Shades of gray: Conscientious objection in medical assistance in dying.

With the advent of legalized medical assistance in dying [MAiD] in Canada in 2016, nursing is facing intriguing new ethical and theoretical challenges. Among them is the concept of conscientious objection, which was built into the legislation as a safeguard to protect the rights of healthcare workers who feel they cannot participate in something that feels morally or ethically wrong. In this paper, we consider the ethical complexity that characterizes nurses' participation in MAiD and propose strategies to support nurses' moral reflection and imagination as they seek to make sense of their decision to participate or not. Deconstructing the multiple and sometimes conflicting ethical and professional obligations inherent in nursing in such a context, we consider ways in which nurses can sustain their role as critically reflective moral agents within a context of a relational practice, serving the diverse needs of patients, families, and communities, as Canadian society continues to evolve within this new way of engaging with matters of living and dying.

Moral ambivalence towards the Cancer Drugs Fund.

The UK's Cancer Drugs Fund (CDF) was introduced in 2010 following the Conservative Party's promise to address the fact that numerous efficacious cancer drugs were not available because of their cost ineffectiveness, as deduced by the National Institute of Health and Care Excellence. While, at face value, this policy appears only to promote the UK's public welfare, a deeper analysis reveals the ethically unjustifiable inconsistencies that the CDF introduces; where is the analogous fund for other equally severe diseases? Have the patients without cancer been neglected simply due to the fear-inducing advertising and particularly ferocious speech which surrounds cancer? The CDF is unjustifiable when challenged by such questions. However, it is troubling to think that the CDF might be repealed in order to abolish these ethical concerns. Intuitively, one feels uncomfortable stripping the cancer patient of their benefits just so that they might be on an equally pessimistic footing with others. In the present essay, I argue that, although there are no ethically justifiable grounds for the CDF's introduction, its removal would be inappropriate. Following this realisation, I investigate whether the procedural steps of the CDF itself-theoretically removed from the context of resource distribution for all disease types-represent an ethically justifiable system. I believe that the answer is yes, given the CDF's conformity to accountability for reasonableness, a robust framework of procedural justice, which continuously improves the ethical and epistemological standards of the policies to which it is applied.

Medical Assistance in Dying: A Review of Canadian Nursing Regulatory Documents.

Canada's legalization of Medical Assistance in Dying (MAiD) in 2016 has had important implications for nursing regulators. Evidence indicates that registered nurses perform key roles in ensuring high-quality care for patients receiving MAiD. Further, Canada is the first country to recognize nurse practitioners as MAiD assessors and providers. The purpose of this article is to analyze the documents created by Canadian nursing regulatory bodies to support registered nurse and nurse practitioner practice in the political context of MAiD. A search of Canadian provincial and territorial websites retrieved 17 documents that provided regulatory guidance for registered nurses and nurse practitioners related to MAiD. Responsibilities of registered nurses varied across all documents reviewed but included assisting in assessment of patient competency, providing information about MAiD to patients and families, coordinating the MAiD process, preparing equipment and intravenous access for medication delivery, coordinating and informing health care personnel related to the MAiD procedure, documenting nursing care provided, supporting patients and significant others, and providing post death care. Responsibilities of nurse practitioners were identified in relation to existing legislation. Safety concerns cited in these documents related to ensuring that nurses understood their boundaries in relation to counseling versus informing, administering versus aiding, ensuring safeguards were met, obtaining informed consent, and documenting. Guidance related to conscientious objection figured prominently across documents. These findings have important implications for system level support for the nursing role in MAiD including ongoing education and support for nurses' moral decision making.

Mario Muñoz Monroy, vanguardista de su tiempo / Mario Muñoz Monroy, an avant-gardist of his time

El presente trabajo tiene el objetivo de fundamentar porqué se puede considerar a Mario Muñoz Monroy un vanguardista de su tiempo. Para ello se realizó una intensa investigación que permitió recoger testimonios inéditos que muestran la preocupación de Mario ante el sufrir ajeno y su capacidad de tratar a todos por igual, cualidades que sin dudas se deben tener en cuenta en cada momento de la formación integral del médico en Cuba. Además se evidencia cómo Mario Muñoz Monroy fue un joven integral apasionado por el deporte, la radio y la aviación. Se concluye con la afirmación de que el hombre nuevo que se quiere formar en las universidades de las ciencias médicas, estará incompleto sin el conocimiento de la vida de este valeroso hombre que es sin dudas un ejemplo para todos los cubanos (AU).

