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Patients and family members (N = 671) were surveyed in five Mid-Atlantic U.S. hospitals to ascertain the number and kinds of ethical concerns they are presently experiencing or have previously experienced while being sick or receiving medical care. Seventy percent of participants had at least one (range 0–14) type of ethical concern or question. The most commonly experienced concerns pertained to being unsure how to plan ahead or complete an advance directive (29.4%), being unsure whether someone in the family was able to make their own decisions (29.2%), deciding about limiting life-sustaining treatments (28.6%), wondering about disclosing personal medical information to others in the family (26.4%) and not being sure whether to undergo treatment because of cost (26.2%). Most were interested to some degree in getting help from ethics consultants in the future (76.6%). Given this prevalence, common concerns might usefully be addressed systematically, rather than exclusively on a case-by-case basis. [ABSTRACT FROM AUTHOR]

Assumptions that bioethics was intended to focus only on a narrow set of issues related to research and health care are mistaken. The field of bioethics has long been focused on pressing contemporary issues, and it will play an unduly peripheral and less significant role than it could otherwise if it fails to focus on a broad set of issues, including human relations and the relationship of humans to nonhuman beings and the environment—and if it does not consider how to engage with others in addressing these issues. Bioethicists' traditional approaches, which emphasize an analytical role regarding values and goals, are important, but bioethicists also must include stakeholders in deliberations and consider how to translate goals into policy and practice. [ABSTRACT FROM AUTHOR]

Assumptions that bioethics was intended to focus only on a narrow set of issues related to research and health care are mistaken. The field of bioethics has long been focused on pressing contemporary issues, and it will play an unduly peripheral and less significant role than it could otherwise if it fails to focus on a broad set of issues, including human relations and the relationship of humans to nonhuman beings and the environment—and if it does not consider how to engage with others in addressing these issues. Bioethicists' traditional approaches, which emphasize an analytical role regarding values and goals, are important, but bioethicists also must include stakeholders in deliberations and consider how to translate goals into policy and practice. [ABSTRACT FROM AUTHOR]

A 1999–2000 national study of U.S. hospitals raised concerns about ethics consultation (EC) practices and catalyzed improvement efforts. To assess how practices have changed since 2000, we administered a 105-item survey to "best informants" in a stratified random sample of 600 U.S. general hospitals. This primary article details the methods for the entire study, then focuses on the 16 items from the prior study. Compared with 2000, the estimated number of case consultations performed annually rose by 94% to 68,000. The median number of consults per hospital was unchanged at 3, but more than doubled for hospitals with 400+ beds. The level of education of EC practitioners was unchanged, while the percentage of hospitals formally evaluating their ECS decreased from 28.0% to 19.1%. The gap between large, teaching hospitals and small, nonteaching hospitals widened since the prior study. We suggest targeting future improvement efforts to hospitals where needs are not being met by current approaches to EC. [ABSTRACT FROM AUTHOR]

Background While previous research has examined various aspects of ethics consultation (EC) in U.S. hospitals, certain EC practices have never been systematically studied. Methods To address this gap, we surveyed a random stratified sample of 600 hospitals about aspects of EC that had not been previously explored. Results New findings include: in 26.0% of hospitals, the EC service performs EC for more than one hospital; 72.4% of hospitals performed at least one non-case consultation; in 56% of hospitals, ECs are never requested by patients or families; 59.0% of case consultations involve conflict; the usual practice is to visit the patient in all formal EC cases in 32.5% of hospitals; 56.6% of hospitals do not include a formal meeting in most EC cases; 61.1% of hospitals do not routinely assess ethics consultants' competencies; and 31.6% of hospitals belong to a bioethics network. We estimate the total number of non-case consultations performed in U.S. hospitals to be approximately one half the number of case consultations; we estimate the total number of ECs performed in U.S. hospitals, including both case and non-case consultations, to be just over 100,000 per year. Conclusions These findings expand our current understanding of EC in U.S. hospitals, and raise several concerns that suggest a need for further research. [ABSTRACT FROM AUTHOR]

