Enseñanza de ética en la distribución de los recursos y la protección de la salud para una atención equitativa y segura / Teaching of ethics in the allocation of resources and health protection for a fair and safe healthcare

Algunas de las transformaciones más relevantes sufridas por las Ciencias de la Salud en el pasado siglo han estado en relación con el entorno donde se ha practicado la asistencia. De realizarse en el ámbito privado y con un ejercicio centrado en la relación profesional-paciente, ha pasado a la práctica en equipos multidisciplinares y organizaciones complejas, con un importante desarrollo de las tecnologías sanitarias, lo que ha contribuido al encarecimiento de la atención sanitaria en un contexto donde los recursos son limitados. En esta situación los profesionales sanitarios deben dirigir sus actuaciones a preservar el bien de terceros haciendo un uso racional y justo de los recursos (principio de justicia). El objetivo de este trabajo es determinar las competencias que los estudiantes de Ciencias de la Salud deben adquirir sobre la distribución justa de los recursos sanitarios. Señalar que en los estudiantes de Ciencias de la Salud la adquisición de estas competencias debe comenzar en el pregrado, con los conocimientos sobre las formas de la distribución de los recursos y la protección de la salud para una atención sanitaria equitativa, segura y costo-efectiva

Some of the most relevant transformations suffered by the Health Sciences in the last century have been in relation with the environment where healthcare has been practiced. It was realized in the private area, with an exercise focused on the relation professional - patient, and currently turned to practice in multidisciplinary teams and complex organizations, with an important development of the sanitary technologies, which in his set has contributed to the increasing of healthcare costs in a context where the resources are limited. In this situation the healthcare professionals must direct their actions to preserve the good of third parties doing a rational and fair use of the resources (principle of justice). The aim of this study is to determine the competencies that health students should acquire regarding resource allocation in a fair manner. In health science students the acquisition of these competencies must begin in the undergraduate, with knowledge on the ways of distributing resources and the protection of health for equitable, safe and cost-effective health care

Research approvals iceberg: how a 'low-key' study in England needed 89 professionals to approve it and how we can do better.

BACKGROUND: The red tape and delays around research ethics and governance approvals frequently frustrate researchers yet, as the lesser of two evils, are largely accepted as unavoidable. Here we quantify aspects of the research ethics and governance approvals for one interview- and questionnaire-based study conducted in England which used the National Health Service (NHS) procedures and the electronic Integrated Research Application System (IRAS). We demonstrate the enormous impact of existing approvals processes on costs of studies, including opportunity costs to focus on the substantive research, and suggest directions for radical system change. MAIN TEXT: We have recorded 491 exchanges with 89 individuals involved in research ethics and governance approvals, generating 193 pages of email text excluding attachments. These are conservative estimates (e.g. only records of the research associate were used). The exchanges were conducted outside IRAS, expected to be the platform where all necessary documents are provided and questions addressed. Importantly, the figures exclude the actual work of preparing the ethics documentation (such as the ethics application, information sheets and consent forms). We propose six areas of work to enable system change: 1. Support the development of a broad range of customised research ethics and governance templates to complement generic, typically clinical trials orientated, ones; 2. Develop more sophisticated and flexible frameworks for study classification; 3. Link with associated processes for assessment, feedback, monitoring and reporting, such as ones involving funders and patient and public involvement groups; 4. Invest in a new generation IT infrastructure; 5. Enhance system capacity through increasing online reviewer participation and training; and 6. Encourage researchers to quantify the approvals processes for their studies. CONCLUSION: Ethics and governance approvals are burdensome for historical reasons and not because of the nature of the task. There are many opportunities to improve their efficiency and analytic depth in an age of innovation, increased connectivity and distributed working. If we continue to work under current systems, we are perpetuating, paradoxically, an unethical system of research approvals by virtue of its wastefulness and impoverished ethical debate.

