PRENATAL CARE—A Group Psychotherapeutic Approach

It has been well established that “normal” pregnancy gives rise to much anxiety whose source is variable. When not adequately dealt with, the anxiety may masquerade in the guise of physical symptoms such as fatigue, dizziness, nausea and vomiting, or, more often, as disquieting emotional counterparts, like irritability and depression.A study was undertaken in the outpatient obstetrical department at U.C.L.A. utilizing a group psychotherapeutic approach. The results helped the patients and offered training to staff in dealing with emotional problems of pregnancy. Patients were seen in groups of seven, twice a month for one-hour sessions. Participating in each group were an obstetrical resident, a psychiatric resident and a nurse. The subject material was not selected beforehand. Groups were similar in that the expected time of delivery of the patients was approximately the same. Results of the study suggested that the much needed emotional support may be supplied in this way with little to no additional time expenditure on the part of the physician or nurse.     

WHAT IS THE GOOD OF HEALTH CARE?

This paper sets out to discuss what precisely is meant by 'benefit" when we talk of the requirement that the health care system concern itself with health gain or with maximizing beneficial health care. In particular I argue that in discharging the duty to do what is most beneficial we need to choose between rival conceptions of what is meant by beneficial. One is the patient's conception of benefit and the second is the provider's or funder's conception of benefit. I argue that it is the patient's conception of benefit which is paramount and that if this is followed it commits us to a conception of patient care which must be blind to prognosis in so far as prognosis is thought to bear upon issues of prioritisation or resource allocation.     

DISASTER MEDICAL CARE AND SHELTER—The Federal Program

The role of the physician in event of natural disaster or overwhelming (perhaps nuclear) attack by an enemy is:To assist the layman in preparing to meet his own health needs in a disaster situation until organized health services can reach him.To prepare and plan for the provision of organized medical care when conditions permit.To extend his own capability to render medical care outside his normal specialty.To assist in the training of allied and professional health workers and laymen for specific mobilization assignments in health services.     

NOTHING BUT THE TRUTH? ON TRUTH AND DECEPTION IN DEMENTIA CARE

Lies and deception are often used in the care for demented elderly and often with the best intentions. However, there is a strong moral presumption against all forms of lying and deceiving. The goal of this article is to examine and evaluate concrete examples of deception and lies in dementia care, while addressing some fundamental issues in the process. It is argued that because dementia slowly diminishes the capacities one needs to distinguish between truths and falsehoods, the ability to be lied to also disappears. When the moral reasons to reject lying are explored, it becomes clear that most of them also hold where demented patients are concerned, though this also depends on the capacities of the patient. Lying, though prima facie wrong, can sometimes be justified with an appeal to well-being. The relationship between well-being and the truth is further explored. Two examples of deceiving demented patients for reasons of beneficence are discussed, from which it can be concluded that although in some cases beneficent lies or deception will not enhance patients' well-being, there are circumstances in which they do. In general, methods that enhance the well-being of the patient without deception or lies should be favored above options that use deceit, and methods of getting the truth across without hurting the patient should be favored above blunt honesty Finally it is important to note that not only the patient but also the nursing and medical staff can be affected by the use of lies and deception.     

TAX-SUPPORTED MEDICAL CARE FOR CALIFORNIA'S CHILDREN—Where Should It Be Going?

The multiplication of separate governmental agencies providing health services to California''s children, the increasing difficulties in staffing tax-supported health agencies and the recent studies of the quality of care under these programs, have all pointed to an urgent need for prompt decisions on certain basic questions about the function of tax-supported medical care for children of dependent families.Fourteen separate kinds of health services are currently provided through public funds at an annual cost to California taxpayers of $52,000,000. These funds underwrite an uncoordinated, fragmented, patchwork quilt of medical care for some 500,000 children. Coordination and integration of these services through “one door” with uniform eligibility requirements and maximum utilization of private physicians'' services that meet appropriate standards is needed now. California physicians have an urgent responsibility to provide leadership in the development of more effective and more economical organization and distribution of higher quality medical care services for California''s children dependent on public support.     

DIMINISHING RETURNS? RISK AND THE DUTY TO CARE IN THE SARS EPIDEMIC

The seriousness of the risk that healthcare workers faced during SARS, and their response of service in the face of this risk, brings to light unrealistic assumptions about duty and risk that informed the debate on duty to care in the early years of HIV/AIDS. Duty to care is not based upon particular virtues of the health professions, but arises from social reflection on what response to an epidemic would be consistent with our values and our needs, recognizing our shared vulnerability to disease and death. Such reflection underwrites a strong duty of care, but one not to be borne solely by the altruism and heroism of individual healthcare workers.     