Many health systems have adopted online patient portals that allow patients to easily view their health records. As a result, notes written by health care professionals are increasingly read by both clinicians and patients, and clinicians in specialties that routinely involve sensitive information (eg, mental health care) have had to construct notes in a manner that respectfully promotes therapeutic relationships with patients. This article discusses whether ethics consultation services should share notes with patients through online portals and ways to handle practical implementation challenges. In support of sharing notes, this article appeals to an existing right that patients have to access their health record and suggests that sharing ethics consultation notes might help patients understand key clinical ethics concepts and practices. [ABSTRACT FROM AUTHOR]

Context: Engaging underrepresented communities in health research priority setting could make the scientific agenda more equitable and more responsive to their needs. Objective: Evaluate democratic deliberations engaging minority and underserved communities in setting health research priorities. Methods: Participants from underrepresented communities throughout Michigan (47 groups, n = 519) engaged in structured deliberations about health research priorities in professionally facilitated groups. We evaluated some aspects of the structure, process, and outcomes of deliberations, including representation, equality of participation, participants' views of deliberations, and the impact of group deliberations on individual participants' knowledge, attitudes, and points of view. Follow‐up interviews elicited richer descriptions of these and also explored later effects on deliberators. Results: Deliberators (age 18‐88 years) overrepresented minority groups. Participation in discussions was well distributed. Deliberators improved their knowledge about disparities, but not about health research. Participants, on average, supported using their group's decision to inform decision makers and would trust a process like this to inform funding decisions. Views of deliberations were the strongest predictor of these outcomes. Follow‐up interviews revealed deliberators were particularly struck by their experience hearing and understanding other points of view, sometimes surprised at the group's ability to reach agreement, and occasionally activated to volunteer or advocate. Conclusions: Deliberations using a structured group exercise to engage minority and underserved community members in setting health research priorities met some important criteria for a fair, credible process that could inform policy. Deliberations appeared to change some opinions, improved some knowledge, and were judged by participants worth using to inform policymakers. [ABSTRACT FROM AUTHOR]

The author discusses the need for healthcare ethics consultants to initially check internal behaviors and practices that have racist consequences to put anti-racism into action. Topics covered include the possible education of healthcare organizations and practitioners on racism in healthcare delivery and its lead into unfair health outcomes, and the review of policies that may reflect structural injustice. Also noted is the consideration of allied actions to form solutions to racism.

In low-income settings resource constraints force clinicians to make harsh choices. We examine the criteria Ethiopian physicians use in their bedside rationing decisions through a national survey at 49 public hospitals in Ethiopia. Substantial variation in weight given to different criteria were reported by the 587 participating physicians (response rate 91.7%). Young age, primary prevention, or the patient being the family's economic provider increased likelihood of offering treatment to a patient, while small expected benefit or low chance of success diminished likelihood. More than 50% of responding physicians were indifferent to patient's position in society, unhealthy behavior, and residence, while they varied widely in weight they gave to patient's poverty, ability to work, and old age. While the majority of Ethiopian physicians reported allocation of resources that was compatible with national priorities, more contested criteria were also frequently reported. This might affect distributional justice and equity in health care access. [ABSTRACT FROM AUTHOR]

Context: 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. Methods: 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. Findings: 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 medical care. They struggled with the place of personal responsibility in coverage decisions. In commenting on the exercise, participants found the degree of consensus despite differing opinions surprising and valuable. Conclusion: The Swiss population is particularly attentive to the costs of health care and means of reducing these costs. Swiss citizens are capable of making trade‐offs and setting priorities for complex health issues. [ABSTRACT FROM AUTHOR]

The article focuses on broadening the scope of health care ethics consultation a response to open peer commentaries on patient and family description of ethical concerns. Topics include the commentaries has received pose constructive suggestions, the attentive to those patient and family concerns that have been unheard or underappreciated, and the number of patients' and families' concerns has involved times when they felt mistreated or encountered ethics violations.

