The ethical politics of well-being in English care homes for adults with intellectual disabilities
by Michael Dunn
Dunn, M., Clegg, J., Clare, I. and Holland, A. (under review) 'The ethical politics of well-being in English care homes for adults with intellectual disabilities'.
ABSTRACT
Contemporary approaches to conceptualising good practice in residential care settings in England... more
ABSTRACT
Contemporary approaches to conceptualising good practice in residential care settings in England have focused on how the support environment functions to respect residents’ autonomy and to improve their quality of life. Increasingly, empirical and theoretical enquiry is exposing how the everyday practices of care work render problematic the ways in which this focus has been operationalised in practice, particularly with regards to autonomy-related considerations. This paper develops this emerging strand of research, exploring how support worker providing residential care to adults with intellectual disabilities make sense of the ethical dimensions of their support role. Drawing on a qualitative analysis of twenty-one interviews with support workers employed in residential care homes, and extended observations of care practices in these settings, it is shown how support workers identify, and negotiate, a particular account of good care. It is argued that day-to-day life in care homes is characterised by an ‘ethical politics of well-being’ as support workers define, defend, and seek to enact strategies for enhancing the quality of residents’ everyday lives in ways that are subject to continual challenge within the care home environment. These findings provide an insight into the complex ethical character of long-term care, and pose a number of challenges to contemporary political and regulatory frameworks of good practice across a range of health and social care settings.
A Descriptive and Exploratory Study of the Ethics Program at Austin State Hospital: The Common Elements of the Program and Managers' Beliefs About the Puspose and Usefulness of the Program
by Texas State PA Applied Research Projects
Thornton, Wayne, "A Descriptive and Exploratory Study of the Ethics Program at Austin State Hospital: The Common Elements of the Program and Managers' Beliefs About the Puspose and Usefulness of the Program" (2000). Applied Research Projects, Texas State University-San Marcos. Paper 123.
http://ecommons.txstate.edu/arp/123
Challenging ethical dilemmas are part of the daily lives of the managers at Austin State Hospital. What resources are... more
Challenging ethical dilemmas are part of the daily lives of the managers at Austin State Hospital. What resources are currently available at the Austin State Hospital to assist the staff with these ethical dilemmas? The purpose of this research is to explore the extent to which compliance, moral reasoning to guide employees in making ethical decisions or guiding ethical behavior, and encouraging employees to act as moral agents are present in the Austin State Hospital ethics program including: the ethics code, the ethics training, and the ethics committee. Working hypotheses are utiIized to explore the elements and nature of the ethics program. The second research question addresses the managers' beliefs about the purpose and usefulness of the ethics program at the Austin State Hospital. Descriptive categories are used to conceptualize the managers' beliefs about the purpose and usefulness of the program.
The research is both exploratory and descriptive. A case study model is employed to analyze the ethics program. The ethics code is explored by document analysis. Interviews are conducted with the chair of the ethics committee and the trainer for the ethics training. The code, the committee, and the training are explored to determine if compliance with laws and rules, utilizing moral reasoning, and encouraging staff to act as mom1 agents is present. A suwey is administered to thirty three of the managers to describe their beliefs regarding the purpose and usefulness of the ethics program.
When faced with clinical, business, and even issues of life and death, the managers at Austin State Hospital do have access to a well designed ethics program. The ethics code, the committee and the training program have elements of compliance, moral reasoning, and encouragement to act as moral: agents. The managers believe that the training program and the committee are the most usefil elements of the program. In general, the managers believe that utilizing moral principles to guide decisions and shape ethical behavior are the main purpose of the program. A large number of the managers believe that the purpose of the program is to encourage employees to act as moral agents. The research does demonstrate that the managers at Austin State Hospital do have a substantia1 array of resources available to them for assistance when faced with ethical dilemmas.
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Download (.pdf) The ethics of long-term care practice: A global call to arms
by Michael Dunn
Hope, T. and Dunn, M. (under review). 'The ethics of long-term care practice: A global call to arms'.
