HHH

Environments of nonmedical forms of influence

biggest, messiest realm everybody having an opinion, marketers telling you what is good for your body, ppl with no portion of moral obligations of protecting your body telling you to get somehing-can't make all marketers physicians, healers have a higher moral standard byt don't have control over these processes

ake an argument for the most important ethical concerns in global transplant medicine. Use specific examples from A Death Retold and the film "Rough Cut" to justify various moral obligations and ethical choices.

biological citizenship medical error impact of media attention/social context structural violence research imperative treatment imperative commodfication of body parts brain death norms of care/ethical variability

What groups engage in ethics?

biomedicine, govnt, religion, education

Dotty said she never thought she was ____ till her daughter was diagnosed

black

andrew and darlene were told their child was _______ which was not legally speaking quite the situation

brain dead

Key points to capture from Alma Ata

broad definition of health acknowledgmet of health inequality affirming govnt responsibility for humanitarian engagemnt defining primary health care broadly calling for a spirit of partnership, a genuine detente and disarmament with the acceleration of social and economic development call to action with year 2000 goals

How does kleinman's explanatory model framework make more ethical care possible

broad-get full picture without influencing-get cultural idea Descriptive Level: How would you describe the problem that has brought you to me? Conceptual Level: What does the illness do to you? How does it work? Why do you think it started when it did? What are the results you hope for? What will happen if you don't get treatment? Apart from me, who else can help you get better? How can they help? Personal: Why did you in particular get sick?

Norms

broadly accepted standards, behaviors, and values within a community; includes standards of action as well as moral character traits or virtues

Susan E. Lederer. 2006. "Tucker's Heart: Racial Politics and Heart Transplantation in America". WLG

bruce tucker's heart transplanted to a white man first interracial tranplsna virginia first transplant in 1960s transplanting age everyone wanted to transplant bruce o tucker unacclaimed dead family didnt get to know abt his death fast because of transplant race racially motivated barnard in s africa

according to WLG, the rapid pace of the santillan story and the intensity and immediacy of reactions prohibited

careful reflection

Nocebo Effect

causation of sickness by expectations of sickness and by associated emotional states

CHIP

child health insurance plan-provides low cost health coverage to children in familes that earn too much money to qualify for medicaid ; in some states chip covers pregnant women

chavez's chapter emphasizes how the santillan cases forces us to reflect on issues of belonging legitimacy and the reqards of _____

citizenship

Climates of hyperindividualism

climate changes and climate spaces around the world so that you can find patterns but generally see a lot of variation- see individualism anround the world-every community wants to build good individuals, how you perform god individualism from place to place

Dotty produces _____ of her daughter's condition

clinical narrative

Gawande a "Lifesaving Checklist"

closed by govnt because not getting patient and dcotor authorization-weird talks about necessity to be reviewed by IRB-this checklist would be

narrative re-envisioning

coming to see oneself in a new way, coming to reform one's sense of possibility and reframe one's commitments

in their introduction, WLG emphasize the contradictions among sharp lines of _________________ coming from a variety of actors, clinicians, transplant organizations, media, legislators, the menagerie of american attitudesq

commentary

5 ecological metaphors

commodified landscapes, climates of hyperindividualism, environments of nonmedical forms of influence, habitats for authoritative knowledge, stadardizing niches

5 Ecological metaphors of pharmaceuticals

commodified landscapes-global take commodity attitude to globe where no other options climates of hyperindividualsim-every community wants to build good, see a lot of variation environments of nonmedical forms of influence-biggest, messiest realm everybody having an opinion, marketers telling you what is good for your body, ppl with no portion of moral obligations of protecting your body telling you to get something habitats for authoritative knowledge-ppl who are owning their space a bit-think of kinds of organisms in habitat-have control over space? standardizing niches-adaptation, population level movement not individual

in pharamceutical nexus, wellbeing is recast as

commodity

commodity v right

commodity=a raw material or product that can be bought or sold right which is morally just correct or honorable a moral or legal entitlement

humanitarian intervention

common morality humans respected above states can't actually produce evidence towards consensus say humans are respected above states but humans are very statist in their willingness to get involved fairly consistently where the UN as a whole tends to land the use of military force against a country that engages in gross violations of human rights

universal norms

common morality-set of norms that we claim universal to all humans

Mark Kuczewski. 2009. "The Common Morality in Communitarian Thought: Reflective Consensus in Public Policy". Canvas

communitarian approach to ethics embraces common morality in shared piusuit of the good as a universal aspect of morality and the deliberations, traditions, and common construction of the narrative of ppl state public policy relies on model of consensusindividual is the original and primary unit of social organization community is responsible for helping to provide the conditions that enable its members to pursue projects health care can be necessary to pursue of good life with community members fundamental insight of communitarian philosophy is that virtually every attempt to apply such a right will require interpretation and delineation of specific communal arrangements must reflect others in society

according to what rouse calls the clinical paradigm, chronically ill tenns are often treated by pediatricians as ____ before the age of 18

competent

pluralism

condition when many cultures coexist in one society

confessionals

confess all that hurting you, all that happened

moral dilemma

conflict between two moral obligations

Investigator responsibilities (10)

consistent with three ethical principles in belmont report: respect for persons, beneficence, justice comply with all applicable fed regulations ensure all research submitted and approved by IRB comply with all IRB codes informed consent, assent in according with federal regulations and IRB document consent as IRB and fed would like report any unexpected events to IRB report progress regularly as prescribed by and to IRB retain records at least 3 years after

care in mattingly text

cultivating virtues

cultural relativism

cultural ideas or practices should not be judged using the ideals and values of another cultural system

Challenges to ethical care

culture and language lack of adequate time and resources chronic care and elective surgery bioethics and free market care

Commercialized Clinic Trials

dangerous break between bioethics and realities of local moral worlds ethical imperialism v ethical relativism scarcity/vulnerability of subjects treatment naivete ethical codes v etical regs and enforcements

Urban and Pharmaceutical Ecologies by

das and das

standard of care

description of acceptable level of patient care issue is people abuse of how it differs in diff communities and also is it right to give them something that is inaccessible after trial over

