent,” “seeker–supplier inversion,” “interlocking Russian dolls,” “vanishing author,” and “one size fits all.” At least one instance of these findings existed in all analyzed forms (median 10 per ICF, range 1–18) and in national templates and U.S. documents. Conclusions: Linguistic discourse analysis identified recurrent pitfalls in the language of REC-approved ICFs and templates. This approach may provide new tools to improve ICFs.

Anderson-Shaw and colleagues' focus in their very interesting case discussions is that the three patients they describe are no longer the same person as before (2010). Their personal identity has changed. As the authors recognize, however, personal identity has several components. So what, exactly, has changed in these patients? It seems to be their character, rather than their physical or psychological continuity—ie, their numerical identity (Parfit 1984 4. Parfit, D. 1984. Reasons and persons, Oxford: Oxford University Press.

A ce jour, les formulaires d'information et de consentement éclairé dans le cadre de la recherche clinique ont été étudiés sous l'angle des éléments devant y figurer selon la loi et les directives internationales d'éthique de la recherche, et sous celui du niveau d'éducation nécessaire pour les comprendre. De telles approches se limitent aux éléments de contenu des formulaires. A ce titre, elles n'aboutissent qu'à des recommandations visant à compléter et à augmenter la liste des items d'information destinés aux sujets de recherche. Mais à ...

Approaches to priority-setting for scarce resources have shifted to public deliberation as trade-offs become more difficult. We report results of a qualitative analysis of public deliberation in Switzerland, a country with high health-care costs, an individual health insurance mandate and a strong tradition of direct democracy with frequent votes related to health care. We adapted the Choosing Healthplans All Together (CHAT) tool, an exercise developed to transform complex health-care allocation decisions into easily understandable choices, for use in Switzerland. We conducted focus groups in twelve Swiss cities, recruiting from a range of socio-economic backgrounds in the three language regions. Participants developed strategic arguments based on the importance of basic coverage for all, and of cost-benefit evaluation. They also expressed arguments relying on a principle of solidarity, in particular the importance of protection for vulnerable groups, and on the importance of medica...

Background: As universal health coverage becomes the norm in many countries, it is important to determine public priorities regarding benefits to include in health insurance coverage. We report results of participation in a decision exercise among residents of Switzerland, a high-income country with a long history of universal health insurance and deliberative democracy. Methods: We adapted the Choosing Healthplans All Together (CHAT) tool, an exercise developed to transform complex healthcare allocation decisions into easily understandable choices, for use in Switzerland. We conducted CHAT exercises in twelve Swiss cities with recruitment from a range of socioeconomic backgrounds, taking into account differences in language and culture. Results: Compared to existing coverage, a majority of 175 participants accepted greater general practice gatekeeping (94%), exclusion of invasive life-sustaining measures in dying patients (80%), longer waiting times for non-urgent episodic care (78%), greater adherence to cost-effectiveness guidelines in chronic care (66%), and lower premium subsidies (51%). Most initially chose greater coverage for dental care (59%), quality of life (57%), and long-term care (90%). During group deliberations, participants increased coverage for out-of-pocket costs (58%) and mental health to current levels (41%) and beyond current levels for rehabilitation (50%), and decreased coverage for quality of life to current levels (74%). Following group deliberation, they tended to change their views back to below current coverage for help with out-of-pocket costs, and back to current levels for rehabilitation. Most participants accepted the plan as appropriate and fair. A significant number would have added nothing. Conclusion: Swiss participants who have engaged in a priority setting exercise accept complex resource allocation trade-offs in healthcare coverage. Moreover, in the context of a well-funded healthcare system with universal coverage centered on individual choice, at least some of our participants believed a fully sufficient threshold of health insurance coverage was achieved. Implications for policy makers • Given appropriate tools, public participation in complex trade-offs regarding priority setting in healthcare is possible. • Participants assigned lower priority to interventions which lacked proof of effectiveness or showed benefits that were too small, mostly to increase coverage for long-term care. • In the context of a well-funded healthcare system, at least some participants believe that a sufficient threshold of health insurance can be fully achieved. Implications for the public In distributing healthcare resources, it is important to compare interventions to each other in order decide which ones to cover: public participation in such trade-offs is important and possible. In this study of Swiss citizens, the decisions reached by participants differed from the current distribution in the Swiss healthcare system. Participants in this study did not agree about all choices, but ultimately most of them found the plan they had developed together to be a fair one.

Should we be allowed to sell blood, or kidneys? The standard answer is no. A broad consensus in international regulatory documents supports a ban on all forms of sale of organs and human body parts. This consensus has, however, been critiqued and prominent calls made for „ economic rewards to motivate blood donation“ and for regulated markets for human organs.