The current work is aimed to explain why it can be considered that Mario Muñoz Monroy is an avant-gardist of his time. For that reason, an intensive research was developed allowing collecting unknown testimonies that show Mario's preoccupation for the suffering of other people and his capacity of treating everybody in the same way, qualities that should be considered at every moment of the physician's integral training in Cuba. It also evidences how Mario Muñoz Monroy was an integral young man that loved sport, radio communication and aviation. As a conclusion it is stated that the new man we want to prepare in Medical Sciences universities will be incomplete without knowing this courageous man's life that is an example for all the Cuban people (AU).

Mario Muñoz Monroy, vanguardista de su tiempo / Mario Muñoz Monroy, an avant-gardist of his time

El presente trabajo tiene el objetivo de fundamentar porqué se puede considerar a Mario Muñoz Monroy un vanguardista de su tiempo. Para ello se realizó una intensa investigación que permitió recoger testimonios inéditos que muestran la preocupación de Mario ante el sufrir ajeno y su capacidad de tratar a todos por igual, cualidades que sin dudas se deben tener en cuenta en cada momento de la formación integral del médico en Cuba. Además se evidencia cómo Mario Muñoz Monroy fue un joven integral apasionado por el deporte, la radio y la aviación. Se concluye con la afirmación de que el hombre nuevo que se quiere formar en las universidades de las ciencias médicas, estará incompleto sin el conocimiento de la vida de este valeroso hombre que es sin dudas un ejemplo para todos los cubanos (AU).

The current work is aimed to explain why it can be considered that Mario Muñoz Monroy is an avant-gardist of his time. For that reason, an intensive research was developed allowing collecting unknown testimonies that show Mario's preoccupation for the suffering of other people and his capacity of treating everybody in the same way, qualities that should be considered at every moment of the physician's integral training in Cuba. It also evidences how Mario Muñoz Monroy was an integral young man that loved sport, radio communication and aviation. As a conclusion it is stated that the new man we want to prepare in Medical Sciences universities will be incomplete without knowing this courageous man's life that is an example for all the Cuban people (AU).

Which strings attached: ethical considerations for selecting appropriate conditionalities in conditional cash transfer programmes.

Conditional cash transfers (CCTs) present a promising approach to simultaneously tackle chronic poverty and poor health. While these programmes clearly embody beneficent aims, questions remain regarding the ethical design of CCTs. Limited guidance exists for the ethical evaluation of the defining feature of these programmes: the conditionalities. Drawing upon prominent public health ethics frameworks and social justice theories, this paper outlines five categories of morally relevant considerations that CCT programme designers should consider when assessing which behaviours or outcomes they select as conditionalities for payment: (1) likelihood of yielding desired health outcomes, (2) risks and burdens, (3) receptivity, (4) attainability and (5) indirect impacts and externalities. When evaluating potential conditionalities across these five categories of considerations, it is important to recognise that not all beneficiaries or subgroups of beneficiaries will fare equally on each. Given that most CCTs aim to reduce inequities and promote long-term health and prosperity for the most disadvantaged, it is critical to apply these considerations with due attention to how different segments of the beneficiary population will be differentially affected. Taken on balance, with due reflection on distributional effects, these five categories represent a comprehensive set of considerations for the moral analysis of specific conditionalities and will help ensure that CCT designers structure programmes in a way that is both morally sound and effective in achieving their goals.

