Looking into the kaleidoscope of activism: the engagement of care ethics and global bioethics for a refined health security

During public health crises, the United States utilizes a statist approach for securing its population’s health, which places state structures at the center of a (mainly economic) health security. The fairness of this approach relies on a distribution of resources to “trickle down” from institutions to individuals. Yet, “fairness,” in this regard, is determined a priori, that is, without reference to specific individuals who are receiving resources of health. This ignores contextual needs that arise from the disproportionate damage that epidemics and pandemics have on vulnerable populations. A statist approach can make a more equitable impact on global society if it integrates care ethics into its distributive justice. In this paper, I demonstrate how an ethic of care can substantiate health security. First, I show how an ethic of care can be engaged anywhere embodiment is recognizable—not just in the one-on-one setting of the clinical encounter—but in the (inter)national contexts through which public health crises have a full effect on. Second, I provide a methodology for state institutions to recognize the social embodiment necessary to engage an ethic of care in these contexts, specifically engaging the social embodiment that manifests through the social activism of vulnerable populations during public health crises. Third, I demonstrate how the social embodiment that activism lives through forces an encounter with state institutions, mimicking in this manner a clinical encounter on a macrocosmic scale. Finally, I assign an ethic of care to this encounter, meshing caring values to the criteria of distribution.

Understanding Medication Adherence in Patients with Limited English Proficiency

Introduction. Approximately 41.6% of the US population who speak a language other than English (20% over all) and have limited English proficiency (LEP) status.1 Health outcomes for patients with LEP status or who are language discordant (speak a different language than their clinicians) have been studied in several settings, including the hospital and outpatient, with results widely demonstrating that these patients have worse outcomes when a professional interpreter is not used consistently. 2,3 The aim of this study was to investigate the impact of preferred language and language discordance on medication adherence. Methods. Data were collected via review of pharmacy-acquired medication profiles for three primary language cohorts: Nepali, Spanish, and English. Total Days of Adherence, Adherence Ratio, and Maximum Days Non-adherent were calculated and compared between language groups. We examined these statistics for regular and long-acting insulin, metformin and ACE inhibitors, testing for differences between language groups and those who experienced greater vs less than the median value for language concordant clinical encounters. Results. The most adherent group over all (highest adherence-ratio) were the Nepali-speaking, but the results showed high variability across outcomes and medications. Conclusions. After adjustment and stratification for greater vs lesser language concordant patient visit experience, we found that language-spoken plays an important role in the clinical encounter, and that LEP patients could have improved outcomes in their adherence to medications by having providers who speak their language or use an interpreter.

Four Core Concepts in Psychiatric Diagnosis

In the present article, we aimed at describing the diagnostic process in Psychiatry through a phenomenological perspective. We have identified 4 core concepts which may represent the joints of a phenomenologically oriented diagnosis. The “tightrope walking” attitude refers to the psychiatrist’s ability to swing between 2 different and sometimes contrasting tendencies (e.g., engagement and disengagement). The “holistic experience” includes all those intuitive, nonverbal, and pre-thematic elements that emerge in the early stages of the clinical encounter as an emanation of the atmospheric quality of the intersubjective space. The “co-construction of symptoms” regards the hermeneutic process behind psychiatric symptoms, involving both the patient as a self-interpreting agent and the clinician as a translator of his/her experience. Finally, by the “evolving typification” we mean that the closer the relationship becomes with the patient, the more specific and nuanced becomes the typification behind psychiatric diagnosis. Each of these concepts will be accompanied by an extract from a clinical case deriving from one of the authors’ most recent clinical experiences.

What Do Placebo and Nocebo Effects Have to Do With Health Equity? The Hidden Toll of Nocebo Effects on Racial and Ethnic Minority Patients in Clinical Care

A placebo effect is a positive clinical response to non-specific elements of treatment with a sham or inert replica of a drug, device, or surgical intervention. There is considerable evidence that placebo effects are driven by expectation of benefit from the intervention. Expectation is shaped by a patient’s past experience, observations of the experience of others, and written, verbal, or non-verbal information communicated during treatment. Not surprisingly, expectation in the clinical setting is strongly influenced by the attitude, affect, and communication style of the healthcare provider. While positive expectations can produce beneficial effects, negative information and experiences can lead to negative expectations, and consequently negative or nocebo effects. Key components identified and studied in the placebo and nocebo literature intersect with factors identified as barriers to quality care in the clinical setting for Black patients and other patients of color, including poor patient-clinician communication, medical mistrust, and perceived discrimination. Thus, in the context of discrimination and bias, the absence of placebo and presence of nocebo-generating influences in clinical settings could potentially reinforce racial and ethnic inequities in clinical outcomes and care. Healthcare inequities have consequences that ripple through the medical system, strengthening adverse short- and long-term outcomes. Here, we examine the potential for the presence of nocebo effects and absence of placebo effects to play a role in contributing to negative outcomes related to unequal treatment in the clinical encounter.