Aspectos críticos contextuales de un hospital de alta complejidad / Critical contextual aspects of a highly complex hospital / Aspectos críticos contextuais de um hospital de alta complexidade

Este artículo presenta los resultados parciales de un análisis FODA realizado en el Instituto Nacional del Tórax, con el fin de generar información sobre los aspectos críticos que afectan la gestión estratégica de un hospital público de alta complejidad, y abrir una reflexión ética sobre tales procesos. Para su determinación se usaron focus group, entrevistas en profundidad, propuestas por el equipo Directivo del Hospital y discusiones en torno al ámbito contextual. Las entrevistas individuales y grupales tuvieron una duración de una hora y veinte minutos aproximadamente y se realizaron en dependencias del hospital. La conceptualización de los datos, se hizo desde la Teoría Fundamentada. El estudio muestra, de acuerdo con la percepción de los entrevistados, que hay aspectos contextuales, tales como reglas del juego, stakeholders y cultura país, cuya tensión ética con la organización, afectan el quehacer del Instituto Nacional del Tórax, en cuanto hospital público de alta complejidad.

This article presents the partial results of a SWOT analysis at the National Chest Institute, in order to generate information on critical issues affecting the strategic management of a public hospital of high complexity, and open an ethical reflection on such processes. For their determination were used: focus groups, interviews, proposed by the management team of the Hospital and discussions on the contextual level. The Individual and group interviews lasted about an hour and twenty minutes and were performed at hospital units. The conceptualization of the data was made from Grounded Theory. The study shows, according to the perception of the interviewees, their contextual issues such as rules, stakeholders and cultural country, whose ethical tension with the organization, affect the work of the National Chest Institute as a high complexity public hospital.

objetivo: Este artigo apresenta resultados parciais de uma análise FOFA realizada no Instituto Nacional de Tórax do Chile, com a finalidade de gerar informações sobre os aspectos críticos que afetam a gestão estratégica de um hospital público de alta complexidade, e gerar uma reflexão ética sobre tais processos. Método: para sua determinação fora utilizado o focus group, entrevistas em profundidade propostas pela equipe de gestão do hospital e discussões acerca do escopo contextual. A conceitualização dos dados, foi feita a partir da Teoria Fundamentada. Conclusões: o estudo demonstra que, de acordo com a percepção dos entrevistados, há aspectos contextuais, tais como as regras do jogo, stakeholders e a cultura do país, cuja tensão ética com a organização afetam o trabalho do Instituto Nacional do tórax, enquanto hospital público de alta complexidade.

Promising waste: biobanking, embryo research, and infrastructures of ethical efficiency.

Biobanks are custodial institutions that enhance the utility and value of biological materials by collecting and curating them. Their custodial functions tend to include ethical oversight and governance. This paper explores how biobanks increase the value of biological materials by standardizing routines of governance in order to engender "ethical efficiency." Focusing in particular upon banking of human embryos for research, the article offers an historical account of how human embryos came to be "waste" available for use by researchers in the US. It offers a case study of a human embryo biobank and the practices of ethical governance that the biobank employs to capture this waste and convert it into a valuable resource for research use. The article draws attention to the ways biobanks' emphasis on efficiency and resolving problems of ethical governance up front codifies otherwise contested normative relationships and authorizes uses of human biological materials that some see as ethically problematic, even as it eliminates institutionalized mechanisms of reflection in which such problems would otherwise be acknowledged and confronted.

Health research and systems' governance are at risk: should the right to data protection override health?