Violência obstétrica no Brasil: uma revisão narrativa / Violencia obstétrica en Brasil: una revisión narrativa / Obstetrical violence in Brazil: a narrative review

Resumo Este artigo teve como objetivo realizar uma revisão narrativa de estudos sobre violência obstétrica. Para isso, abordou-se o histórico do parto e suas intervenções, o conceito de violência obstétrica, os marcos legais e o panorama brasileiro da assistência ao parto. Após a revisão das pesquisas realizadas sobre o assunto, constatou-se que não há um consenso em relação ao conceito de violência obstétrica no Brasil, embora as evidências indiquem que essa prática ocorra. Os dados apontam para a necessidade de uma conceituação de violência obstétrica, preferencialmente em documentos legais que a definam e criminalizem. Tal conceituação auxiliará na identificação e enfrentamento dessas situações. Consideram-se necessárias mudanças nas práticas assistenciais vigentes, visando a reduzir as intervenções desnecessárias e as violações aos direitos das mulheres.

Resumen Este artículo tuvo como objetivo realizar una revisión narrativa de los estudios sobre la violencia obstétrica. Para esto, se abordó la historia del parto y sus intervenciones, el concepto de violencia obstétrica, los marcos legales del parto y el panorama brasilero de la asistencia al parto. Después de la revisión de las investigaciones realizadas sobre el asunto, se verificó que no hay un consenso en relación al concepto de violencia obstétrica en Brasil, así las evidencias indiquen que esa práctica ocurre. Los datos apuntan a la necesidad de una conceptualización de la violencia obstétrica, preferiblemente en documentos legales que la definan y la criminalicen. Tal conceptualización ayudará en la identificación y enfrentamiento de esas situaciones. Se consideran necesarios cambios en las prácticas asistenciales vigentes, apuntando a reducir las intervenciones desnecesarias y las violaciones a los derechos de las mujeres.

Abstract This paper aims to fulfill a narrative review of researches on obstetric violence. Therefore, to approach the topic, we used concepts such as child-birth history, as well as its interventions, obstetric violence theories, legal marks, and the Brazilian panorama on delivery care. After reviewing published researches on the subject, we noted that there is no consensus about what obstetric violence is in Brazil, although evidences point that it happens. Data point to the need of defining obstetric violence, especially in legal documents which define it and criminalize it. Such concept will help to identify and to face these situations. We consider the changes in the current care practices compulsory, aiming to reduce unnecessary interventions and violations of women's rights.

Health fee exemptions: controversies and misunderstandings around a research programme. Researchers and the public debate.

Our research programme on fee exemption policies in Burkina Faso, Mali and Niger involved sensitive topics with strong ideological and political connotations for the decision-makers, for health-workers, and for users. Thus we were confronted with reluctance, criticism, pressures and accusations. Our frank description of the shortcomings of these policies, based on rigorous research, and never polemical or accusatory, surprises political leaders and health managers, who are accustomed to official data, censored evaluations and discourse of justification.

The ethics and economics of pharmaceutical pricing.

The cost of drugs is a major and rapidly rising component of health-care expenditures. We survey recent literature on the ethics and economics of skyrocketing pharmaceutical prices and find that advances in economic research have increased the sharpness and focus of the ethically based calls to increase access by modifying patent protection and reducing prices. In some cases, research supports ethical arguments for broader access. Other research suggests that efforts to broaden access result in unintended consequences for innovation and the medical needs of patients. Both ethicists and economists need to be more cognizant of the real clinical settings in which physicians practice medicine with real patients. Greater cross-disciplinary interaction among economists, ethicists, and physicians can help reduce the disjunction between innovation and access and improve access and patient care. This dialogue will impact private industry and may spur new multistakeholder paradigms for drug discovery, development, and pricing.

A voz do paciente: por que ele se sente coagido? / The patient's voice: why he feels coerced? / La voz del paciente: ¿por que se siente coercionado?

O processo de consentimento livre e esclarecido é essencial para garantir aos pacientes o direito de opinar e decidir sobre seu tratamento médico; todavia, a expressão de coerção pode estar associada a essa prática de modo que o sujeito sente que não foi capaz de exercer sua autonomia e voluntariedade. Neste sentido, buscou-se compreender que fatores levaram os participantes a identificarem coerção ao expressarem-se em relação ao seu tratamento. O presente estudo é de caráter qualitativo e foi realizado por meio de entrevistas semiestruturadas com seis sujeitos que apresentaram algum grau de expressão de coerção. As entrevistas foram analisadas utilizando-se análise de conteúdo. Observou-se que a identificação, pelo paciente, de que não teve voz no tratamento parece interligada ao fornecimento de informação, às vivências junto ao hospital e a elementos como o tempo de vinculação à instituição, à gratidão e ao modo como as vivências foram integradas psiquicamente.(AU)

