Medical advocacy in the face of Australian immigration practices: A study of medical professionals defending the health rights of detained refugees and asylum seekers.

While medical advocacy is mandated as a core professional commitment in a growing number of ethical codes and medical training programs, medical advocacy and social justice engagement are regularly subordinated to traditional clinical responsibilities. This study aims to provide insight into factors that motivate clinician engagement and perseverance with medical advocacy, so as to inform attempts by policymakers, leaders and educators to promote advocacy practices in medicine. Furthermore, this study aims to provide an analysis of the role of medical advocates in systems where patients' rights are perceived to be infringed and consider how we might best support and protect these medical advocates as a profession, by exploring the experiences and perspectives of Australian clinicians defending the health of detained asylum seekers. In this qualitative study thirty-two medical and health professionals advocating on asylum seeker health in immigration detention were interviewed. Transcripts were coded both inductively and deductively from interview question domains and thematically analysed. Findings suggested that respondents' motivations for advocacy stemmed from deeply intertwined professional and personal ethics. Overall, advocacy responses originated from the union of three integral stimuli: personal ethics, proximity and readiness. We conclude that each of these three integral factors must be addressed in any attempt to foster advocacy within the medical profession. In light of current global trends of increasingly protectionist immigration practices, promoting effective physician advocacy may become essential in ensuring patients' universal right to health.

Evolving Vision of Regulatory Science in the Global Medical Community.

"Regulatory science" (RS) has been defined in various ways, but, nevertheless, the definitions of RS in different parts of the world include many common elements. It seems to be a common view that RS is not basic or applied science but, rather, focuses on the estimation and prediction of safety and efficacy. Thus, we think RS overall should incorporate not only RS specifically for medical product assessment but also RS engineering to provide prediction and estimation tools for those purposes, including guideline/guidance development. It is important as well to consider the potential contribution of RS to rational medicine (i.e., to evidence-based medicine in a broader context), and especially to real-world evidence generation. We will look at how definitions of RS have evolved, and how we believe RS might develop in the future. Taking a patient-centric view, we re-emphasize RS is an ethical science contributing to society and human welfare.

Preventing conscientious objection in medicine from running amok: a defense of reasonable accommodation.

A US Department of Health and Human Services Final Rule, Protecting Statutory Conscience Rights in Health Care (2019), and a proposed bill in the British House of Lords, the Conscientious Objection (Medical Activities) Bill (2017), may well warrant a concern that-to borrow a phrase Daniel Callahan applied to self-determination-conscientious objection in health care has "run amok." Insofar as there are no significant constraints or limitations on accommodation, both rules endorse an approach that is aptly designated "conscience absolutism." There are two common strategies to counter conscience absolutism and prevent conscientious objection in medicine from running amok. One, non-toleration, is to decline to accommodate physicians who refuse to provide legal, professionally accepted, clinically appropriate medical services within the scope of their clinical competence. The other, compromise or reasonable accommodation, is to impose constraints on accommodation. Several arguments for non-toleration are critically analyzed, and I argue that none warrants its acceptance. I maintain that non-toleration is an excessively blunt instrument to prevent conscientious objection in medicine from running amok. Instead, I defend a more nuanced contextual approach that includes constraints on accommodation.

Towards a Patient-Centred Regulation of Gamete Donation in Canada.

Commercial gamete donation in Canada is prohibited by the Assisted Human Reproduction Act. However, the Act permits gamete recipients to reimburse donors for donation-related expenses. Until recently, the types of expenses that were eligible and the process for reimbursing donors were not specified. In 2016, Health Canada announced its intent to develop regulations that would regulate gamete donor reimbursement; it released the proposed policy in 2017. As a result of consultations with Canadian lawmakers, physicians, and patients, debates surrounding commercial gamete donation are being revisited. Considering the ethical implications of gamete donation payment arrangements, a patient-centred care framework is useful going forward in the regulation of this practice. Patient-centred values of communication, respecting relational autonomy, and respecting patient interests should guide decisions regarding regulation of gamete donation arrangements in Canada.

Navigating difficult conversations.

Breaking bad news and navigating difficult conversations is challenging and a frequent occurrence in surgical oncology practice. Cancer communication recommendations are guided by ethical principles, legal precedence, and emerging evidence regarding patient preference and efficacy of communication tools. Evidence continues to mount supporting a patient-centered communication approach and a model of shared decision making. Likewise, physician training in effective patient-centered cancer communication continues to evolve.

Developing clinical ethics support for an Australian Health Service: A survey of clinician's experiences and views.