The European Union (EU) Data Protection Regulation will have profound implications for public health, health services research and statistics in Europe. The EU Commission's Proposal was a breakthrough in balancing privacy rights and rights to health and healthcare. The European Parliament, however, has proposed extensive amendments. This paper reviews the amendments proposed by the European Parliament Committee on Civil Liberties, Justice and Home Affairs and their implications for health research and statistics. The amendments eliminate most innovations brought by the Proposal. Notably, derogation to the general prohibition of processing sensitive data shall be allowed for public interests such as the management of healthcare services,but not health research, monitoring, surveillance and governance. The processing of personal health data for historical, statistical or scientific purposes shall be allowed only with the consent of the data subject or if the processing serves an exceptionally high public interest, cannot be performed otherwise and is legally authorised. Research, be it academic, government,corporate or market research, falls under the same rule.The proposed amendments will make difficult or render impossible research and statistics involving the linkage and analysis of the wealth of data from clinical,administrative, insurance and survey sources, which have contributed to improving health outcomes and health systems performance and governance; and may illegitimise efforts that have been made in some European countries to enable privacy-respectful data use for research and statistical purposes. If the amendments stand as written, the right to privacy is likely to override the right to health and healthcare in Europe.

Diseño y validación de la escala RSC-HospitalES para medir responsabilidad social corporativa / Design and validation of the CSR-Hospital-SP scale to measure corporate social responsibility

Objetivo: Diseñar y validar una escala (RSC-HospitalES) para conocer la percepción que los profesionales sanitarios tienen de los enfoques en responsabilidad social corporativa (RSC) de su hospital. Método: Revisión de la literatura para identificar escalas de RSC de referencia y delimitar dimensiones a evaluar. Versión inicial de 25 elementos. Se seleccionó una muestra de conveniencia de cómo mínimo 224 profesionales sanitarios de cinco hospitales públicos de cinco comunidades autónomas. Se analizaron efecto suelo y techo, consistencia interna, fiabilidad y validez de constructo. Resultados: Respondieron 233 profesionales. RSC-HospitalES contiene 20 elementos agrupados en cuatro factores. Correlaciones ítem-total superiores a 0,30, cargas factoriales superiores a 0,50, varianza explicada del 59,57%, alfa de Cronbach de 0,90 y coeficiente de Spearman-Brown de 0,82. Conclusiones: RSC-HospitalES es una herramienta pensada para aquellos hospitales que ponen en marcha mecanismos de rendición de cuentas y que promueven enfoques de dirección socialmente responsables (AU)

Objective: To design and validate a scale (CSR-Hospital-SP) to determine health professionals" views on the approach of management to corporate social responsibility (CSR) in their hospital. Methods: The literature was reviewed to identify the main CSR scales and select the dimensions to be evaluated. The initial version of the scale consisted of 25 items. A convenience sample of a minimum of 224 health professionals working in five public hospitals in five autonomous regions were invited to respond. Floor and ceiling effects, internal consistency, reliability, and construct validity were analyzed. Results: A total of 233 health professionals responded. The CSR-Hospital-SP scale had 20 items grouped into four factors. The item-total correlation was higher than 0.30; all factor loadings were greater than 0.50; 59.57% of the variance was explained; Cronbach's alpha was 0.90; Spearman-Brown's coefficient was 0.82. Conclusion: The CSR-Hospital-SP scale is a tool designed for hospitals that implement accountability mechanisms and promote socially responsible management approaches (AU)

[Shared governance and reasonableness as ethical contributions to health policy]. / La gobernanza compartida y la razonabilidad como aportaciones éticas a la política sanitaria.

Health is one of the fundamental human rights. Recognizing it as a right means that the State has an obligation to ensure a minimum level of opportunities is maintained, and to restore it when lost. This minimum level may not be covered in periods of economic crisis, such as the one we are currently experiencing.Managed care, focused on economic questions, emerged after the crisis of 1973 in order to help make clinical decisions based on economic factors. In practice, the result of managed care was to turn economic cost control into an end in itself while forgetting about equity; something for which it has been challenged from an ethical perspective. Since then, many authors have attempted to reconcile efficiency and equity in health management, but the debate remains open.In this article, and basing our approach on the theories of P. Ruger and Norman Daniels, we argue that shared health governance and accountability for reasonableness can offer significant ethical contributions in the process of achieving an efficient and fair health system. In the model we propose, citizens, professionals and health institutions all play an active role in capacity building in the field of health. These capacities are related to healthy lifestyles, accessible and transparent information, the promotion of self-care, the acquisition of knowledge, skills and appropriate attitudes, leadership based on values and co-responsibility to achieve set goals in a reasonable way. If we develop these capacities, we will have used the current economic crisis as an opportunity for improving ethical practice in the field of health.