The increasing complexity of human subjects research and its oversight has prompted researchers, as well as institutional review boards (IRBs), to have a forum in which to discuss challenging or novel ethical issues not fully addressed by regulations. Research ethics consultation (REC) services provide such a forum. In this article, we rely on the experiences of a national Research Ethics Consultation Collaborative that collected more than 350 research ethics consultations in a repository and published 18 challenging cases with accompanying ethical commentaries to highlight four contexts in which REC can be a valuable resource. REC assists: 1) investigators before and after the regulatory review; 2) investigators, IRBs, and other research administrators facing challenging and novel ethical issues; 3) IRBs and investigators with the increasing challenges of informed consent and risk/benefit analysis; and 4) in providing flexible and collaborative assistance to overcome study hurdles, mediate conflicts within a team, or directly engage with research participants. Institutions that have established, or plan to establish, REC services should work to raise the visibility of their service and engage in open communication with existing clinical ethics consult services as well as the IRB. While the IRB system remains the foundation for the ethical review of research, REC can be a valuable service for investigators, regulators, and research participants aligned with the goal of supporting ethical research. [ABSTRACT FROM PUBLISHER]

The authors assert that deliberation designed and operationalized to address worrisome health trends has the potential to build a "we" in the pursuit of a healthier, more equitable nation. Topics discussed include core principles and practices of deliberation, deliberation in health care and public health, and operationalizing deliberation in population health.

Clinicians must inevitably make therapeutic decisions under nonideal conditions. They practice in circumstances that involve incomplete evidence. They deliver care in health care systems that are complex and poorly coordinated. Each of the patients that they take care of is unique while research offers evidence regarding relatively homogeneous populations of patients. Under these circumstances, many parties—medical scientists, reviewing agencies, insurers, and accountable care organizations—can and should contribute to optimizing the development, approval, funding, and prescription of therapies—particularly expensive and marginally beneficial therapies. In aggregate, they should aspire to achieve a pattern of fair, cost-effective therapeutic decisions to ensure a sustainable health care system. Here we offer some suggestions regarding decisions that physicians might pursue to facilitate fair and cost-effective patient care. [ABSTRACT FROM AUTHOR]

The article presents the author's views on scenarios created by moral theorists frequently for eliminating health and welfare deficits which may increase tension among disadvantaged groups with reference to a study on health disparities for poor Whites by Erika Blacksher. She opines on the current state of public discourse in the U.S.

The problems of racism and racially motivated violence in predominantly African American communities in the United States are complex, multifactorial, and historically rooted. While these problems are also deeply morally troubling, bioethicists have not contributed substantially to addressing them. Concern for justice has been one of the core commitments of bioethics. For this and other reasons, bioethicists should contribute to addressing these problems. We consider how bioethicists can offer meaningful contributions to the public discourse, research, teaching, training, policy development, and academic scholarship in response to the alarming and persistent patterns of racism and implicit biases associated with it. To make any useful contribution, bioethicists will require preparation and should expect to play a significant role through collaborative action with others. [ABSTRACT FROM AUTHOR]

Purpose: The objective of this study was to explore abuse survivor perspectives on optimal physician approaches to trauma inquiry in prenatal care. Methods: Focus group involving six adult female abuse survivors. Results: Five themes emerged for framing 'safe' trauma inquiry: (1) a clear definition of trauma, (2) clear purpose for inquiry, (3) reassurance that inquiry was routine, (4) confidentiality, and (5) mention of helpful resources other than psychiatric therapy. Conclusions: Explaining the purpose of trauma inquiry may be important for effectively engaging abuse survivors in obstetrics. [ABSTRACT FROM AUTHOR]

Background: Concerns about unsustainable costs in the US Medicare program loom as the number of retirees increase and experiences serious and costly illnesses like cancer. Engagement of stakeholders, particularly cancer patients and their families, in prioritizing insured services offers a valuable strategy for informing Medicare coverage policy. We designed and evaluated a decision exercise that allowed cancer patients and family members to choose Medicare benefits for advanced cancer patients. Methods: The decision tool, Choosing Health plans All Together (CHAT) was modified to select services for advanced cancer patients. Patients with a cancer history (N = 246) and their family members (N = 194) from North Carolina participated in 70 CHAT sessions. Variables including participants’ socio-demographic characteristics, health status, assessments of the exercise and results of group benefit selections were collected. Routine descriptive statistics summarized participant characteristics and Fisher’s exact test compared group differences. Qualitative analysis of group discussions were used to ascertain reasons for or against selecting benefits. Results: Patients and family members (N = 440) participated in 70 CHAT exercises. Many groups opted for such services as palliative care, nursing facilities, and services not currently covered by the Medicare program. In choosing among four levels of cancer treatment coverage, no groups chose basic coverage, 27 groups (39%) selected intermediate coverage, 39 groups (56%) selected high coverage, and 4 groups (6%) chose the most comprehensive cancer coverage. Reasons for or against benefit selection included fairness, necessity, need for prioritizing, personal experience, attention to family needs, holistic health outlook, preference for comfort, freedom of choice, and beliefs about the proper role of government. Participants found the exercise very easy (59%) or fairly easy (39%) to understand and very informative (66%) or fairly informative (31%). The majority agreed that the CHAT exercise led to fair decisions about priorities for coverage by which they could abide. Conclusions: It is possible to involve cancer patients and families in explicit discussions of their priorities for affordable advanced cancer care through the use of decision tools designed for this purpose. A key question is whether such a conversation is possible on a broader, national level. [ABSTRACT FROM AUTHOR]