Brandt, Allan. 1978. "Racism and Research: The Case of the Tuskegee Syphilis Study" Hastings Center Report 8(6): 21-29. Canvas

did not have care for syphillis so initial approval not declared by IRB- within a few years of start of study which recruited aa military veterans who had syphillis already recruited to look at how disease works, what should have happened was halt to study when care was found but that was not provided and patients, not give legally and morally necessary care, and don't let anyone else give care (went to hospitals and told each doctor of each of patients to not tell them that antibiotic existed, nobody questions

characteristics of capitalist medicine

direction of public funds to centralizes medical centers, pharamcetuical remedies, medical technlogy, specialization health care and research tied closely to economic market; health not a social good-market goals-PLK and RBF direction of public funds to individualized goals (fee-based care, specialized services, PLK_ Marketplace priorities do not match public health priorities (RBF) Loss of traditional and lay knowledge (lower cost); devaluation of these models nonmedical forms of influence (pharmaceticalc ompany gifts to doctors)

disease vs illlness

disease is what find in codebook illness is all bad symptoms one may feel

Das and Das have described an ethnomedical context in which treatement is perfored through ____ rather than through diagnosis and prescription

dispensation

utilitarian approach

do most good for most numbers of ppl

Authoritative knowledge in clinical setting

does patient have own say over body r doctor's superior knowledge get upper hand

To become professional according to Taylor two acculturations (modification to one's own culture)

dominant culture professional culture

structural violence

don't have to physically harm someone to hurt them-lack of ER, imbalance in power dynamic of nations, that determine who gets what medicine and whether there is medical review of resources in our country -anything that creates harm

What new project of care allows Marcy to reinhabit streets in a new way?

drill team coach

Discuss pharmaceutical nexus

ecological factors (5) hyper-individualized access scarcity of treatments uncommon in the West standardization (of care, of dosage, of ethics) over-fetishization of pharmaceuticals non-medical forms of influence ritualized acts of transparancy transnational regulatory bodies dynamic rationalism (diagnosis creates patients) me-too drugs Titanji (TEDx) - 4 lessons ethnomedical context for sickness (Das & Das, India) audit industry and relationships of reciprocity (Petryna, Argentina) ethical variability of globalization trials states no longer primary units of analysis

way you achieve cultural competency

eight questions show interest and open to info

EMTALA

emergency medical treatment and labor act is a federal law enacted in 1986 that reqs anyone coming into emergency room to be stabilized and treated regardless of insurance or ability to pay

Aristotelian Ethics

emphasize role of habit in conduct. Virtues are habits and that the good life is a life of mindless routine. Hexis is also an active condition- a state in which something must actively hold itself.

primary healthcare

essential healthcare based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in community through their full participation and at the cost that community and country can afford to maintain at every step of development in spirit of self-reliance and self-determination-first level of contact of individuals and familes and the community with national health system being ppl as close as possile to where ppl live and work and constitutes first element of continuing healthcare process

A part ethical and explanatory replace

ethical takes law understanding and explanatory takes one question of why it affected you in particular

adriana petryna's chapter globalizing human subjects research addresses the role of crisis in the consideration of differences in ethical standards granting legitimacy to ethcis being used variably and tactically by actors in the corporate research context; the problem is captured in the phrase

ethical variability

the term covering severl diff ways of examing and understanding the moral life is

ethics

pharmaceutical nexus

ethics of care demands we take into accound local moral wolds: every patient gets to decide own moral patm every morally serious persons gets to pursue their own good well being is recast as commodity

Altman "Hospital Errors"

even elite hospitals aren't immune to errors-surgeons put wrong organs into a teen at Duke, Jessica Santillan, 98000 deaths/year=medical error, operation on wrong side of brain at cancer center, changes should be determined by hospitals or independent panels? deaths preventable if increase safety

local moral worlds

every patient gets to decide own moral path every morally serious person gets to pursue their own good decisions and where getting them

Issue with norms

everyone has different opinions-hard to get a group to broadly accept anything

sharp draws attention to our classical imperative that says biomedicine do all that is possible to repair and _____ human life

extend

medicare

federal health insurance program created in 1965 for ppl 65 or older

resistance to clinical authority

flouting rules, stealthily seeking second opinions, ignoring advice, acting lie you know less than you do Dotty is a good example

six steps of moral reasoning

full range moral concepts moral agent moral obligations of agent moral dilemma resolution residual obligation

principles

general moral norms judged by a community as appropriate for the guiding and evaluating of conduct

commodified landscapes

geographical space and movement across globe taking a commodity attitude to places of the world where they have no options-no ability to exercise autonomy

Moral Hazards

get involved vs extract data bring resources v bring profes supplies return to community v share own knowledge outsourcing clinical trials where ethical restrictions are less post-research obigation (residual) to those who volunteer engagement based on human dignity (all humans =) vs engagement based on resources

ACA

goals to make health insuraance available to more ppl through subsidies to households, expansion of medicaid program to cover more adults based on poverty level and promote innovative medical care delivery methods that would lower health care costs generally

nonmedical forms of influence

govnt, advertising

Native American ethical priorities

greater importaance of collectivism, greater enphasis on holism, relationships between individuals, families, and communities, cooperation and coexistence with environments and sources of food

justice

group of norms for distributing benefits, risks, and costs fairly

Quinn, Kevin P. 2000 Viewing Health Care as a Common Good Southern Cal Law Journal 73: 278-374

health care reform and the limits of liberalism -recent history of health care reforms in the US (1994 Clinton proposal; Oregon Health Plan) the liberal paradigm and health care viewing health care as a common good liberal individualism, medicare privatization, personal values, neutrality, consensus (rawls) political ideals How the marketplace is creating health care options know plans as options this is covered in this article article itself is trying to grapple with idea of justice-distribution-main concern is if shift something to government with any amount of taxpayers you are saying this is an obligation of society for any government of society to go too quickly to the nuts and bolts, will never too effectively unless consider assumptions of common good in united states, culturally and legally we are liberalists-liberalism has a particular definition in terms of ethics and is in US tied to individuaism pg 289-Rawls' view of common good avoids appeal to any comprehensive doctrine (common morality, universally referring to all people at all times every where)-Rawls is an attorney and is trying to operationalize this for ppl in a particulr place-Common good=X (does not equal) common morality common good is Rawls' and Quinn's phrase that goes on to support/seek support of an overlapping consensus-for Rawls, common good is what the consensus says it is (just like Kuczevski says) notion of neutrality-we like to believe in political debates that we are pursuing a neutral position (297)-view that public institutions, laws, and policies should not promote any particular conception of the good life or that the right should be given priority over the good-conceptual tenets of liberal neutrality-it's an ideal but does not always happen personal values-298-so much of political and scientific debate say neutrality is a priority principal target is Rawls' political liberalism-Rawls must insist that ideas of good and political receptive must be distinct from epople with other views healthcare is the common good of concern-do you believe in governnance?what should governance be? Is it a source of law only? How does law lag behind culture, what is the law accomplishing?