Is mandatory research ethics reviewing ethical?

Review boards responsible for vetting the ethical conduct of research have been criticised for their costliness, unreliability and inappropriate standards when evaluating some non-medical research, but the basic value of mandatory ethical review has not been questioned. When the standards that review boards use to evaluate research proposals are applied to review board practices, it is clear that review boards do not respect researchers or each other, lack merit and integrity, are not just and are not beneficent. The few benefits of mandatory ethical review come at a much greater, but mainly hidden, social cost. It is time that responsibility for the ethical conduct of research is clearly transferred to researchers, except possibly in that small proportion of cases where prospective research participants may be so intrinsically vulnerable that their well-being may need to be overseen.

International obligations through collective rights: Moving from foreign health assistance to global health governance.

This article analyzes the growing chasm between international power and state responsibility in health rights, proposing an international legal framework for collective rights - rights that can reform international institutions and empower developing states to realize the determinants of health structured by global forces. With longstanding recognition that many developing state governments cannot realize the health of their peoples without international cooperation, scholars have increasingly sought to codify international obligations under the purview of an evolving human right to health, applying this rights-based approach as a foundational framework for reducing global health inequalities through foreign assistance. Yet the inherent limitations of the individual human rights framework stymie the right to health in impacting the global institutions that are most crucial for realizing underlying determinants of health through the strengthening of primary health care systems. Whereas the right to health has been advanced as an individual right to be realized by a state duty-bearer, the authors find that this limited, atomized right has proven insufficient to create accountability for international obligations in global health policy, enabling the deterioration of primary health care systems that lack the ability to address an expanding set of public health claims. For rights scholars to advance disease protection and health promotion through national primary health care systems - creating the international legal obligations necessary to spur development supportive of the public's health - the authors conclude that scholars must look beyond the individual right to health to create collective international legal obligations commensurate with a public health-centered approach to primary health care. Through the development and implementation of these collective health rights, states can address interconnected determinants of health within and across countries, obligating the international community to scale-up primary health care systems in the developing world and thereby reduce public health inequities through global health governance.

Holding the World Bank accountable for leakage of funds from Africa's health sector.

This article explores the accountability of international financial institutions (IFIs), such as the World Bank, for human rights violations related to the massive leakage of funds from sub-Saharan Africa's health sector. The article begins by summarizing the quantitative results of Public Expenditure Tracking Surveys performed in six African countries, all showing disturbingly high levels of leakage in the health sector. It then addresses the inadequacy of good governance and anticorruption programs in remedying this problem. After explaining how the World Bank's Inspection Panel may serve as an accountability mechanism for addressing the leakage of funds, discussing violations of specific Bank policies and procedures that would support a claim related to leakage and examining the relevance of human rights concerns to such as claim, the article explores some of the Panel's limitations and the positive steps taken to address these concerns.

Clinical governance: the ethical dimension.

The main thrust of the Government's White Paper 'A First Class Service: Quality in the new NHS' (DOH, 1998) was to tackle the issues of quality and modernization in health services. While in part, clinical governance was aligned with positive, developmental and collaborative approaches to quality improvement, it was also designed to protect service users from risks associated with poor performance. Certainly there was more than a suggestion that the implementation of clinical governance would help restore public confidence in health professionals and care delivery. In essence clinical governance for Trusts was intended as a single, coherent local programme for quality improvement. Quality was to infuse all aspects of service delivery and unite fragmented policies and approaches. Clinical governance was also to challenge indifferent organizational cultures and connect grass roots staff to the quality agenda, so encouraging the widespread adoption of the principles and methods of continuous quality improvement.