SUMMARY
A paper that describes the different types of ethical issues that arise in the day-to-day... more
SUMMARY
A paper that describes the different types of ethical issues that arise in the day-to-day activities that constitute long-term care, and that argues that there need to be processes and interventions established at the local, national and international level to enable these issues to be addressed appropriately.
ABSTRACT
This chapter examines the practical ethical issues that arise in long-term care settings. Our attention focuses predominantly on the care provided to people with dementia, a condition which is expected to present a major challenge to countries around the world over the next few decades. By providing specific examples, we show how the bulk of problematic ethical issues arise in the context of day-to-day care practices, and consider how these issues become even more problematic when recent developments in transnational migration for the purposes of providing and receiving long-term care are taken into account. We argue, first, that that these ethical issues need to be addressed in ways that can command broad agreement across different cultures and, second, that whilst contemporary approaches to identify universal principles ought to be part of this process, these principles alone will be insufficient to foster ethical practice. Our claim is that there need to be processes at both the macro and micro level that can facilitate discussion around, and enable the resolution of, context-specific ethical challenges. Such processes will require international collaboration between academic, policy-makers and care providers, and will involve new interventions in practical settings.
To empower or to protect? Constructing the ‘vulnerable adult’ in English law and public policy
by Michael Dunn
Dunn, M., Clare I. and Holland, A. (2008) ‘To empower or to protect? Constructing the ‘vulnerable adult’ in English law and public policy’, Legal Studies, 28(2): 234-253.
SUMMARY
A brief examination of the concept of vulnerability, and a critical analysis of its inclusion and... more
SUMMARY
A brief examination of the concept of vulnerability, and a critical analysis of its inclusion and interpretation in legal and political discourse for the purpose of justifying interventions in adults' everyday lives.
ABSTRACT
Recent judgments in England and Wales have confirmed and extended the High Court’s inherent jurisdiction to make declarations about interventions into the lives of ‘vulnerable’, rather than simply ‘mentally incapacitated’ adults. We argue that this shift is problematic because of the ways that the ‘vulnerable adult’ has been constructed in order to justify such interventions. The accounts of vulnerability drawn upon in the constructive process highlight the person’s inherent characteristics and/or the circumstances within which that person might be denied the ability to make a free choice. Such an approach parallels the public policy protection of ‘vulnerable adults’from abuse in care services and the statutory protection of ‘vulnerable witnesses’in the criminal justice system, and is built on an external and objective assessment of being ‘at risk’, rather than an understanding of the subjective experience of being vulnerable. We argue that this imbalance might act to disempower the ‘vulnerable adult’ by reducing that person’s life to a series of risk factors that fail, first, to place him/her at the heart of the decision to intervene, and, secondly, to engage adequately with the experiences through which that person ascribes meaning to his/her life.
Physical restraint of medical inpatients: Unravelling the red tape
by Michael Dunn
Behrman, S. and Dunn, M. (2010) ‘Physical restraint of medical inpatients: Unravelling the red tape’, Clinical Ethics, 5(1): 16-21.
SUMMARY
An analysis of the legal requirements and ethical issues in using physical methods of restraint in... more
SUMMARY
An analysis of the legal requirements and ethical issues in using physical methods of restraint in general hospital settings, with guidance to assist judgments about how restraint can be used in legally and ethically defensible ways.
ABSTRACT
Restraint has recently become an important legal and clinical issue in England and Wales with the introduction of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards introduced by the Mental Health Act 2007. The requirements of these two new pieces of legislation are complex, and therefore pose major challenges to the provision of high quality and patient centred care, support and treatment in a range of health and social care settings. In this paper, the legal and ethical aspects of physical restraint in an acute medical care environment are considered, and practical guidance is provided to individuals adopting methods of restraint to care for general hospital patients. Aspects of the Introduction below are written in the first person to reflect the personal experiences of the lead author.