Welch, H. Gilbert 2009 To Overhaul the System, 'Health' Needs Redefining New York Times http://www.nytimes.com/2009/07/28/health/views/28essa.html

health is the absence of abnormality, the only way to know you are healthy is to become a customer what to count as a disease-finding more abnormalities is the right thing? health is more than a physical state of being; it's also a state of mind what does healthy really mean-don't sacrifice self to experts with financial incenties

Scheper-hughes suggests that the classical medical ethics are being displaced by a rankly posthumanis utilitarian ethic; in whihc the physician may seem as owing his loyalties to _______ alone as if society did not exist

his patients

as physician Jeff Brenner explained to Atul Gawande for Frontline health acre hot spots are urban areas dense with high cost patients what does brenner propose to reduce costs and improve care

home visits and social work support

what is though to be responsible for as many as 98000 deaths per year in the US, not from a failure of cutting edge medicine but from lapses in basic safety procedures

hospital error

the access to healthcare structures and markets is now ________ is part of what Petryna and kleinamn call the paramceutical nexus

hyperindividualized

Ethical Relativism

idea that each individual group has its own ethical framework which is valued for them; cannot be judged by standards of a diff ethical system; more difficult that cultural to produce, gets to what we believe is truth-very touchy subjects

Principalist approach

if you uphold principles

Mattingly's point of dwelling in detail on small moments in small places

illustrates value of ethnography in moral reasoning

communal nature of ethics mattingly

importance of frienships, group therapy, and public Greek theater in moral life

Placebo effect

improvement in health based on expectation that improvement will occur

Contrasting Ethical Systems of Pima Indians and westerners as done by Smith-Morris

in western medicine-target of care=patient alone, 4 principles approach, hyperindividualism in Pima Indians-communalism (isolating individuals unethical), holistic (reductionism unethical must get whole image vs compartmentalize), must get tribe approval to share knowledge and not all members get all info

IRB

institutional Review Board committee reviews human participants research to assure rights and welfare of human participants adequately protected

most important obligation as a physician

integrity as a physician

professional ethics

internal controls of a profession based on human values or moral principles peer review IRB protocol Gawande(ghostwriters); Singer (life saving checklist)

In 2002, waiting time for cadaveric kidney

is almost x2 as long for African Americans than for whites. A.A. also less likely to have living donors.

Difference between moral relativism and cultural relativism

judgment of ppl versus judgement of acts/events

a group of norms for distributing benefits, risk, and costs fairly is

justice

cultural competency

knowledge used in clinical settings, understanding other cultural systems through 8 questions-shows you are interested and open to information-obtains certain factors specific to each patient

communitarian anthropology

kuczewski replaces the philosophical construct of individual with a cognitive conception of the person, one that sees the good as the object of deliberation individual surrenders some of his or her unlimited freedom in exchange for the safety and advantages that being a member of society affords individual is original and pimary unit of social organization community is responsible for helping to provide the conditions that enable its members to pursue projects; however human flourishing is not merely about pursuing projects per se know moral truth from reflecting on experience

Pfizer

lawsuit over unneccesary prescription with side effects -off label marketing of Neurontin when not approved by FDA- ppl dying from side effects-must think -profit drive for doctors who could get medicine from

Medicaid for salary of

less than $4300 per year Dand and Mayer

Human subject

living individual about whom an investigator conducting researc obtains data or identifiable private information

Andrena's friend Drea

loses her temper when someone suggests cld relate to her pain, stop talking after daughter dies

Most important moral project for Andrena

maintain hope

structural violence, according to Paul Farmer, is characterized by poverty and steep grades of social inequality including racism and gender inequality; it is violence exerted that is indirectly by everyone who belongs to a certain social order- what is anexample

medical care sold as a commodity

principle of justice obligates medical personnel to consider

medical utility and prospect of success as factors in decisions about how to allocate sources

Specific cultural values that attend commercialized pharmaceutical trials (PLK)