Remotely provided open-label placebo reduces frequency of and impairment by allergic symptoms

Background and Objective: Placebos being prescribed with full honesty and disclosure (i.e., open-label placebo = OLP) have been shown to reduce symptom burden in a variety of conditions. With regard to allergic rhinits, previous research provided inconclusive evidence for the effects of OLP, possibly related to a separate focus on either symptom severity or symptom frequency. Overcoming this limitation of previous research, the present study aimed to examine the effects of OLP on both the severity and frequency of allergic symptoms.Methods: In a randomized-controlled trial, patients with allergic rhinits (N=74) were randomized to OLP or treatment as usual (TAU). Due to the COVID-19 pandemic, OLP was administered remotely in a virtual clinical encounter. Participants took placebo tablets for 14 days. The primary outcomes were the severity and frequency of allergic symptoms. The secondary endpoint was allergy-related impairment.Results: OLP did not significantly improve symptom severity over TAU, F(1, 71) = 3.280, p = .074, ɳ²p = .044, but did reduce symptom frequency, F(1, 71) = 7.272, p = .009, ɳ²p = .093, and allergy-related impairment more than TAU, F(1, 71) = 6.445, p = .013, ɳ²p = .083, reflecting medium to large effects. The use of other anti-allergic medication did not influence the results. Conclusions: While OLP was able to lower the frequency of allergic symptoms and allergy-related impairment substantially, its effects on symptom severity were weaker. The remote provision of OLP suggests that physical contact between patients and providers might not be necessary for OLP to work.

Telehealth: A Resource for Vulnerable Populations to Access Oral Healthcare During the COVID-19 Pandemic

Dental care and adherence to daily oral hygiene practices are particularly important for healthy aging. For socially disadvantaged or impoverished, older community residents, populations who are at risk for long-standing oral disease, public dental clinics are safety nets. In March 2020, when COVID-19 cases surged in the New York metropolitan area, a months-long suspension of the area’s community dental services occurred, including clinical operations at the NYU College of Dentistry. To ameliorate the impact of this widespread service suspension, NYU Dentistry implemented an interim Dental Telehealth Service, open to the community, with telehealth consultations delivered by NYU faculty. This consultative service served a diverse population, adhering to guidelines the American Dental Association (ADA) issued on “urgent” and “emergency” care, with the goal of treating with a minimally invasive approach, to relieve the burden on hospital emergency rooms. Older adults, experiencing dental issues and fearing they were particularly vulnerable to the virus, called into this service, as they desperately wanted to avoid the overwhelmed public hospital ERs. A range of significant dental issues, i.e. pain, swelling, tooth fractures, were addressed. Implementing this community resource was a creative strategy to address a serious health services gap during this public health crisis. It also yielded important insights regarding the feasibility, acceptability and utility of telehealth, as a routine component of dental practice, when treating older adults, who often have serious co-morbidities and limited mobility. Certainly, the conversational nature of telehealth is a less stressful and anxiety-provoking clinical encounter.

What’s suffering got to do with it? A qualitative study of suffering in the context of Medical Assistance in Dying (MAID)

Background Intolerable suffering is a common eligibility requirement for persons requesting assisted death, and although suffering has received philosophic attention for millennia, only recently has it been the focus of empirical inquiry. Robust theoretical knowledge about suffering is critically important as modern healthcare provides persons with different options at end-of-life to relieve suffering. The purpose of this paper is to present findings specific to the understanding and application of suffering in the context of MAID from nurses’ perspectives. Methods A longitudinal qualitative descriptive study using semi-structured telephone interviews. Inductive analysis was used to construct a thematic account. The study received ethical approval and all participants provided written consent. Results Fifty nurses and nurse practitioners from across Canada were interviewed. Participants described the suffering of dying and provided insights into the difficulties of treating existential suffering and the iatrogenic suffering patients experienced from long contact with the healthcare system. They shared perceptions of the suffering that leads to a request for MAID that included the unknown of dying, a desire for predictability, and the loss of dignity. Eliciting the suffering story was an essential part of nursing practice. Knowledge of the story allowed participants to find the balance between believing that suffering is whatever the persons says it is, while making sure that the MAID procedure was for the right person, for the right reason, at the right time. Participants perceived that the MAID process itself caused suffering that resulted from the complexity of decision-making, the chances of being deemed ineligible, and the heighted work of the tasks of dying. Conclusions Healthcare providers involved in MAID must be critically reflective about the suffering histories they bring to the clinical encounter, particularly iatrogenic suffering. Further, eliciting the suffering stories of persons requesting MAID requires a high degree of skill; those involved in the assessment process must have the time and competency to do this important role well. The nature of suffering that patients and family encounter as they enter the contemplation, assessment, and provision of MAID requires further research to understand it better and develop best practices.

‘Decolonising’ the clinical encounter via multi-criteria decision support (Preprint)

UNSTRUCTURED According to researchers drawing on the ideas of Jürgen Habermas, Canadian patients and Danish General Practitioners are experiencing ‘colonisation’ of their ‘lifeworlds’ by ‘the system’, Their suggested remedy is to ensure that the clinical encounter, freed of strategic rationality, re-prioritises Habermasian ‘communicative action’ aimed at mutual understanding. However, Blau shows that such communicative action is, and should be, inextricably interwoven into means-end rationality, when Habermas’ caricature of the latter is rejected. We argue that the decision support framework provided by Multi-Criteria Decision Analysis can help produce the ‘communicative means-end rationality’ essential in a public health service based on role-respecting sincerity and autonomy. No ‘positivistic reduction’ is involved in the technique.