This article examines how nations split decision-making about health services between federal and sub-federal levels, creating variation between states or provinces. When is this variation ethically acceptable? We identify three sources of ethical acceptability—procedural fairness, value pluralism, and substantive fairness—and examine these sources with respect to a case study: the fact that only 30 out of 51 US states or territories passed mandates requiring private insurers to offer extensive coverage of autism behavioral therapies, creating variation for privately insured children living in different US states. Is this variation ethically acceptable? To address this question, we need to analyze whether mandates go to more or less needy states and whether the mandates reflect value pluralism between states regarding government’s role in health care. Using time-series logistic regressions and data from National Survey of Children with Special Health Care Needs, Individual with Disabilities Education Act, legislature political composition, and American Board of Pediatrics workforce data, we find that the states in which mandates are passed are less needy than states in which mandates have not been passed, what we call a cumulative advantage outcome that increases between-state disparities rather than a compensatory outcome that decreases between-state disparities. Concluding, we discuss the implications of our analysis for broader discussions of variation in health services provision. [ABSTRACT FROM PUBLISHER]

The article offers information on impact of participation of citizen scientists in clinical research and their access to research ethics consultation. Topics include rise in patient engagement through multiple mechanisms and at all stages of research by the U.S. Food and Drug Administration (FDA); information on the bioethics consultation service at the National Institutes of Health (NIH); and information on ethical issues raised by participation of citizen scientists in the research process.

Imperfect efficiency in healthcare delivery is sometimes given as a justification for refusing to ration or even discuss how to pursue fair rationing. This paper aims to clarify the relationship between inefficiency and rationing, and the conditions under which bedside rationing can be justified despite coexisting inefficiency. This paper first clarifies several assumptions that underlie the classification of a clinical practice as being inefficient. We then suggest that rationing is difficult to justify in circumstances where the rationing agent is or should be aware of and contributes to clinical inefficiency. We further explain the different ethical implications of this suggestion for rationing decisions made by clinicians. We argue that rationing is more legitimate when sufficient efforts are undertaken to decrease inefficiency in parallel with efforts to pursue unavoidable but fair rationing. While the qualifier 'sufficient' is crucial here, we explain why 'sufficient efforts' should be translated into 'benchmarks of efficiency' that address specific healthcare activities where clinical inefficiency can be decreased. Referring to recent consensus papers, we consider some examples of specific clinical situations where improving clinical inefficiency has been recommended and consider how benchmarks for efficiency might apply. These benchmarks should state explicitly how much inefficiency shall be reduced in a reasonable time range and why these efforts are 'sufficient'. Possible strategies for adherence to benchmarks are offered to address the possibility of non-compliance. [ABSTRACT FROM AUTHOR]