PROBLEMS ASSOCIATED WITH MEDICAL DISASTER CARE—Preparations in a Large Southern California Area

In the organization for dealing with medical disaster, the region is in an intermediary position, between the State Disaster Office and the operational areas. Regional functions are largely those of coordinating the activities of the areas, and are based upon directives and plans from the state level.The regional medical chief is a member of the staff of the Civil Defense coordinator and must advise him in all matters related to the health of the people, including medical and casualty care, hospitalization, public health, sanitation, preventive medicine and the special problems of biological, chemical and radiation hazards. Coordination with the other Civil Defense services is necessary.The basic medical plan is to give emergency care in the first aid stations and then evacuate casualties to hospitals when and how the situation permits. Regional function is to obtain personnel, supply, equipment and hospitalization support when required.Dispersal of danger zone populations to support areas creates many medical and public health problems among the displaced people and the residents.Survival of the nation requires altered concepts of casualty management. The least injured who have the greatest productive potential should have the highest treatment priority. Short, lifesaving surgical procedures must have precedence over long, complicated operations.No plan is any better than the individual doctors, nurses and other personnel who will put it into operation.     

ARE PATIENTS’ DECISIONS TO REFUSE TREATMENT BINDING ON HEALTH CARE PROFESSIONALS?

When patients refuse to receive medical treatment, the consequences of honouring their decisions can be tragic. This is no less true of patients who autonomously decide to refuse treatment. I distinguish three possible implications of these autonomous decisions. According to the Permissibility Claim, such a decision implies that it is permissible for the patient who has made the autonomous decision to forego medical treatment. According to the Anti-Paternalism Claim, it follows that health-care professionals are not morally permitted to treat that patient. According to the Binding Claim it follows that these decisions are binding on health-care professionals. My focus is the last claim. After arguing that it is importantly different from each of the first two claims, I give two arguments to show that it is false. One argument against the Binding Claim draws a comparison with cases in which patients autonomously choose perilous positive treatments. The other argument appeals to considered judgments about cases in which disincentives are used to deter patients from refusing sound treatments.     

WHAT IS IT TO BE A DAUGHTER? IDENTITIES UNDER PRESSURE IN DEMENTIA CARE

This article concentrates on the care for people who suffer from progressive dementia. Dementia has a great impact on a person’s well‐being as well as on his or her social environment. Dealing with dementia raises moral issues and challenges for participants, especially for family members. One of the moral issues in the care for people with dementia is centred on responsibilities; how do people conceive and determine their responsibilities towards one another? To investigate this issue we use the theoretical perspective of Margaret Walker. She states that ideas about identity play a crucial role in patterns of normative expectations with regard to the distribution of responsibilities in daily practices of care. The results of this study show how the identity of a family‐member is put under pressure and changes during her loved one’s illness that leads to difficulties and misunderstandings concerning the issue of responsibility. These results offer an insight into the complexities of actual practices of responsibility and highlight the importance for those caring for people with dementia of attending carefully to how they see themselves and how they see other people involved (Who am I? Who do I want to be for the other?). Answers to such questions show what people expect from themselves and from one another, and how they, at any rate, are distributing responsibilities in a given situation. Professional caregivers should take into account that family members might have different ideas about who they are and consequently about what their responsibilities are.     

VULNERABILITY IN RESEARCH AND HEALTH CARE; DESCRIBING THE ELEPHANT IN THE ROOM?

Despite broad agreement that the vulnerable have a claim to special protection, defining vulnerable persons or populations has proved more difficult than we would like. This is a theoretical as well as a practical problem, as it hinders both convincing justifications for this claim and the practical application of required protections. In this paper, I review consent-based, harm-based, and comprehensive definitions of vulnerability in healthcare and research with human subjects. Although current definitions are subject to critique, their underlying assumptions may be complementary. I propose that we should define vulnerability in research and healthcare as an identifiably increased likelihood of incurring additional or greater wrong. In order to identify the vulnerable, as well as the type of protection that they need, this definition requires that we start from the sorts of wrongs likely to occur and from identifiable increments in the likelihood, or to the likely degree, that these wrongs will occur. It is limited but appropriately so, as it only applies to special protection, not to any protection to which we have a valid claim. Using this definition would clarify that the normative force of claims for special protection does not rest with vulnerability itself, but with pre-existing claims when these are more likely to be denied. Such a clarification could help those who carry responsibility for the protection of vulnerable populations, such as Institutional Review Boards, to define the sort of protection required in a more targeted and effective manner.