medicalization authority four principles "A dangerous break" between bioethics and the realities of local moral worlds (Ch.2 - pp.33-35) Ethical imperialism vs. ethical relativism Scarcity/vulnerability of subjects Treatment naiveté (unequal Standard of Care) - pp.40-46 Ethical codes vs. ethical regulations (pp.46-52) and enforcement The Declaration of Helsinki Prior to the 1947 Nuremberg Code there was no generally accepted code of conduct governing the ethical aspects of human research, although some countries, notably Germany and Russia, had national policies [3a]. The Declaration developed the ten principles first stated in the Nuremberg Code, and tied them to the Declaration of Geneva (1948), a statement of physicians' ethical duties. The Declaration more specifically addressed clinical research, reflecting changes in medical practice from the term 'Human Experimentation' used in the Nuremberg Code. A notable change from the Nuremberg Code was a relaxation of the conditions of consent, which was 'absolutely essential' under Nuremberg. Now doctors were asked to obtain consent 'if at all possible' and research was allowed without consent where a proxy consent, such as a legal guardian, was available (Article II.1). example of off-labeled use pg 48 What does petryna say about the chain of complicity that produces these types of off-label abuses chain of complicity (49) relationship between pharmaceutical companies, national governments and negative ethical circumstances arise across multiple moral agents who are probably trying to do something positive-develop skills in moral reasoning rather than arguing just topics recognize importance of which moral actors hav epower and ability to influence a moral event identify guiding rules in their work in this case, chain of complicity made children available for research-selected subjects for industry sponsored clinical trial Morality is not law-don't have legal force behind universal declaration, international covenant, those kinds of things codes cannot be reliedupon as basis of legal support in certain courts private medical research groups are supposed to establish them in order to bring any of findings back to United States diversity of moral agents 48-50 Titanji-placebo vs standard of care-standard of care is the idea-n petrinome standard of care defined locally-trials held in third world countries because lower standard of care-not hierarchy of IRBs-core has power and periphery ain't got it whose standard of care? standard of care about differences between ppl conducting and benefiting from research and where getting results from pg 41-treatment naivete-absence of treatment for common and uncommon diseases-bodies that are -want their bodies because they havent been exposed to anything else-when see effect, know it must be from the drug or relationship specific to that body Ethical review of research-53-humanitarian crisis-"ethics free"-groups of ppl can become ethical subjects without being informed pharamaceutical citizenship-statist laws - all laws restricted to states-a nationstate-all laws must be enforced by a state, everything else is a acode or aspirational rule figuring out how to be a better world-doing it all the time but cannot find a model that is not a global, fascist state-many things become about citizenship-pharamaceutical citizenship and governance means access to things linked by citizenship pg 50 by suggesting that their experimental tratment could do good only by that context-desperate contexts After the research-Titanji says ppl get paid but lose all treatment had before-researchers can just walk away but Titanji says you should pay for their lifelong medication Churnoble chapter-longterm obligation of different moral agents told petryna greatest concern was liability pg 58 note number 24 great example that moral obligations are not bounded by the start and end date of a research project-morality is a continuous self-moral agent is a continuous moral person-decisions you make today must be consistent with decisions you make in the past discern things differently-should not be making same distinctions make today about gender as made in 1920s about gender ethical variability trials as a social good-those who defend trials in underresearched communities-relevant limits to that argument if you're balancing two moral obligations and trying to find greater good must pick which one to favor-being knowledgable, curiosity over virtue who will benefit from that knowledge-straight out of nuremburg list Urban Ecologies-Das and Das-how people in India given a certain mediaction that they should take and because can't afford it take whatever there is/leftover-where go to get care?-govnt hospitals but also many different levels of qualifications pattern of resort*-depending on cost depending on how hard it is to get there-wait a long time before fork it out to go to govnt hospital They are going to pharmacies-key to this case study is that this is diagnosis through dispensation rather than treatment based on diagnosis In US, we will go through rounds and rounds of diagnosis and spend lots of money just to get diagnosis-tie you in tight for sake of diagnosis-clean pathwy to reatment that tells us exactly what to do-ppl, knowledge, history of knowledge, history of ppl, not doctors for all of these locations-ideally you have someone who is knowledgable about subject and a ton of indigenous pharmaceutical knowledge-continuum between locally known and medically controlled place talking about ppl who are not looking for a diagnosis-looking to treat symptoms don't want to pay because if doesn't work, don't want in body conflict between what is morally engaged care-very different system of knowledge patients could see same weeks and next week would say was for another reason-something else going on

biomedicine's culture of no culture

medicine as its own religious belief system-like Taylor in culture of no culture begins to strip away anything that biomedicine says isn't important idea that Science should not be questioned-because we are always right=authoritative knowledge

chavez's chapter on jessica santillan questions ______ as the single most immediate challenge to america's traditional identity

mexican immigration

Andrew and Darlene's baby

miracle baby vs braindead baby incommensurable rival moralities

Devries and Rott ocmpare bioethcists to

missionaries

Virtue ethics considers life for humans not merely about surviving but

moral thriving

BC refer to what audience

morally serious persons

individualism

more interested in indivual's sake The belief that individuals should be left on their own by the government.

Biological citizenship

nation-state enforcement boundaries medical resources provided only to documented citizens

Pfizer-Zoran

nigeria very outdated consent chain of complicity

treament naivete

no background in medication so ideal research patients

Morality is not law

no force behind in courts, not legal support

Harris' Issues with Alma Ata and UDHR

no globalization in UDHR in support of moral philosophy-all parts of globe influence each other and shouting out things but not and not arguing just employing ppl just employed if agree not if of diff part and will find a consensus "Human rights reports are becoming refernce points for ethical decision-making"-institutionalization is an issue-just because it is on paper doesn't mean all ethics is covered-this is not law-must be able to argue each situation or conduct moral reasoning

Moral Relativism

no single objective standard exists by which we can judge the morality of any given act, event, or idea

the causation of sickness by patient expectations of sickness, and associated beliefs and emotional states is

nocebo effect

moral obligations

norms, virtues, principles, rules

while virginia law required a 24 hour waiting period before Tucker's organs could be harvested, the surgeons disregarrded the waiting period and began surgery ________

one hour

Smith-Morris' and Sargent's take on authoritative knowledge

ongoing social processt that constructs and refelects power relationships that are simply accepted and unquestioned (B_C don't refer to this acceptance)-don't get to challenge really-doctors think know how to treat but so many different views and ethnographies and speaking of things too educated to understand for many

documentation of consent

ordinary terms shorter sentences clear cause and effect active tenses

Smith, Michael J. 2009. "Humanitarian Intervention: An Overview of the Ethical Issues". Ethics & International Affairs 12(1): 63-79. Canvas

outlines the crisis of when to intervene in international issues-he explains the variety of arguments there are on what kind of conflicts can be intervened and what kind cannot and the issues with consistency and effectiveness because of varying resources and issues. He ultimately states that there is still much to be established as to exactly what requires assistance but there cannot be a lack of assistance-simply assistance must go to where it is most needed and where resources may give.

Deontology

philosophers who think there are universals (common morality)

Utilitarianism

philosophical approach toward utility; something useful

Rejection of moral incomensurability is a hallmakr of modern moral

philosophy

Rouse echoes Sharp in declaring four powerful cultural beliefs about the body and medicine 1. that it is rational to want to preserve the body at any cost 2. that all medical interventions reduce suffering 3 that adults should deided for minors about quality of life 4, that )_____ know best about rational decision-making

physcicians

improvement in health that is attributable to the patient's expectatoon or belief that improvement will occur is

placebo effect

Features of globilization of ethics

poor standard of ethical argument in international committtee pronouncements, brief committtee convention are themselve cited as ethical justification rather than the source arguments on which these declarations were built international conventions are under pressure to achieve consensus ad produce conclusions this is possible only around high minded, resonant, and increasingly abstract and ambiguous principles NOT set by marketplace of ideas

habitats for authoritative knowledge

ppl who are owning their space a little bit; think of kind of orgnaisms in habitat have own space?