BACKGROUND: Patients' willingness to discuss costs of treatment alternatives with their physicians is uncertain. OBJECTIVE: To explore public attitudes toward doctor-patient discussions of insurer and out-of-pocket costs and to examine whether several possible communication strategies might enhance patient receptivity to discussing costs with their physicians. DESIGN: Focus group discussions and pre-discussion and post-discussion questionnaires. PARTICIPANTS: Two hundred and eleven insured individuals with mean age of 48 years, 51 % female, 34 % African American, 27 % Latino, and 50 % with incomes below 300 % of the federal poverty threshold, participated in 22 focus groups in Santa Monica, CA and in the Washington, DC metro area. MAIN MEASUREMENTS: Attitudes toward discussing out-of-pocket and insurer costs with physicians, and towards physicians' role in controlling costs; receptivity toward recommended communication strategies regarding costs. KEY RESULTS: Participants expressed more willingness to talk to doctors about personal costs than insurer costs. Older participants and sicker participants were more willing to talk to the doctor about all costs than younger and healthier participants ( OR = 1.8, p = 0.004; OR = 1.6, p = 0.027 respectively). Participants who face cost-related barriers to accessing health care were in greater agreement than others that doctors should play a role in reducing out-of-pocket costs ( OR = 2.4, p = 0.011). Participants did not endorse recommended communication strategies for discussing costs in the clinical encounter. In contrast, participants stated that trust in one's physician would enhance their willingness to discuss costs. Perceived impediments to discussing costs included rushed, impersonal visits, and clinicians who are insufficiently informed about costs. CONCLUSIONS: This study suggests that trusting relationships may be more conducive than any particular discussion strategy to facilitating doctor-patient discussions of health care costs. Better public understanding of how medical decisions affect insurer costs and how such costs ultimately affect patients personally will be necessary if discussions about insurer costs are to occur in the clinical encounter. [ABSTRACT FROM AUTHOR]

Rationale: Intensive care unit (ICU) resources are limited in many hospitals. Patients with little likelihood of surviving are often admitted to ICUs. Others who might benefit from ICU are not admitted. Objective: To provide an updated consensus statement on the principles and recommendations for the triage of patients for ICU beds. Design: The previous Society of Critical Care Medicine (SCCM) consensus statement was used to develop drafts of general and specific principles and recommendations. Investigators and consultants were sent the statements and responded with their agreement or disagreement. Setting: The Eldicus project (triage decision making for the elderly in European intensive care units). Participants: Eldicus investigators, consultants, and experts consisting of intensivists, users of ICU services, ethicists, administrators, and public policy officials. Interventions: Consensus development was used to grade the statements and recommendations. Measurements and main results: Consensus was defined as 80 % agreement or more. Consensus was obtained for 54 (87 %) of 62 statements including all (19) general principles, 31 (86 %) of the specific principles, and 10 (71 %) of the recommendations. Inconsistencies in responses were noted for ICU admission and discharge. Despite agreement for guidelines applying to individual patients and an objective triage score, there was no agreement for a survival cutoff for triage, not even for a chance of survival of 0.1 %. Conclusions: Consensus was reached for most general and specific ICU triage principles and recommendations. Further debate and discussion should help resolve the remaining discrepancies. [ABSTRACT FROM AUTHOR]

This brief essay describes the purpose, the content, and the development, by a group of Hastings Center fellows and a scholar at the Center, of the Hastings Center Bioethics Timeline. The timeline covers the wide range of contemporary events pertaining to the intersection of bioethics with the medical and biological sciences, health care, and health policy, as well as the medical arts and medical humanities. A collaborative effort that documents events in a collaborative field, the timeline is meant to be updated and edited so that it improves over time. [ABSTRACT FROM AUTHOR]

Active and engaged patients seek the understanding, knowledge, and skills to promote their own health. Efforts to promote such patient activation and engagement are ethically justified because they are consonant with the well-established principle of respect for persons and, as the evidence shows, because they are likely to produce better outcomes for patients. Yet patient activation and engagement can also go ethically awry if, for example, nonadherent patients are abandoned or are unduly disadvantaged by punitive policies and practices, or if the conditions for successful activation and engagement are missing. In this article we discuss the ethical issues and responsibilities that pertain to patients, clinicians, health care organizations, delivery systems, insurers, payers, and communities. For example, physicians or payers could hold patients blameworthy for not following recommendations, but we suggest that a better approach would be for providers and payers to empower patients to effectively share responsibility for defining goals and achieving them. An ethical approach to patient activation and engagement should place obligations not only on patients but also on clinicians, health care organizations and delivery systems, insurers, and communities. [ABSTRACT FROM AUTHOR]