BACKGROUND: International developments suggest that providing clinical ethics services to help clinicians negotiate ethical issues that arise in clinical practice is beneficial and reflects best practice in promoting high ethical standards and patient-centered care. The aim of this study was to explore the needs and experiences of clinical staff members to inform the development of future clinical ethics support. METHODS: Health professionals at a large regional health service completed an online survey containing questions about the frequency of ethical and legal issues encountered in clinical practice, the type of situations that gave rise to the ethical and/or legal uncertainty or concern, how clinicians currently address these issues, and what support would be welcome. RESULTS: The survey was completed by 369 staff members, including 61% with more than 10 years in the profession and 51% in nursing/midwifery. Two-thirds (66%) indicated they often considered ethical implications of their clinical decisions, and half (49%) often considered the legal implications. More than half (58%) were often/occasionally concerned about the ethically right thing to do. Patient requests for borderline treatment (47%), staff disagreements about patient care (48%), and patients declining recommended treatment (54%) were the most frequent reasons given for ethical or legal uncertainty. Sixty-nine percent of respondents indicated that the way their department addressed ethical issues could be improved and 85% agreed that there is a need for more discussion on ethical issues. The majority (82%) of respondents had encountered ethically challenging clinical situations where additional support would have helped. Common approaches to issues were discussion with colleagues/supervisor (91.1%), discussion at handover/group forums (50.8%), and consultation with guidelines/protocols (60.9%). CONCLUSIONS: A majority of clinical staff members surveyed have encountered ethically/legally challenging cases daily for which they have often sought additional advice. This study indicates that many clinical staff members would welcome some form of additional clinical ethics support including advice and education.

An NHS Trust and others v Y and another [2018] UKSC 46: Reducing the Role of the Courts in Treatment Withdrawal.

In An NHS Trust and others v Y and another, the Supreme Court was asked to address the question of whether a court order must always be obtained before clinically assisted nutrition and hydration (CANH), which is keeping alive a person with a prolonged disorder of consciousness (PDOC). This case note explores the Court's decision to dispense with the need for such a court order and analyses that important change in approach from the perspective of the right to life protected in Article 2 European Convention on Human Rights (ECHR) as well as in the broader context of end of life decision-making.

Therapeutic jurisprudence's future in health law: Bringing the patient back into the picture.

More than 25 years ago, Professors David Wexler and Bruce Winick envisioned broad application of therapeutic jurisprudence (TJ), an interdisciplinary theory of law suggesting that legislatures, regulators, and judges consider the extent to which their decisions impact the psychological well-being of those upon whom the law acts. TJ most obviously plays a significant role in mental health and criminal law, where it originated, but Wexler and Winick long ago opined that TJ could be useful in a wide variety of other disciplines as well. Indeed, TJ has expanded exponentially in application over the years. Yet, although Wexler and Winick originally suggested that health law was an "obvious" field in which it could expand, application of TJ in that discipline has been less robust than one might have expected. This article will examine the extent to which TJ has been applied in health law other than mental health law, categorize the areas of health law in which it has been applied, and suggest future paths for expansive application in this most obvious of areas.

The Role of Government in Precision Medicine, Precision Public Health and the Intersection With Healthy Living.

This paper focuses on the significant role of government in promoting precision medicine and public health and the potential intersection with healthy living (HL) and population health. Recent research has highlighted the interplay between genes, environments and different exposures individuals and populations experience over a lifetime. These interactions between longitudinal behaviors, epigenetics, and expression of the human genome have the potential to transform health and well-being, even within a single generation. Precision medicine can elucidate these longitudinal interactions with a granularity that has not been previously possible across the exposome. Understanding the interactions between genes, epigenetics, proteins, metabolites, and the exposome may inform more evidence-based, effective policy, system, and environmental change to optimize individual and population health. Government has an important role in helping to fund primary research in precision medicine and precision public health, as well as creating and enforcing standards related to food systems, air quality, and access to health care, defining and optimizing measures of health care quality and safety, and ensuring data privacy standards and protections, interoperability, and integration with surveillance systems. Government partnership and collaboration with the non-profit and private sectors can optimize precision medicine and precision public health for the benefit of the United States and global population.

Scenario-based simulation training as a method to increase nursing students' competence in demanding situations in dementia care. A mixed method study.

Dementia is a debilitating condition affecting personality, day-to-day activities and cognitive function, which in turn may hamper the patient's decision-making capacity. This challenges staff competence in ethics and legislation in order to enhance dignity through improved communication and avoid coercive treatment. Scenario-based simulation training can increase communication skills in demanding situations. This study aimed to explore if this also applies to nursing students within dementia care, and if nursing students improve their ethical reflection and ability to avoid the use of coercion. This was piloted in a concurrent mixed method design using focus groups, questionnaires and observations. Twelve students from the bachelor of nursing programme participated. The results showed that two training sessions increased the use of confidence-building approaches and the students became more aware of the importance of person-centred dementia care and the importance of knowing the patient's history, to gain the patient's trust. Furthermore, the students' knowledge regarding legislation concerning coercion increased, and they became more aware of own attitudes and documenting deviations from treatment. Scenario-based simulation training seems to be a useful approach for preparing nursing students to become more aware of demanding situations in dementia care and how to handle such situations.

The Politics of Primary Care Expansion: Lessons From Cancer Survivorship and Substance Abuse.