Mattingly says family is a _______ because _____

primary moral site raising good children is a universal function of the family

institutionalization/globalization of ethics

pronouncements made by national government and international organizations if you can name it from a source now we think you have covered ethics but this is absolutely wrong this is not a rule book-it is a statement as close as we can get to consensus and we do not have a legal standard to give you-cannot tell you hot to enforce this something to initiate conversation will not conclude conversation Harris is concerned about globalization and institutionalization globalization-ideas across nations thrown around and not well argued just employed strategically if you're even willing to agree people are throwing all kinds of statements out institutionalization-if it is cautified it Is not the end failure to adequately argue or conduct moral reasoning

race issue

race=species-have things that make them separate from rest of group who among human group is speciating-none of them to speciate you must not be able to reproduce toegther-isolated so that traits/mutations contained to becom dominant in a subgroup-cannot be a subgroup with long earlobes because can mate only one race=human race gets camoflaged as a biological effect over time-ex poor and uneducated family history ppl using biological explanation for something that is social

the lawsuits filed by Bruce Tucler's brother William alleged ________ in both the medical examiner's undue haste and in the hospital;s failure to find and use William's business card which was in Bruce's wallet

racism

How do political, economic, media, and maret features shape control we have over our health care-consider Tucker, Satillan, L.Lee, genetic perdition, medical hotspotting

racism views of ppl

Sharp, Lesley 2006 "Babes and Baboons: Jesica Santillan and Experimental Pediatric Transplant Research in America" WLG

radical, surgical interventions to extend childrens lives kids' organ transplant much harder bc need from kids experimentation 2 surgeries just before 18th birthday-but say she was a small, frail child heat lung transplant is rare child's death considered worst death crazy explore bc of potential childern ended in autopsies that didnt show why failure baboon heart transplant by bailey -into baby (baby feas) dies of graft infection but still praised ; religious issues research vs therapeautic trials jessica's transplants=experimental hoep and experiment

Steven's chapter abt 1975-1976 quilan case -sleeping beauty-challenges readers to consider doctors' roles and authority in making moral decisions for their patients, in this case quijnlan's doctor

refused to pull the plug on his patient

Chain of complicity

relationship between pharm companies, natl govnts, and negative ethical circumstanses arise across mulyiple moral agents who are probably trying to do something positive-develop skills rather than argue just topics recognize importance of which moral agents have power and ability to influence a moral event ex made children available for research-Pfizer's consent forms backdated-parents thought children getting Trovan that proven to work but not (49)

in the karen ann quinlan case, her parents sued to have their daughter

removed from respirtory support, which they consideredextraodinary means for prolonging life

carolyn rouse suggests the ______ is especially strong for childrne

research imperative

the obligation created by the gap when choice of one path in a moral dilemma produces guilt about not having taken the other path, and a continuing compulsion to address the abridged moral obligation is

residual obligation

flouting rules, stealthily seeking second opinions; ignoring advice, and acting like you know less than you do are all examples of

resistance to clinical authority

a norm of respecting the decision-making capacities of individual persons is

respect for autonomy

4 Principles

respect for autonomy, nonmaleficence, beneficence, justice

Moral laboratory

reveal deeply experimental qualities of little moments by recognizing the temporality with moral experiments experience as a passagesmall events as experiments in possible futures-change future one had envisioned

ethical review

review ethical safety of trial, lacking or insufficient in many developing countries, review ethical issues associated with different countries, independent review as appropriate

Harris wrote

scope and importance of bioethics globalization and institutionalization issue

Rough Cut: India: A Pound of Flesh Selling Kidneys to Survive by Samantha Grant, 2006 http://www.pbs.org/frontlineworld/watch/player.html?pkg=flw_rc&seg=32&mod=0

selling kidneys for survival in india because of payment can get-noncertified ppl; ppl want to give kidneys, push for it

Tanya, Frank, and Andy

soccer game cerebral palsy education

Cross-cultural strategies as applied to Kleinman's 8 questions of explanatory model

social capital and social networks clinic modalities that incorporate the patient's context decentralized models for care and treatment collaboration, not just involvement in care sustainibility and co-learning in dissemination

Nocebo of social death

society no longer sees person as person-ostracize because of disease diagnosis can lead to negative health outcomes/death

Faith

something one believe in that he or she cannot prove/has not yet measured-we have faith that our scientists will do everything right

according to Dr. Boghuma Kabisen Titanji, differences in the ______ between a researcher's home country and the country where research is conducted should be ignored for voluntary research subjects

standard of care

Some issues Harris has with globalization

standard of ethical argument poor/excluded reports that aren't good are guidelines arguments unavailable public consultation can sway research a certian way

3 things that limit our perception of ethics

standardization nonmedical forms of influence monopolies over strategic knowledge on our perceptions of what is ethical

according to the pharmaceutical nexus, 3 things that limit our perceptions of what is ethical include

standardization, nonmedical forms of influence, and monopolies over strategic knowledge

standardization

standardize ideas and say this is ideal science- is our favorite source to trust

broad definition of health from Alma Ata

state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity

AZT Trials

subsaharan Africa Tatanji informed consent, standard of care

Mattingly's ethnography focuses heavily on moral perils of parents trying to become

superstrong black parents

research

systematic investigation designed to develop or contribute to generalizable knowledge

Nancy Scheper-Hughes

talks about divisible body-says we think we are indivisible-not dividable-individuals-we are one complete person and we end at the skin-kind of makes sense but in many ways doesn't it-we have many ways of interacting beyond our skin with other organisms and outside world-many examples where people are not so individualistic dividuals-I am this role over here and that role extends into that person-conveyed metaphorically but in many cultures you don't exist outside that role nobody wants to go live in a closet or does well when goes home and isolates themselves-humans do not do well in isolation Nacy Shepherd Hughes-free market requires divisible body and has taken advantage of divisible body inspired and fueled by these advances-further ethical challenges-market dilemmas-healthcare can now be sep from a healthcare market physicians like to believe they can make casuist ethical decisions but cannot because they are highest trained, highest paid, and have obligation to accept market dilemmas-unequal position that donors and recipitents have In the market particularly across countries and that laws are always outdated bc always lag behind culture laws immediately outdated even when we work so hard to get our laws as good as we can-still have to fund regulation The culture of transplant; bioavailability

Cultural relativism

that is their culture and I cannot judge them by the standards of my culture

the bioethics is now less a decisionmaking process, and more a set of rules or mandates embodied in institutions (national and international), is what harris calls

the institionalization of bioethics

illness narrative

the personal stories that people tell to explain their illnesses

Scheper-Hughes argues that opposed to the softer medical ethic of the clinic where there is the commitment to save the sickest, transplant ethics save

the salvageable and allow the sickest to die

Moral reasoning

the thought process of identifying, evaluating, and estimating (or judging) what is right and wrong, then using choice and evidence in decision-making; distinct from problem-solving

medicalization

the transformation of a human condition into a matter to be treated by physicians Turn general life experiences into medical problems supplying of a medical remedy to a problem you did not know you had (prozac for mood brightening, hair transplants, viagra) not to say all medical products are just trying to make money but that is what makes medicalization so effective, so many people would like to be happy-no one wants to be blue well-being is recast as a commodity-pharmaceutical nexus PLK climates of hyperindividualism p 7-8 ch5 enviros on nonmedical forms of influence p9-13 ch 6, 7 what is too much commoditization?