The process of informed consent is essential to guarantee patients the right to opine and decide on their medical treatment. However, the expression of coercion may be associated with this practice by restricting the autonomy and willingness of the subject. Accordingly, we sought to understand what factors had influenced the perception of coercion manifested by the research subjects. This is a qualitative study, with the completion of semi-structured interviews with six subjects who had some degree of perceived coercion. The interviews were analyzed using content analysis. It is observed that this identification by the patient, who had no voice in the treatment appears linked to the provision of information, the experiences with the hospital, and the elements as time linking to the institution, to gratitude and how the experiences were integrated psychically.(AU)

El proceso de consentimiento libre y esclarecido es esencial para garantir a los pacientes el derecho a opinar y decidir sobre su tratamiento médico. Sin embargo, la expresión de coerción puede estar asociada a esa práctica de manera que el sujeto sienta que no fue capaz de ejercer su autonomía y voluntariedad. Así, hemos tratado de comprender que factores llevaron a los sujetos de la pesquisa a identificar coerción para expresarse sobre su tratamiento. Es un estudio cualitativo, usando entrevistas semi-estructuradas con seis sujetos que presentaron algún grado de expresión de coerción. Las entrevistas fueron analizadas utilizando análisis de contenido. La percepción del paciente de que no tuvo voz en su tratamiento parece relacionada al suministro de información, las vivencias junto al hospital y a elementos como el tiempo de vinculación a la institución, a la gratitud y al modo como las vivencias fueron integradas psíquicamente.(AU)

A voz do paciente: por que ele se sente coagido? / The patient's voice: why he feels coerced? / La voz del paciente: ¿por que se siente coercionado?

O processo de consentimento livre e esclarecido é essencial para garantir aos pacientes o direito de opinar e decidir sobre seu tratamento médico; todavia, a expressão de coerção pode estar associada a essa prática de modo que o sujeito sente que não foi capaz de exercer sua autonomia e voluntariedade. Neste sentido, buscou-se compreender que fatores levaram os participantes a identificarem coerção ao expressarem-se em relação ao seu tratamento. O presente estudo é de caráter qualitativo e foi realizado por meio de entrevistas semiestruturadas com seis sujeitos que apresentaram algum grau de expressão de coerção. As entrevistas foram analisadas utilizando-se análise de conteúdo. Observou-se que a identificação, pelo paciente, de que não teve voz no tratamento parece interligada ao fornecimento de informação, às vivências junto ao hospital e a elementos como o tempo de vinculação à instituição, à gratidão e ao modo como as vivências foram integradas psiquicamente.

The process of informed consent is essential to guarantee patients the right to opine and decide on their medical treatment. However, the expression of coercion may be associated with this practice by restricting the autonomy and willingness of the subject. Accordingly, we sought to understand what factors had influenced the perception of coercion manifested by the research subjects. This is a qualitative study, with the completion of semi-structured interviews with six subjects who had some degree of perceived coercion. The interviews were analyzed using content analysis. It is observed that this identification by the patient, who had no voice in the treatment appears linked to the provision of information, the experiences with the hospital, and the elements as time linking to the institution, to gratitude and how the experiences were integrated psychically.

El proceso de consentimiento libre y esclarecido es esencial para garantir a los pacientes el derecho a opinar y decidir sobre su tratamiento médico. Sin embargo, la expresión de coerción puede estar asociada a esa práctica de manera que el sujeto sienta que no fue capaz de ejercer su autonomía y voluntariedad. Así, hemos tratado de comprender que factores llevaron a los sujetos de la pesquisa a identificar coerción para expresarse sobre su tratamiento. Es un estudio cualitativo, usando entrevistas semi-estructuradas con seis sujetos que presentaron algún grado de expresión de coerción. Las entrevistas fueron analizadas utilizando análisis de contenido. La percepción del paciente de que no tuvo voz en su tratamiento parece relacionada al suministro de información, las vivencias junto al hospital y a elementos como el tiempo de vinculación a la institución, a la gratitud y al modo como las vivencias fueron integradas psíquicamente.