Opposition to selling human organs is usually based on risks of harms for vendors and buyers, the potential for exploitation in an asymetric power relationship, and concerns regarding commodification. Proponents of markets in organs argue that such concerns are weaker than they appear, and can be allayed by appropriate regulations. Moreover, banning the sale of human body parts is an obstacle to access to care for patients on transplantation lists. Were we to be allowed to sell organs or other body parts, such as blood, availability would dramatically increase and lives would be saved. If arguments in favor of a ban are weaker than we thought, it is argued, they should not in such diminished form trump the chance to save many lives by making more organs available than is currently the case.

The case in favour of regulated markets in human organs is strong and should be properly understood. In this paper, I will argue that we nevertheless have good reason to ban the sale of human organs.

Background: Resource scarcity in health care is a universal challenge. In high-income settings, bedside rationing is commonly discussed and debated as a means to addressing scarcity. However, little is known about physicians' experiences in resource-limited contexts in low-income countries. Here we describe physicians' experiences regarding scarcity of resources, bedside rationing, use of various strategies to save resources, and perceptions of the consequences of rationing in Ethiopia. Methods: A national survey was conducted amongst physicians from 49 public hospitals using stratified, multi-stage sampling in six regions. All physicians in the selected hospitals were invited to respond to a self-administered questionnaire. Data were weighted and analyzed using descriptive statistics. Results: In total, 587 physicians responded (91 % response rate). The majority had experienced system-wide shortages of various types of medical services. The services most frequently reported to be in short supply, either daily or weekly, were access to surgery, specialist and intensive care units, drug prescriptions and admission to hospital (52, 49, 46, 47 and 46 % respectively). The most common rationing strategies used daily or weekly were limiting laboratory tests, hospital drugs, radiological investigations and providing second best treatment (47, 47, 47 and 39 % respectively). Availability of institutional or national guidelines for whom to see and treat first was lacking. Almost all respondents had witnessed different adverse consequences of resource scarcity; 54 % reported seeing patients who, in their estimation, had died due to resource scarcity. Almost 9 out of 10 physicians were so troubled by limited resources that they often regretted their choice of profession. Conclusion: This study provides the first glimpses of the untold story of resource shortage and bedside rationing in Ethiopia. Physicians encounter numerous dilemmas due to resource scarcity, and they report they lack adequate guidance for how to handle them. The consequences for patients and the professionals are substantial.

Parkinson's disease (PD) is one of the commonest neurodegenerative diseases, causing enormous human suffering as well as an increasingly heavy burden for health care systems and social support networks. Given the worldwide increase in life expectancy, its prevalence is expected to rise sharply in the near future (Dorsey et al. 2007). Since established pharmacological treatments have major limitations as regards long-term use, intense efforts are underway to find innovative therapies for PD. Among these, cell therapy raises ...

Edited by Marion Danis, Samia A. Hurst, Len Fleck, Reidun Forde, and Anne Slowther

    The book offers a unique combination of normative analyses of the moral grounds for resource allocation and rationing at the bedside, empirical evidence about the prevalence of rationing by physicians, and concrete suggestions about how clinicians and health care systems can work together to make resource allocation and rationing as fair as possible.
    This book presents an international comparison of attitudes towards and reported bedside rationing by physicians. It illustrates and justifies why the relevant question regarding bedside rationing is not whether it ought to be practiced, but how it can be practiced in a manner which respects everyone.

Of every thousand children born in Iceland, two will die before their first birthday, but in Mozambique the death rate is sixty times higher. Even within countries - including some of the wealthiest - inequalities in longevity and health can be substantial. In recent years, epidemiologists have documented the extent of these inequalities both between and within countries, stimulating in turn research both on their sources and on possible means for their alleviation. These extensive and influential efforts in research and in policy development have raised health inequalities to a prominent position among the central concerns of both national and global health.

Less attention has been given to careful analysis and refinement of some key concepts and values that guide and motivate these studies of health inequalities. The essays in this book demonstrate the need to identify and debate alternative positions on the choice of measures of health inequality; the definitions of 'inequality' and 'inequity' in health, and their interrelationship; the ethical basis for attaching priority to narrowing gaps in longevity and health among individuals, groups, and societies; and the possible solutions to a series of puzzles involving uncertainty and variable population size.

The authors of these essays are philosophers, economists, epidemiologists, and physicians contributing to our understanding of ethical issues in population health. Their contributions will be of interest to anyone interested in inequalities in health, including specialists in health policy, public health, epidemiology, moral philosophy, demography, and health economics.