Aristotelian ethics relies on self that continues through

time

aristtelian virtue ethics depends upon some notion of a self that continue, or endures through

time

clinical narratives accoridng to Taylor

transform what patients say into what physicians write in charts and say to each other-bracket off questopms pf patient's life and experience (discount patient's narrative)

Three cases Sargent SM

translator, coma, take off, doctor yes, wife no mentally retarded according to doctor, according to nurse, what it means to be delusional/decision making capacity to look at trend or to just get rid of annoyance

eugenics

try to improve pop through genetic traits and selective breeding as mandated by govnt

before his hert was tranplanted into a retired white businessman in 1968, bruce tucker had been declared ________ which allowed the swift harvesting of his orgsn

unclaimed dead

Hoffman's chapter helps illuminate the highly untypicl aspects of Santillan's case for immigrant health, and the largely false image of illegal immigrants _________ precious health resources

using up

Peer review is conducted to ensure which 3 aspects of research

validity, significance, originality

What Smith-Morris says is issue with incompatibility of healthcare

variation in acculturation, can't get treatment in way allow, self-determination, endemic

Smith-Morris and Sargent v. Common morality

very hard to find a point of common morality because of different cultures

Aristotelian

virtue ethics

Aristotelian Ethics

virtue thics, create good and happy life, moral thriving, morality as moral reasoning and discernment

Numberg Code Ten Points

voluntary consent must yield new knowledge that could not be gathereid in another manner anticipated results justify conduct of experiment avoid unnecessary suffering or injury no research when death/ disabling injury expected risks may never exceed humanitarian importance of new knowledge poper prep and protections only sci quealified personel subjects can withdraw and terminate researched must be prepared to terminate if any death or injury likely

Nuremberg Code

voluntray consentk stop if issues, ppl can drop out, must stop if any harm, must be done by professionals, no other ways to get knowledge, humanitarian

Mattingly talks about narrative as

way for us to imagine or play out diff moral possibilities, way of exp, linked to lived experiences, not as coherent and linear as critics suggest

health expenditure per capita 2014 stats suggest

we spend more on healthcare privately to reach purchasing power parity so high above others, our public spending is not the highest, and our health levels are still lower than other countries

What are the specific cultural values that a commercialized pharmaceutical trials and the biotechnological focus in biomedicine (as described in the PLK volume and lecture films). Be sure to address define and utilize key concepts of the authors in your response.ethics of "care"

well-being as commodity limits to our perception of what is ethical human subjects research informed consent gifts surveillnace local ethnomedicines pharmaceutical governance ethical variability/standards of care IRB's and institutionalization of ethics RCT's authoritative knowledge free market medicine/neoliberal medicine medicalization

DeVries conducted interviews at a European bioethics training with particpants who

were from parts of the world where christianity was not dominant, were from developing parts of the world where principalism s not an asy fit, found the guidelines unhelpful given local religious and technological characteristsics

Authoritative knowledge

when more than one knowledge system exists and one kind of knowledge gains ascendance-devaluation of others' ways of knowing, one system comes to appear natural, reasonable, shared

speaking about the ethics of care in contexts of extreme poverty devries and rott argue that autonomy is meaningless

when patients have no power to act on it

Hotspotting

where local policing can make a difference

Explanatory model

white dominant-talks about asking questions to patients to get info but ends up making them respond in a way that doesn't look at their ethical background

drug seeding

withholding information Neurontin trial-involve a lot of doctors and a lot of patients and research study done by advertising department (not research)-not illegal, unethical Medtronic-look at bone growth enhancer for spinal surgery; fail to report 10-15% complications of cancer, sterility, bone dissolution, neurosurgeons got a lot of money you should disclose problems to doctors and patients we live in a society that benefits from a much more complicated marketplace with information getting to patients

Drug-seeding Trial for Advertising

withholding information, neurontin trial involved a lot of doctors and patients and research study done by advertising department (not research), not illegal, unethical medtronic-look at bone growth enhancer for spinal surgery; fail to report complications of cancer terility bone dissolution 10-15% bc neurosurgeons got a lot of money

New reproductive tech

women being abused for eggs eggsploitaion Creighton Model for Fertility

Informed consent

written-not a single event or fomr-edu process that is between investigator and prospective subject-basic events: full disclosure of nature of research and particpation, adequate comprehension, voluntary choice to particopate

Atul Gawande

"A Lifesaving Checklist" Moral Dilemmas: Beneficence/Non-Maleficence Professional Ethics (IRB protocol) Integrity, Conscientiousness Moral vs. Legal Responsibility lifesaving checklist create checklist-don't want record kept so govnt removed-not changing a single rule but keeping a record to hep ppl remember to do it, interesting aspect is how they went about justifying removal of checklist defended removal by saying patient needed to consent-but had nothing to do with this had to do with liability of physician and hospital, described it as an alteration in medical care-nothing had changed but like bathroom cleaning monitor page plenty of good reasons to justify this-the one I do not accept is protecting the patient because we have proven that it is not protecting the patient moral reasoning-balance of good that you are after-protection of the patient for an issue about protection of patient-no balance of good is to do checklist cost benefit vs balance of good-difference between capitalist argument and moral arguments

commercialized clinical trials

"A dangerous break" between bioethics and the realities of local moral worlds (Ch.2 - pp.33-35) Ethical imperialism vs. ethical relativism Scarcity/vulnerability of subjects Treatment naiveté (unequal Standard of Care) - pp.40-46 Ethical codes vs. ethical regulations (pp.46-52) and enforcement Global Pharmaceutcical