Living ‘a life like ours’: Support workers’ accounts of substitute decision-making in residential care homes for adults with intellectual disabilities
by Michael Dunn
Dunn, M., Clare, I. and Holland, A. (2010) ‘Living ‘a life like ours’: Support workers’ accounts of substitute decision-making in residential care homes for adults with intellectual disabilities’, Journal of Intellectual Disabilities Research, 54(2): 144-160.
SUMMARY
An empirical analysis of surrogate decision-making to support an argument that the legal... more
SUMMARY
An empirical analysis of surrogate decision-making to support an argument that the legal requirements for substitute decision-making in long-term care settings for adults with intellectual disabilities are misaligned with the values at stake in the practice of everyday care work.
ABSTRACT
Background: In England and Wales, the Mental Capacity Act 2005 (MCA) provides a new legal framework to regulate substitute decision-making relating to the welfare of adults who lack the capacity to make one or more autonomous decisions about their care and support. Any substitute decision made on behalf of an adult lacking capacity must be in his/her ‘best interests’. However, the value of adopting established principles and procedures for substitute decision-making in practice is uncertain, and little is known about the legal or ethical dynamics of social care support, including the day-to-day residential support provided to adults with intellectual disabilities (ID). Methods: This paper reports a qualitative, grounded theory analysis of 21 interviews with support workers working in residential care homes for adults with ID, and observations of care practices. Results: In contrast to the narrow legal responsibilities placed upon them, it is argued that support workers interpret substitute decision-making within a broad moral account of their care role, orientating their support towards helping residents to live ‘a life like ours’. In so doing, support workers describe how they draw on their own values and life experiences to shape the substitute decisions that they make on behalf of residents. Conclusions: Support workers’ accounts reveal clear discrepancies between the legal regulation of substitute decision-making and the ways that these support workers make sense of their work. Such discrepancies have implications both for the implementation of the MCA, and for the role of support workers’ values in the conceptualisation and delivery of ‘good’ care.
Discourses of disability and clinical ethics support
by Michael Dunn
Dunn, M. (2011) ‘Discourses of disability and clinical ethics support’, Clinical Ethics, 6(1): 32-38.
SUMMARY
A review of different accounts of 'disability' that shows both how disagreements between these... more
SUMMARY
A review of different accounts of 'disability' that shows both how disagreements between these accounts centre on different ways of making sense of the concept's factual and evaluative meaning, and how these disagreements have important implications for the provision of clinical ethics support.
ABSTRACT
It is now broadly accepted that disability is a concept infused with both descriptive and evaluative meaning, such that invoking the concept of disability necessarily involves making judgements of moral value as well as describing certain facts about individuals. This paper aims to map the complex terrain that shapes our current understandings of disability by outlining five distinct ‘discourses of disability’. It is shown how the similarities and differences between the discourses hinge on different ways of making sense of the descriptive and evaluative dimensions of the concept, and the relationships between these dimensions. The paper concludes by considering the specific implications that these different ways of elucidating the concept of disability might have for the provision of clinical ethics support, both in terms of shaping ethical decision-making relating to people with disabilities and in terms of framing the process of providing clinical ethics support itself.
Ethical issues in the use of fall detectors
by Michael Dunn
Ganyo, M., Dunn, M. and Hope, T. (2011) ‘Ethical issues in the use of fall detectors’, Ageing and Society, 31(8): 1350-1367.
SUMMARY
An overview of the ethical issues raised by the use of falls detectors, and the integration of... more
SUMMARY
An overview of the ethical issues raised by the use of falls detectors, and the integration of these detectors into a person's care regime.