Costs at the end of life disproportionately contribute to health care costs in the United States. Addressing these costs will therefore be an important component in making the U.S. health care system more financially sustainable. In this paper, we explore the moral justifications for having discussions of end-of-life costs in the doctor-patient encounter as part of an effort to control costs. As health care costs are partly shared through pooled resources, such as insurance and taxation, and partly borne by individuals through out-of-pocket expenses, we separate our defense for, and approach to, discussing both pooled and individual aspects of cost. We argue that there needs to be a shift away from formulating the options as a dichotomous choice of paying attention to end-of-life costs versus ignoring such costs. The question should be how personal costs will be managed and how societal expenditures should be allocated. These are issues that we believe patients care about and need to have addressed in a manner with which they are comfortable. Conversations about how money will be spent at the end of life should begin before the end is near. We propose discussing costs from the onset of chronic illness and incorporating financial issues in advance care planning. Through these approaches one can avoid abruptly and insensitively introducing financial issues at the very conclusion of a person's life when one would prefer to address the painful and important issues of spiritual and existential loss that are appropriately the focus when a person is dying. [ABSTRACT FROM AUTHOR]

It is a basic and intuitive assumption that the relation of moral preference must be transitive--if A is overall morally preferable to B; and B is overall morally preferably to C; then, if our views are coherent, it better be the case that A is overall morally preferable to C. However, recent work by Temkin and Rachels has undermined that assumption by showing that common-sense ethical distributive principles that we are unlikely to give up generate intransitive sets of moral preferences. The consequences of this for resource allocation are profound--how can we come up with a just way of rationing limited resources if whatever course of action we adopt, there will be other alternatives that are morally preferable to it? However, regardless of the theoretical challenges, practical resource allocation decisions must be made every day! We explore an approach to dealing with some of the pragmatic aspects of the problem, even though the theoretical problem of intransitivity remains unsolved. We begin by considering whether the ways in which counterexamples to transitivity have (of necessity) been oversimplified actually contribute to the intractability of the problem by taking the possibilities of cost sharing, benefit splitting, and compensation (which are often available in real-life tradeoff situations) off the table. The proposal we end up suggesting does not rely on any assumptions or judgments about interpersonal aggregation, and so has a chance of allowing us to work around the most troubling kind of intransitivity. [ABSTRACT FROM AUTHOR]

The article discusses the socio-economic determinants of health (SEDH), as well as the public provision of a wide array of health-promoting socio-economic interventions. It also presents the socio-economic determinants of health, including the non-medical factors such as education, income, employment and housing. It also cites the opinion of Alan Derickson concerning the universal health insurance in the U.S., which he said was based in three major components, namely, needs, efficiencies and rights.

Objectives In order to teach medical students to engage more fully with patients, we offer ethics education as a tool to assist in the management of patient health issues. Methods We propose that many dilemmas in clinical medicine would benefit by having the doctor embark on an iterative reasoning process with the patient. Such a process acknowledges and engages the patient as a moral agent. We recommend employing Kant’s ethic of respect and a more inclusive definition of patient autonomy drawn from philosophy and clinical medicine, rather than simply presenting dichotomous choices to patients, which represents a common, but often suboptimal, means of approaching both medical and moral concerns. Discussion We describe how more nuanced teaching about the ethics of the doctor–patient relationship might fit into the medical curriculum and offer practical suggestions for implementing a more respectful, morally engaged relationship with patients that should assist them to achieve meaningful health goals. [ABSTRACT FROM AUTHOR]

Purpose/methods: This study investigated the relationship between ethics education and training, and the use and usefulness of ethics resources, confidence in moral decisions, and moral action/activism through a survey of practicing nurses and social workers from four United States (US) census regions. Findings: The sample (n = 1215) was primarily Caucasian (83%), female (85%), well educated (57% with a master's degree). no ethics education at all was reported by 14% of study participants (8% of social workers had no ethics education, versus 23% of nurses), and only 57% of participants had ethics education in their professional educational program. Those with both professional ethics education and in-service or continuing education were more confident in their moral judgments and more likely to use ethics resources and to take moral action. Social workers had more overall education, more ethics education, and higher confidence and moral action scores, and were more likely to use ethics resources than nurses. Conclusion: Ethics education has a significant positive influence on moral confidence, moral action, and use of ethics resources by nurses and social workers. [ABSTRACT FROM AUTHOR]