Paul Farmer's Structural violence

"Structural violence is one way of describing social arrangements that put individuals and populations in harm's way... The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people ... neither culture nor pure individual will is at fault; rather, historically given (and often economically driven) processes and forces conspire to constrain individual agency. Structural violence is visited upon all those whose social status denies them access to the fruits of scientific and social progress."

healthcare budget in Texas

$35 billion according to Dand and Mayer

Jessica Santillan

(December 26, 1985 - February 22, 2003) was a Mexican national who died after an organ transplant operation in which she received the heart and lungs of a patient whose blood type did not match hers. Doctors at the Duke University Medical Center failed to check the compatibility before surgery began.

ethics of care

(a gendered ethics) (Psychologist Carol Gilligan) "Women speak in a different voice" Ethics of care-gendered approach to ethics-female ethics, relational ethics as opposed to logic ethics

integrity

(n.) honesty, high moral standards; an unimpaired condition, completeness, soundness

genetic perdition

-idea that your genetic put you at risk dangers of your genetics and how you may want to manipulate some of your genetics as well as what they may make you prone to-biologically unique and advanced and holds a lot of promise despite the fact that any of conditions there is nothing we can do about it-but very expensive also a question of justice-when look at investment in science-in medical research, must take into account availibility of resources for global health not of genetic conditions but genetic perdition of not being able to access a genetic test-now that certain states have gun to create funds so that certain inmates can have DNA tests brough to their interests-as of 2018, national registry has 466 exonerations on DNA evidence and just on that one source assume 99 % of people that go into law enforcement are good people but epidemic of police error-quick motion -often not convicted bc of balance of fear but put into citutions where they are publicly convicted-public sees a portion of what happened Among people 12 and older, about 83.5% of the US population is white, and 82.5% of rape victims are white; 13.3% of victims are black, compared to 12.3% of the population; and 4.2% of both victims and the population are of other races. (NCVS, 2000) Blacks are about 10% more likely to be attacked than whites. In 2000, there were 1.1 victimizations per 1,000 white people, and 1.2 victimizations per 1,000 black people. (NCVS, 2000) Only 10% of reported sex assaults are allegations of white women attacked by black men. Yet most - 54% - of all convictions proven to be unjust (through DNA evidence) involve African American men wrongfully convicted of assaulting white women. (Peter Neufeld, attorney) Few inmates can afford the requisite $5k for DNA technology.

Kleinman 8 Questions

1. "What do you call the problem? 2. What do you think has caused the problem? 3. Why do you think it started when it did? 4. What do you think the sickness does? How does it work? 5. How severe is the sickness? Will it have a long or a short course? 6. What kind of treatment do you think the patient should receive? 7. What are the chief problems the sickness has caused? 8. What do you fear most about the sickness?