ABSTRACT
Fall detectors are a form of remote monitoring assistive technology that have the potential to enhance the wellbeing of adults at risk from falling. In this paper, the ethical issues raised by the use of fall detectors are examined. The fall detection devices currently available are outlined, and a summary of how these devices require social-care services, or family carers, to respond in particular ways, is provided. The ethical issues associated with the use of fall detectors are classified under four headings: autonomy, privacy, benefit, and the use of resources. These issues, we argue, arise out of the nature of the technology itself, and the way that this technology is integrated into the day-to-day support package of the person for whom it is provided. It is argued that manufacturers have a duty to provide information about the ‘ethical side-effects’ associated with the use of a particular device, and that the process of making a decision to provide a person with a fall detector should include a checklist of questions that is designed to enable decision makers to work through the ethical issues raised.
Health policy, patient-centred care and clinical ethics
by Michael Dunn
McClimans, L., Dunn, M. and Slowther, A. (2011) ‘Health policy, patient-centred care and clinical ethics’, Journal of Evaluation in Clinical Practice, 17(5): 913-919. (Special Issue: Virtue, Progress and Practice)
SUMMARY
An argument that health policymakers need to engage with clinical ethics if the value of... more
SUMMARY
An argument that health policymakers need to engage with clinical ethics if the value of patient-centred care is to be clarified, understood and defended.
ABSTRACT
Patient-centred care has been a central part of US and UK health policy for over a decade, but despite its importance the policy literature often fails to provide an adequate theoretical justification for why and how we should value it. This omission is problematic because it renders the status, content and appropriate evaluation of patient-centredness unclear. In this paper we examine two different accounts of patient-centred care and argue that neither of them appropriately grounds patient-centredness because neither takes into account the inherently moral nature of terms such as ‘respect’ and ‘dignity’, terms that are central to discussions of patient-centred care. We suggest that clinical ethics can (1) help to provide a theoretical framework for patient-centred care and (2) further patient-centred initiatives through ethics consultation, education and policy development and review.
Navigating the twilight zone
by Michael Dunn
Dunn, M. (under review) 'Navigating the twilight zone'.
SUMMARY
A commentary arguing that society's obligations towards individuals with chronic diseases ought to... more
SUMMARY
A commentary arguing that society's obligations towards individuals with chronic diseases ought to be orientated towards responding to the transformative impact that these diseases have on those individuals' varied and everyday experiences of living with chronic ill-health.
INTRODUCTION
Issues raised by the care and treatment of chronic diseases currently languish in the backwaters of biomedical ethical discourse. Slow, progressive decline heralds none of the bells and whistles of life and death decision-making, or radical technological advancement, that has proven to be so seductive to contemporary bioethicists. Nevertheless, there is an extensive body of evidence showing how chronic diseases are posing, and will continue to pose, significant political and practical challenges to public service infrastructures within both developed and developing nations that are already straining under economic and demographic pressures. It is to their credit, then, that Berlinger and Gusmano interrogate the ethical question of how healthcare organisations – and society more generally – ought to respond to the challenges of chronic disease.
For Berlinger and Gusmano, identifying the obligations we have in relation to those living with chronic health conditions depends, first, on being clear about what we mean when we invoke the concept of ‘chronicity’, and, second, on determining how different ways of conceptualising chronicity establish different normative pathways for ascribing responsibility in the treatment and care of chronic diseases. In this paper, it is argued that, however chronicity is defined, and whatever chronic condition is being described, chronic disease can be distinguished from other health conditions on the differential – and morally significant – kinds of impact that they have on individuals’ everyday lives. I claim, on the basis of this argument, that Berlinger and Gusmano’s directions for reforms in both policy and practice relating to the management of chronic disease point us in the right kinds of directions, but do not go far enough.
Threats and offers in community mental health care
by Michael Dunn
Dunn, M., Maughan, D., Hope, T., Canvin, K., Rugkasa, J., Sinclair, J. and Burns, T. (in press) 'Threats and offers in community mental health care', Journal of Medical Ethics.
SUMMARY
An ethical analysis of the practice of making threats or offers to patients as a way of increasing... more
SUMMARY
An ethical analysis of the practice of making threats or offers to patients as a way of increasing treatment adherence in community mental health care.