Objective To demonstrate that employees can gain understanding of the financial constraints involved in designing health insurance benefits. Background While employees who receive their health insurance through the workplace have much at stake as the cost of health insurance rises, they are not necessarily prepared to constructively participate in prioritizing their health insurance benefits in order to limit cost. Design Structured group exercises. Setting and participants Employees of 41 public and private organizations in Northern California. Intervention Administration of the CHAT (Choosing Healthplans All Together) exercise in which participants engage in deliberation to design health insurance benefits under financial constraints. Main outcome measures Change in priorities and attitudes about the need to exercise insurance cost constraints. Results Participants ( N = 744) became significantly more cognizant of the need to limit insurance benefits for the sake of affordability and capable of prioritizing benefit options. Those agreeing that it is reasonable to limit health insurance coverage given the cost increased from 47% to 72%. Conclusion It is both possible and valuable to involve employees in priority setting regarding health insurance benefits through the use of structured decision tools. [ABSTRACT FROM AUTHOR]

This article reports on a study that sought to identify what employment benefit packages were desired by low-income populations in the U.S. which would also be affordable for most companies. A group of low-income people were asked to choose the employee benefits they most desired and health care topped the list followed by retirement, vacation, disability pay and other factors. Although low-income status with or without health insurance is a source of poorer health, the authors say employee benefits might at least improve the health of the risk population.

Purpose: The purpose of this study was to demonstrate the feasibility and results of ascertaining Medicare enrollees' priorities for insured medical benefits. Design and Methods: Structured group exercises were conducted with Medicare enrollees from clinical and community settings in central North Carolina. By participating in a decision exercise, CHAT: Choosing Healthplans All Together, individuals and groups chose medical benefits within the constraints of a monthly Medicare + Choice premium. The acceptability of the exercise and the resulting benefit package were assessed. Results: Ten groups (121 individuals) made trade-oils that involved the selection of more tightly managed care in order to add pharmacy, dental, and long-term care benefits. All were willing to forgo experimental therapy; 7 groups gave priority to insuring the uninsured. Participants found the exercise overwhelmingly acceptable and were willing to abide by their groups' choices. Implications: Medicare enrollees are able to come to consensus about financially constrained benefit packages that may be useful in reform of the Medicare program. [ABSTRACT FROM AUTHOR]

Focuses on the influence of multinational corporations of the health status of the population. Determination of the socioeconomic determinants of health; Review of business ethics literature; Use of the social contract theory to develop a framework for an international agreement between multinational enterprise and potential host countries.

Efforts to improve end-of-life care in the United States have paid little attention to the unique concerns of participants in clinical research who are terminally ill. In this paper we focus attention on and offer an analysis of how to meet the needs of these individuals. To address their concerns, we consider how to reconcile two important tasks: providing optimal end-of-life care and conducting clinical research. First, we examine the inherent tension between the goals of medicine and the goals of science. Second, we focus more specifically on the tensions between a good death and conducting clinical research in patients with a short life expectancy. We examine six domains that have been suggested for measuring a good death: physical symptoms; psychological and cognitive symptoms; economic and caregiving needs; social relationships; spiritual beliefs; hopes and expectations. For each of these domains we examine how the goals of clinical research may conflict or coincide with taking care of a patient with a terminal illness. Finally, we offer suggestions to address these tensions: (1) modify the informed consent discussion for terminally ill participants in research; (2) build a palliative care component into clinical trials; (3) attend to the needs of family caregivers of terminally ill research subjects; (4) arrange for continuity of care so that dropping out of a trial does not jeopardize medical care; (5) train clinical investigators in end-of-life care; (6) develop a counseling strategy for terminally ill participants in clinical research. [ABSTRACT FROM AUTHOR]

Objective: A frequently cited obstacle to universal insurance is the lack of consensus about what benefits to offer in an affordable insurance package. This study was conducted to assess the feasibility of providing uninsured patients the opportunity to define their own benefit package within cost constraints.Design: Structured group exercises.Setting: Community setting.Participants: Uninsured individuals recruited from clinical and community settings in central North Carolina.Measurements: Insurance choices were measured using a simulation exercise, CHAT (Choosing Healthplans All Together). Participants designed managed care plans, individually and as groups, by selecting from 15 service categories having varied levels of restriction (e.g., formulary, copayments) within the constraints of a fixed monthly premium comparable to the typical per member/per month managed care premium paid by U.S. employers.Main Results: Two hundred thirty-four individuals who were predominantly male (70%), African American (55%), and socioeconomically disadvantaged (53% earned <$15,000 annually) participated in 22 groups and were able to design health benefit packages individually and in groups. All 22 groups chose to cover hospitalization, pharmacy, dental, and specialty care, and 21 groups chose primary care and mental health. Although individuals' choices differed from their groups' selections, 86% of participants were willing to abide by group choices.Conclusions: Groups of low-income uninsured individuals are able to identify acceptable benefit packages that are comparable in cost but differ in benefit design from managed care contracts offered to many U.S. employees today. [ABSTRACT FROM AUTHOR]