EXECUTIVE SUMMARY: The purpose of this study is to understand the perspectives of primary care innovators treating patient populations not traditionally considered to be within the purview of primary care. Data were obtained from the 2015 Working Conference for PCMH (Patient-Centered Medical Home) Innovation funded by the Agency for Healthcare Research and Quality. The conference convened representatives from 10 innovative primary care practices and content experts to discuss experiences with integrating care for two nontraditional populations: patients with substance abuse issues and cancer survivors. Transcripts of the conference, one-on-one interviews, and written summaries of practice innovations were coded in NVivo (QSR International) and analyzed by means of an immersion/crystallization approach to identifying thematic patterns. Our study findings suggest that the politics surrounding entrenched professional identities contributed to barriers faced by conference participants in their efforts to provide innovative care for these nontraditional populations. Specifically, obstacles surfaced in relation to sharing patients across disciplinary boundaries, which resulted in issues of possessiveness, a questioning of provider qualifications, and a lack of interprofessional trust. Though support is increasing for primary care expansion and care integration, policy change may precede the identity transformations necessary for medical practitioners to embrace new primary care-centered models. For this reason, it is important that the formation and entrenchment of professional identities be critically considered as part of future efforts to transform primary care practice.

Informed consent: a global perspective.

Our aim in this paper was to investigate the guidelines and laws governing informed consent in the English-speaking world. We noted a recent divergence from medical paternalism within the United Kingdom, highlighted by the Montgomery v Lanarkshire Health Board ruling of 2015. We investigated the situation in the United Kingdom, Australia, New Zealand, Canada, and the United States of America. We read the national guidance regarding obtaining consent for surgical intervention for each country. We used the references from this guidance to identify the laws that helped inform the guidance, and reviewed the court documents for each case. There has been a trend towards a more patient-focused approach in consent in each country. Surgeons should be aware of the guidance and legal cases so that they can inform patients fully, and prevent legal problems if outdated practices are followed. Cite this article: Bone Joint J 2018;100-B:687-92.

Getting Paid for Clinical Services.

Increasingly, pharmacists are providing advanced, patient-centered clinical services. However, pharmacists are not currently included in key sections of the Social Security Act, which determines eligibility to bill and be reimbursed by Medicare. Many state and private health plans also cite the omission from Medicare as the rationale for excluding reimbursement of pharmacists for clinical services. This has prompted forward-thinking pharmacists to seek opportunities for reimbursement in other ways, allowing them to provide value to the health care system, while carving out unique niches for pharmacists to care for patients.

Legislative and Policy Developments and Imperatives for Advancing the Primary Care Behavioral Health (PCBH) Model.

The Primary Care Behavioral Health (PCBH) practice model continues to gain converts among primary care and behavioral health professionals as the evidence supporting its effectiveness continues to accumulate. Despite a growing number of practices and organizations using the model effectively, widespread implementation has been hampered by outmoded policies and regulatory barriers. As policymakers and legislators begin to recognize the contributions that PCBH model services make to the care of complex patients and the expansion of access to those in need of behavioral health interventions, some encouraging policy initiatives are emerging and the policy environment is becoming more favorable to implementation of the PCBH model. This article outlines the necessity for policy change, exposing the policy issues and barriers that serve to limit the practice of the PCBH model; highlights innovative approaches some states are taking to foster integrated practice; and discusses the compatibility of the PCBH model with the nation's health care reform agenda. Psychologists have emerged as leaders in the design and implementation of PCBH model integration and are encouraged to continue to advance the model through the demonstration of efficient and effective clinical practice, participation in the expansion of an appropriately trained workforce, and advocacy for the inclusion of this practice model in emerging healthcare systems and value-based payment methodologies.

Determining the features of person-centred models of care that patients value

Providing care that is person-centred is a key goal for provincial and territorial health systems in Canada.(1) This is demonstrated by a number of provinces having recently put forward legislation or key strategies working towards this aim. For example, in 2014, the Ministry of Health of British Columbia (where this rapid synthesis was requested from) released their strategic plan, Setting Priorities for the B.C. Health System, which posited that the province's health system needed improvement with respect to meeting the needs of key patient populations.(2) The plan listed providing patient-centred care as one of the eight priorities for the healthcare system and reiterated its importance in the 2015 report - B.C. Health System Strategy Implementation.(

Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference?

ISSUE: Prior to the Affordable Care Act (ACA), blacks and Hispanics were more likely than whites to face barriers in access to health care. GOAL: Assess the effect of the ACA's major coverage expansions on disparities in access to care among adults. METHODS: Analysis of nationally representative data from the American Community Survey and the Behavioral Risk Factor Surveillance System. FINDINGS AND CONCLUSIONS: Between 2013 and 2015, disparities with whites narrowed for blacks and Hispanics on three key access indicators: the percentage of uninsured working-age adults, the percentage who skipped care because of costs, and the percentage who lacked a usual care provider. Disparities were narrower, and the average rate on each of the three indicators for whites, blacks, and Hispanics was lower in both 2013 and 2015 in states that expanded Medicaid under the ACA than in states that did not expand. Among Hispanics, disparities tended to narrow more between 2013 and 2015 in expansion states than nonexpansion states. The ACA's coverage expansions were associated with increased access to care and reduced racial and ethnic disparities in access to care, with generally greater improvements in Medicaid expansion states.