ABSTRACT
Making threats and offers to patients is a strategy used in community mental health care to increase treatment adherence. In this paper, we present an ethical analysis of these types of proposal. It is argued (i) that the primary ethical consideration is to identify the professional duties of care held by those working in community mental health because the nature of these duties will enable a threat to be differentiated from an offer, (ii) that threatening to act in a way that would equate with a failure to uphold the requirements of these duties is wrong, irrespective of the benefit accrued through treatment adherence, and (iii) that making offers to patients raises a number of secondary ethical considerations that need to be judged on their own merit in the context of individual patient care. The paper concludes by considering the implications of these arguments, setting out a pathway designed to assist community mental health care practitioners to determine whether making a specific proposal to a patient is right or wrong.
Caring to Death: Health Care Professionals and Capital Punishment
The aim of this article is to describe the role of health care professionals in the capital punishment process. The... more The aim of this article is to describe the role of health care professionals in the capital punishment process. The relationship between the protocol of capital punishment in the United States and the use of health care professionals to carry out that task has been overlooked in the literature on punishment. Yet for some time, the operation of the medical sciences in prison have been `part of a disciplinary strategy' `intrinsic to the development of power relationships'. Many capital punishment statutes require medical personnel to be present at, if not actively involved in, executions. Through analyses of these statutes, show the degree to which these professionals have become part of the state's executive apparatus.
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Shifting subjects of healthcare: Placing ‘medical tourism’ in the context of Malaysian domestic healthcare reform
Ormond, M. (2011) Shifting subjects of healthcare: Placing ‘medical tourism’ in the context of Malaysian domestic healthcare reform, Asia Pacific Viewpoint, 52(3), 247-259.
‘Medical tourism’ frequently has been held to unsettle naturalised relationships between the state and its citizenry.... more ‘Medical tourism’ frequently has been held to unsettle naturalised relationships between the state and its citizenry. Yet, in casting ‘medical tourism’ as either an outside ‘innovation’ or ‘invasion’, scholars have too often ignored the role that the neoliberal retrenchment of social welfare structures has played in shaping the domestic healthcare systems of the ‘developing’ countries increasingly recognised as international medical travel destinations. While there is little doubt that ‘medical tourism’ impacts destinations’ healthcare systems, it remains essential to contextualise them. This paper offers a reading of the emergence of ‘medical tourism’ from within the context of on-going healthcare privatisation reform in one of today’s most prominent destinations: Malaysia. It argues that ‘medical tourism’ to Malaysia has been mobilised politically both to advance domestic healthcare reform and to cast off the country’s ‘under-developed’ image not only among foreign patient-consumers but also among its very own nationals, who are themselves increasingly envisioned by the Malaysian state as prospective healthcare consumers.
How Is Health-Related “Deservingness” Reckoned? Perspectives from Unauthorized Im/migrants in Tel Aviv
by Sarah Willen
Willen, Sarah S. 2012. “How Is Health-Related ‘Deservingness’ Reckoned? Perspectives from Unauthorized Im/migrants in Tel Aviv.” Special Issue: “Migration, ‘Illegality,’ and Health: Mapping Embodied Vulnerability and Debating Health-Related Deservingness.” S. Willen, guest ed. Social Science and Medicine. 74(6): 812-821.
Do unauthorized im/migrants have a right to health? Do they deserve health care, or health protection, or access to... more
Do unauthorized im/migrants have a right to health? Do they deserve health care, or health protection, or access to the social determinants of good health? Are they party to prevailing social contracts, or does their exclusion from mainstream systems of health promotion, prevention, and care “make sense”? Questions like these, which generate considerable attention in multiple spheres of scholarship, policy, and public debate, revolve around an issue that merits substantially greater consideration among social scientists of health: health-related “deservingness.” In addition to putting the issue of health-related deservingness squarely on the map as an object of analysis, the paper further argues that we cannot focus solely on those with power, influence, and public voice. Rather, we also must investigate how deservingness is reckoned in relation to – and, furthermore, from the perspectives of – unauthorized im/migrants and members of other groups commonly constructed in public and policy discourse as undeserving. Additionally, we must also examine the complicated relationship between universalizing juridical arguments about formal entitlement to health rights, on one hand, and situationally specific, vernacular moral arguments about deservingness, on the other.