Morbidade ambulatorial como expressão das necessidades de saúde da população / Outpatient services to reflect the health needs of the population

O perfil de morbidade pode ser considerado um parâmetro básico para monitoramento das necessidades de saúde da população. A informação de morbidade pode ser obtida de diversas fontes e todas elas se mostram de alguma forma, incompletas ou parciais...

Análisis funcional de los cuidados aplicados a los enfermos de cólera durante la epidemia de 1885 en la ciudad de Murcia, a través de la prensa / Functional analysis of care applied to those suffering from cholera during the epidemic of 1855 in the town of Murcia, in the press

El estudio tuvo como objetivo conocer, a través de la prensa, los cuidados que se aplicaban a los enfermos durante el brote epidémico de cólera de 1885 en la ciudad de Murcia y quiénes los aplicaban. La fuente utilizada fue "El Diario de Murcia" del que se revisaron todos los números del día 14 de junio de 1885, fecha en que aparecen los primeros casos, al 9 de octubre de 1885, primer día sin muertes. Los resultados fueron analizados de acuerdo a los postulados del análisis funcional, destacando los profesionales implicados en el cuidado. Se concluye que la unidad funcional es la Iglesia Católica representada por los valores de las obras de misericordia. El marco funcional es, principalmente, el domicilio aunque se crean hospitales de emergencia para la atención a los enfermos coléricos y los elementos funcionales son el cuidador familiar, en la mayoría de los casos, las religiosas y algunos profesionales (practicantes o enfermeras) (AU)

The study had such as an objective to know, via the press, cares that were applied to the sick people during the outbreak epidemic of cholera of 1885 in the city of Murcia and the people who applied the caring them. The source use was "Diario de Murcia" of the one which were revised all numbers of the aforementioned daily newspaper of on 14 June 1885, date in which appear first cases, to 9 October 1885, first day without deaths. Results were analysed according to postulates of the functional analysis, emphasising implicated professionals in the care. We conclude that the functional unit is the Catholic Church represented by the values of works of mercy. The functional framework is primarily the home but are created emergency hospital care for cholera patients and functional elements are the family caregiver, in most cases, religious and some professionals (practitioners or nurses) (AU)

Legislation affecting governmental assistance for children of parents with substance use: a policy analysis of social justice.

There is legislation that withdraws governmental assistance where parents are using drugs. Social justice is an important consideration in any policy that modifies governmental assistance that benefits vulnerable children. The purpose of this policy analysis is to analyze identified legislation that effect governmental assistance for children in response to parents' substance misuse. A selective review of data-driven studies examined findings describing actual or potential effects on children of legislation targeting parental substance misuse. Challenges in design, processes, and implementation contribute to poor child outcomes. Identifiable constructs of social justice were missing in the reviewed legislation. Social injustice is a potential outcome for children when legislative intent focuses solely on addressing parental drug behaviors. Legislative alternatives to withdrawing support can address substance abuse while maintaining health promotion for these vulnerable children.

The appeal to nature implicit in certain restrictions on public funding for assisted reproductive technology.

Certain restrictions on public funding for assisted reproductive technology (ART) are articulated and defended by recourse to a distinction between medical infertility and social infertility. We propose that underlying the prioritization of medical infertility is a vision of medicine whose proper role is to restore but not to improve upon nature. We go on to mark moral responses that speak of investments many continue to make in nature as properly an object of reverence and gratitude and therein (sometimes) a source of moral guidance. We draw on the work of Ludwig Wittgenstein in arguing for the plausibility of an appeal to nature in opposition to the charge that it must contain a logical fallacy. We also invite consideration of the moral plausibility of some appeal to nature. Finally, we examine what follows in the case of ART. Should medicine respect as natural limits that should not be overcome: the need for a man and a woman in reproduction; menopause; and even declining fertility with age? We must first ask ourselves to what degree we should defer to nature in the conduct of medicine, at least in the particular if not the general case. This will involve also asking ourselves what we think is natural and in what instances and spirit might we defy nature. Divergent opinions and policies concerning who should receive ART treatment and public funding are more easily understood in view of the centrality, complexity and fundamental nature of these questions.