Cornerstones of ‘fair’ drug coverage: appropriate cost sharing and utilization management policies for pharmaceuticals

At the heart of all health insurance programs lies ethical tension between maximizing the freedom of patients and clinicians to tailor care for the individual and the need to make healthcare affordable. Nowhere is this tension more fiercely debated than in benefit design and coverage policy for pharmaceuticals. This paper focuses on three areas over which there is the most controversy about how to judge whether drug coverage is appropriate: cost-sharing provisions, clinical eligibility criteria, and economic-step therapy and required switching. In each of these domains we present ‘ethical goals for access’ followed by a series of ‘fair design criteria’ that can be used by stakeholders to drive more transparent and accountable drug coverage.

The Experiences of Ethical Tensions When Using Harm Reduction with High-Risk Youth

Little is known about the ethical experiences of psychologists who work with high-risk youth using a harm reduction approach. We used interpretative phenomenological analysis (IPA) to explicitly explore this phenomenon. In this small exploratory study three participants were interviewed to glean their experiences of ethical tension. Data analysis revealed three superordinate themes (questioning, acting, and holding) within which eight subthemes are subsumed (questioning beneficence, questions from others, self-care, social change, negotiation, consultation and supervision, acceptance, and sitting with tension). The results of this research suggest that context-specific ethical tensions may arise for psychologists who work with high-risk youth using a harm reduction approach, which in turn lead to and necessitate a tailored ethical response. The results also suggest that harm reduction promoters may benefit from increased dialogue with licencing and professional bodies to foster awareness and develop guidelines on promoting ethical practice when using a harm reduction approach with high-risk youth. Future research can profitably be directed towards an increased experiential understanding of some of the central themes of this research, such as “sitting with tension” and “holding.”

‘Your country needs you’: the ethics of allocating staff to high-risk clinical roles in the management of patients with COVID-19

As the COVID-19 pandemic impacts on health service delivery, health providers are modifying care pathways and staffing models in ways that require health professionals to be reallocated to work in critical care settings. Many of the roles that staff are being allocated to in the intensive care unit and emergency department pose additional risks to themselves, and new policies for staff reallocation are causing distress and uncertainty to the professionals concerned. In this paper, we analyse a range of ethical issues associated with changes to staff allocation processes in the face of COVID-19. In line with a dominant view in the medical ethics literature, we claim, first, that no individual health professional has a specific, positive obligation to treat a patient when doing so places that professional at risk of harm, and so there is a clear ethical tension in any reallocation process in this context. Next, we argue that the changing asymmetries of health needs in hospitals means that careful consideration needs to be given to a stepwise process for deallocating staff from their usual duties. We conclude by considering how a justifiable process of reallocating professionals to high-risk clinical roles should be configured once those who are ‘fit for reallocation’ have been identified. We claim that this process needs to attend to three questions that we consider in detail: (1) how the choice to make reallocation decisions is made, (2) what justifiable models for reallocation might look like and (3) what is owed to those who are reallocated.

Zones of major ethical tension for the students’ dealing with information: The case analysis based on the «academic fraud triangle» AT

The findings of the study revealed the heightened tension zones for the students’ dealing with information based on checking graduation theses texts for matching content at Ryazan S. Yesenin State University. The case analysis was applied as the main method of investigation. Generalized data, obtained as the result of four cases analysis, demonstrate that the highest tension is observed in the area of the academic ethos values like honesty, respect and responsibility.

Education versus screening: the use of capacity to consent tools in psychiatric genomics

Informed consent procedures for participation in psychiatric genomics research among individuals with mental disorder and intellectual disability can often be unclear, particularly because the underlying ethos guiding consent tools reflects a core ethical tension between safeguarding and inclusion. This tension reflects important debates around the function of consent tools, as well as the contested legitimacy of decision-making capacity thresholds to screen potentially vulnerable participants. Drawing on human rights, person-centred psychiatry and supported decision-making, this paper problematises the use of consent procedures as screening tools in psychiatric genomics studies, particularly as increasing normative emphasis has shifted towards the empowerment and participation of those with mental disorder and intellectual disabilities. We expound on core aspects of supported decision-making, such as relational autonomy and hermeneutic competence, to orient consent procedures towards a more educative, participatory framework that is better aligned with developments in disability studies. The paper concludes with an acknowledgement of the pragmatic and substantive challenges in adopting this framework in psychiatric genomics studies if this participatory ethos towards persons with mental disorder and intellectual disability is to be fully realised.

Oral History and Biographical Method. Common Framework and Distinctions Resulting from Different Research Perspectives

Reflections undertaken in this article are a direct result of the research into the fate of Children Born of War (CBOW) in Poland and relate to the methodological, epistemological and ethical tension experienced while working with the interview partners and analyzing their biographical accounts. The encountered difficulties became a root cause of the critical reflection and an impulse to an attempt to systematize the knowledge about the mutual relations of two research traditions: oral history and biographical method which have coexisted over the past few decades, interfering and penetrating each other to such an extent that many researchers began to equate them or consider one of them as a part of the other and vice versa. The chaos of terms and concepts was of great importance in this process. The text also presents similarities and differences of the two approaches both in an epistemological and ethical sense. The attitude towards the narrator, which is mainly the result of different scientific goals that researchers aim at in both research fields was recognized as the fundamental difference. However, underscoring the differences has no purpose of setting boundaries, but it is a postulate to be more careful and bear theoretical and methodological self-awareness of researchers, it is also meant to foster mutual learning and inspiration, which can positively affect the quality of research and analysis.

Enabling identity as an ethical tension in a community of philosophical inquiry with children and young adults

This article focuses on an ethical tension in a community of philosophical inquiry with children and young adults; the resolution that the author suggests is called “enabling identity.” The “enabling identity” model seeks to endow a voice to children and adolescents from marginalized groups by challenging the mainstream hegemonic discourse that governs the discourse where communities of philosophical inquiry operate. One of the challenges that philosophy for children faces today is enabling the voices of marginalized groups represented within communities of philosophical inquiry comprising children or adults to be heard. The participants in communities of philosophical inquiry who come from non-privileged backgrounds and low socio-economic sectors or national minorities, whose narrative does not accord with that of the dominant national narrative, feel uncomfortable expressing their feelings and experiences, preferring not to raise the questions that interest them. Even if they are amicable, such communities of inquiry are governed—even if implicitly—by the hegemonic metanarrative. This article analyzes this ethical tension and suggests a three-phase theoretical and practical model which depicts this enabling while relying on narrative theory as well as the philosophical and dialogical work of Emmanuel Levinas and Martin Buber. The last part also offers insights from research in German and Israeli communities of inquiry with children and young adults that have used this model.

Ethics and Research with Children

This chapter explores the ethical tension between protecting vulnerable children from research risks and protecting children through access to appropriate research in support of safe and effective pediatric products. The history of the debate over pediatric research is reviewed briefly, along with central ethical themes within that debate. Each of the chapters in this volume are set within this context. Themes examined include the role of the clinician-investigator, the concept of the best interests of the child, appropriate risk assessment, the importance of component analysis to the assessment of pediatric research protocols, the choice of an appropriate control group, parental permission and child assent, compensating children for research participation, and the fetus as research subject.