KEYWORDS: Israel – unauthorized im/migration – im/migrant health – “illegality” – deservingness – health care access – idioms of social justice mobilization – renegade moralities
Asylum Seekers and the Right to Access Health Care
available on SSRN: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1657946
In recent years, the issue of access to health care by asylum seekers has raised serious questions for government, the... more
In recent years, the issue of access to health care by asylum seekers has raised serious questions for government, the courts and the medical profession. Who has the right to medical treatment in the United Kingdom is a political, humanitarian and human rights matter. For the Government - often facing public hostility towards asylum seekers and migrants, fearful of health tourism or “pull factors” to the UK, and confronting burgeoning financial constraints - treatment is often regarded as a concession rather than a right. For the courts, any decision to grant treatment to non-nationals, particularly those with no right to remain, is seen as having has political implications far beyond the needs of the individual. The medical profession, by contrast, prefers in the main to focus on the patient, without regard for immigration status, and is uncomfortable with a dual role.
Where the balance should lie is currently being assessed by Government as it considers responses to a Consultation Paper on Review of Access to the NHS by foreign nationals. At this timely point, this article offers a multi-disciplinary approach to the question of access to health care by asylum seekers, by examining not only the legal position but also government policy, its impact on the individual, and, significantly, the ethical and philosophical arguments pro or contra treatment. It is contended that only through this comprehensive analysis can an appropriate legislative approach be adopted at a time when this critical social right is gaining ascendance.
Keywords: Asylum Seekers, Refugees, Health Care, NHS, Social Rights
I confini politici e simbolici dell'accesso globale alle cure
by Paola Russo
Published in F. Sciacca (Ed.), Giustizia globale. Problemi e prospettive, Soveria Mannelli: Rubbettino, 2011, pp. 181-201.
I confini politici e simbolici dell'accesso globale alle cure
1. L'ambivalenza semantica e simbolica del... more
I confini politici e simbolici dell'accesso globale alle cure
1. L'ambivalenza semantica e simbolica del farmaco
2. Dalla simbolica alla politica delle case farmaceutiche
3. La svista di Pogge
4. Brevetti e ricerca
Diritti, salute e distribuzione di risorse. Forme occidentali e africane
by Paola Russo
Published in R. Cammarata (a cura di), Chi dice universalità. I diritti tra teoria, politica e giurisdizione, L'Ornitorinco, Milano 2011, pp. 195-217.
Diritti, salute e distribuzione di risorse.
Forme occidentali e africane
1. Questioni preliminari
Forme occidentali e africane
1. Questioni preliminari
2. Etnofarmacologia, risorse e accessibilità alle cure
3. Il nesso antropologico come comune denominatore
4. Senso, dovere e diritti
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An anthropological exploration of contemporary bioethics: the varieties of common sense.
by Leigh Turner
Patients and physicians can inhabit distinctive social worlds where they are guided by diverse understandings of moral... more Patients and physicians can inhabit distinctive social worlds where they are guided by diverse understandings of moral practice. Despite the contemporary presence of multiple moral traditions, religious communities and ethnic backgrounds, two of the major methodological approaches in bioethics, casuistry and principlism, rely upon the notion of a common morality. However, the heterogeneity of ethnic, moral, and religious traditions raises questions concerning the singularity of common sense. Indeed, it might be more appropriate to consider plural traditions of moral reasoning. This poses a considerable challenge for bioethicists because the existence of plural moral traditions can lead to difficulties regarding "closure" in moral reasoning. The topics of truth-telling, informed consent, euthanasia, and brain death and organ transplantation reveal the presence of different understandings of common sense. With regard to these subjects, plural accounts of "common sense" moral reasoning exist.