In the article, the author discusses the importance of palliation of symptoms for Ebola virus disease (EVD) patients in West Africa. He examines the arguments raised by P. M. Rosoff that effective palliative care, particularly the use of morphine and benzodiazepines, to ease the pain and anxiety of the patients. Also cited is the recommendation by the author to use acetaminophen to ease the pain felt by patients.

Examines study on relationship between patient incompetence to decisions withholding life-sustaining treatment. Details of ailments of patients in study; Information on research methods; Details of results; Authors' conclusions on decisions of patients on treatment.

Focuses on an investigation into physician specialty training relating to the treatment of special diseases. Objective of study; Methods used; Results; Conclusion. INSET: Subjects and methods..

Presents a study on the attitudes of the critically ill toward prolonging life. Role of social support in defining the context in which the stressors of unfinished business and fear of death prompted desires to prolong life; Effect of ethnicity on attitudes toward death and life-sustaining treatment; Differing attitudes of Americans and Africans toward death.

Presents a study which examined the stability of patients' choices for life-sustaining treatments in the event of terminal illness. Factors associated with a change of choices; Methods used in the study; Results.

The article discusses several ethical issues regarding the communication and management of research risk. It refers to regulatory issues, assuming that the data monitoring committee (DMC) and relevant bodies comply with their various mandates and fulfilled reporting requirements. It describes the relevant risks involved in the sudden appearance and management of an unanticipated adverse event.

To design effective strategies to improve ethics consultation (EC) practices, it is important to understand the views of ethics practitioners. Previous U.S. studies of ethics practitioners have overrepresented the views of academic bioethicists. To help inform EC improvement efforts, we surveyed a random stratified sample of U.S. hospitals, examining ethics practitioners' opinions on EC in general, on their own EC service, on strategies to improve EC, and on ASBH practice standards. Respondents across all categories of hospitals had very positive perceptions of their own ethics consultation service (ECS) and few concerns about quality. Our findings suggest that the ethics-related needs of small, rural, non-teaching hospitals may be very different from those of academic medical centers, and therefore, different approaches to addressing ethical issues might be warranted. [ABSTRACT FROM AUTHOR]

In this article the author present their views on the aspect of resource allocations involving medical ethics committee in the U.S. In their own study, they found that clinicians commonly face limited resources and the need to ration at the bedside, yet they rarely seek advice from ethics consultants to address the attendant ethical concerns. Discussion on how can clinical ethicists contribute to addressing concerns about resource allocation more effectively is also offered.

The article discusses the post-trial responsibilities to research participants considered as post-trial care or responsible transition of patients or research participants. Topics include how post-trial care safeguards research participants who have no access to health care outside of research and the need for investigators and sponsors to set additional post-trial care like financial support, social services and medical care to retain public trust and ensure ethical clinical research.

The article discusses concealing some health information from researchers to avoid exclusion from enrolment in a study. It mentions clinicians are expected to address the health needs of patients regardless of patient behaviour, including lying and other forms of deception. It also mentions consequences on the patient are that the patient's behaviour runs the risk of imposing harms or other negative effects on others.

Background Adherence to widely accepted practice standards is a frequently used measure of healthcare quality. In the U.S., the most widely recognized authoritative source of practice standards for ethics consultation (EC) is the second edition of the American Society for Bioethics and Humanities' Core Competencies for Healthcare Ethics Consultation report. Methods To determine the extent to which EC practices in U.S. hospitals adhere to these practice standards, we developed and analyzed 12 evaluative measures from a national survey. Results Only three of the 12 standards achieved over 75% adherence with reported EC practices: allowing anyone involved in a case to request an EC (100%), not requiring an attending physician's permission to conduct an EC (97.6%), and having at least one person on the ethics consultation service (ECS) with advanced level EC proficiency (79.3%). Conclusions Implications are discussed for achieving consensus on EC standards as they continue to evolve. [ABSTRACT FROM AUTHOR]