Who Plays God

1. Introduction to U.S. Health Care (01:26) Health-care economist Uwe Reinhardt says the American health care system "defies description." Americans spend more per capita on health care than any other country. 2. Organ Transplant System (04:19) There are 17,000 people in the U.S. currently waiting for a new heart, liver, or lung. Only 40% will receive the transplants they need. New drugs and technology have increased the success rate for transplants. Jim Steen needs a new lung. 3. Transplantation Act of 1994 Selection Guidelines (04:01) Congress established a system to control organ allocation. Jim Steen must meet medical, social, and financial requirements before his name will be added to the registry. Steen's alcohol and tobacco use are discussed. 4. Ineffective Use of Resources (03:18) Multiple hospitalizations will be required for those who do not get the transplants they need. This costs hundreds of thousands of dollars before the patient eventually dies. Bill Hinkle is on the lung transplant list. He is kept alive by expensive drugs. 5. Questioning Value of Human Life (03:19) Bill Hinkle's insurance will cover most of his medical expenses including his lung transplant. Jim Steen does not want to cause a financial burden to his family if costly treatment will only keep him alive for a short period of time. 6. Egalitarian View on Transplantation (01:57) Bill Hinkle is a former alcoholic. He was also a heavy smoker. He credits God with his sobriety. He is awaiting a lung transplant. Some people take issue with substance abusers receiving donated organs. 7. Living with Lung Disease (04:34) Jim Steen's health is deteriorating. He talks with his doctor about his decline. He must learn to conserve his energy while waiting for a lung transplant. Mrs. Steen expresses her fears. Bill Hinkle is confident he will get the transplant. Steen dies in 1995. 8. Is the System Fair? (02:29) Health-care economist Uwe Reinhardt explains the issue of putting a dollar value on human life. Medical ethicist Glen McGee addresses what is involved in deciding who will receive scarce medical resources like donated organs. 9. Rationing Scarce Medical Resources (03:40) Medical journalist George Strait asks Joanne Lynn, M.D. about the ethics of choosing transplant recipients. She addresses the struggle to keep the system egalitarian. Medical ethicist Glen McGee discusses the cost benefit of transplantation. 10. Terminal Cancer Diagnosis (02:49) Sheila Moore received abnormal pap smear results. Her ovarian cancer had metastasized and spread to several organs. She had surgery and started chemotherapy. Her husband describes the depression that followed. 11. Paradigm of Western Medicine (03:47) Joyce Lane has lung cancer. Her daughters tell her story. Surgery showed the cancer was incurable. Her doctors pursued aggressive chemotherapy and radiation. She became weak and addicted to morphine. A new oncologist tried Taxol. 12. Dissatisfaction with Treatment (02:44) Sheila and Frank Moore were not satisfied with the care she is receiving for ovarian cancer. She switched to a new oncologist and her mood improved. Her daughters describe how her diagnosis has affected the family. 13. Ovarian Cancer Prognosis (02:32) Sheila and Frank Moore discuss her latest blood test with her oncologists. Sheila has lived two years since her diagnosis, longer than most people with stage three cancers. 14. Cancer Recurrence (02:21) Frank and Sheila Moore discuss her prognosis. She has just received positive news about her chances of survival. Sheila shares her hopes for the future. She would like to see her youngest daughter graduate from high school. 15. Balancing Treatment and Quality of Life (02:51) Oncologist Bruce Dana M.D. discusses the cost versus benefit of treating terminal illness. The medical director of Blue Cross/Blue Shield insurance company explains the role that the scarcity of money plays in treating patients. 16. Poor Quality on Life (02:37) Joyce Lane began Taxol chemotherapy. her cancer symptoms improved but she suffered the effects of the treatment. Her family felt medical staff were not responsive enough to her condition. A CAT scan revealed the tumor had returned. 17. Lane's Final Days (02:36) Joyce Lane's family gathered to celebrate her 71st birthday. She died in her bed. Her daughters describe her passing. 18. When Treatment Will Not Work (02:24) Medical journalist George Strait and medical ethicist Glen McGee discuss cancer patients Joyce Lane and Sheila Moore. Doctors have to think about quality of life when survival is not likely. He argues that doctors should not offer feudal treatments. 19. Constraints in Managed Health Care (03:43) Health-care economist Uwe Reinhardt says the "never say die" attitude of the American health care system is obsolete. There are no longer unlimited resources. Scarcity brings moral dilemmas in medical choices. 20. Premature Babies (02:14) Many babies born before 28 weeks do not survive. Those who do are likely to have severe handicaps. Terry Williams is 24 weeks pregnant. Mothers are often put in the position of deciding whether their babies will live or die. 21. Trouble Predicting Outcomes (02:42) Drug therapy and advanced technology improve the chances of survival for premature babies. These treatments come with side effects and risks. There are also risks to the mothers. Doctors must try to balance the health of mother and baby. 22. Premature Baby Prognosis (03:06) Terry Williams delivers her baby. He weighs less than one pound. The biggest risks are air leaking from his lungs and internal bleeding. The baby's primary care nurse gives his mother an update. 23. Visit with Premature Baby (02:23) Terry Williams visits her baby in the neonatal intensive care unit. 24. Psychological Trap of Technology (02:07) Baby Christopher's health is deteriorating and he is in critical condition. Blood has begun to leak into his brain. His fragile skin is infected. He is being kept alive by a ventilator. His mother has to decide whether or not to keep him on life support. 25. Financial Constraints in Neonatal Care (02:05) Christopher's doctors try not to consider cost when making medical judgments about premature babies. Terry Williams removed her son from life support after incurring $70,000 in medical costs. She reflects on his short life. 26. Setting Guidelines about Care (02:31) Medical journalist George Strait and medical ethicist Glen McGee talk about Terry Williams and her premature baby. They address the idea of being trapped by technology. Joanne Lynn, M.D. says social expectations would be helpful. 27. Social Commitment to Handicapped Children (01:57) Medical journalist George Strait acknowledges the role the media plays in expectations for premature babies by covering those who leave the hospital but not following up. Medicaid is heavily responsible for caring for these children. 28. Values of Early Life Care (01:54) Medical ethicist Glen McGee suggests taking some of the money that currently goes to the care of premature babies and putting it into better prenatal care for babies and mothers. 29. Public Plea for Medical Help (03:22) One in five people fall below the poverty line in small towns across Kentucky. Access to private health care is limited for those without insurance. Sheree Martin did not qualify for Medicaid; her son was refused an operation for inability to pay. 30. Denied Medical Care (03:51) Many families in rural America earn too much to qualify for Medicaid but not enough to pay for medical services. The public clinic is often the only option for people without health insurance. Funding is limited for these facilities. 31. Emergency Room in Urban America (02:12) D.C. General Hospital was established and financed by Congress to care for the poor. It is legally obligated to treat patients regardless of ability to pay. This includes criminals, homeless, and victims of violence. 32. Overburdened Urban Hospital (04:51) Some patients at D.C. General wait 12 hours to be seen. The E.R. acts as the general care doctor for many. The hospital has accumulated a deficit of 85 million dollars. The high cost of treating victims of violence is crippling hospitals nationwide. 33. American Health Care Approach (02:13) Health-care economist Uwe Reinhardt addresses the unique health care problems facing the poor. There is no focus on preventative care. Waiting until health is dire is an inefficient use of health care resources. 34. Disappearing Public Health Clinics (02:30) Health-care economist Uwe Reinhardt talks about the perception and reality of public hospitals. He calls them the "ultimate cop out for the politician." There is no commitment to preventing illness and injury in U.S. cities. 35. Help with Dying (04:02) Tim Shuck has been diagnosed with AIDS. The virus has penetrated his brain. This will lead to a poor quality of life. He receives constant medical attention covered by his health insurance. He has obtained the medical means to commit suicide. 36. Views on Legalizing Assisted Suicide (02:25) Many religious groups are opposed to assisted suicide. Tim Shuck's mother is prepared to help him end his life since there is no chance of him recovering from AIDS. Her minister does not agree with this decision. 37. Public Policy on Assisted Suicide (02:10) The financial cost of care for terminally ill patients is immense. Dr. Peter Goodwin explains that doctors are not trained to respond to the wishes of dying patients. He believes assisted suicide should be a legal option. Tim Shuck speaks out on the subject. 38. Multiple Views on Assisted Suicide (04:52) Medical journalist George Strait and Joanne Lynn, M.D. discuss the societal implications of physician assisted suicide. Health-care economist Uwe Reinhardt argues in favor of people dying on their own terms. 39. Closing Thoughts on Health Care (02:51) Medical ethicist Glen McGee says it is important to address resources when making decisions about medical care. Joanne Lynn, M.D. wants people to demand better care but learn to accept limits. 40. Credits: Who Plays God? Medicine, Money, and Ethics in American Health Care (02:09) Credits: Who Plays God? Medicine, Money, and Ethics in American Health Care

7 Requirements of Primmary Health care according to alma ata

1.reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience; 2.addresses the main health problems in the community, providing promotive, preventive,curative and rehabilitative services accordingly; 3.includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; anadequate supply of safe water and basic sanitation; maternal and child health care,including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs; 4.involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry,education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors; 5.requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate; 6.should be sustained by integrated, functional and mutually supportive referral systems,leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need; 7.relies, at local and referral levels, on health workers, including physicians, nurses,midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.

Linnaeus

1775, Swedish naturalist categorized Africans as Homo sapiens afer, a different species and different evolutionary track than white men

Samuel george Morton

1839, physician-scientist determined that Caucasians had the largest skulls, and therefore the largest brains, and blacks the smallest

Samuel A Cartwright

1851, Louisiana's M.D., discovered a host of imaginary "black" diseases "whose principle symptoms seemed to be a lack of enthusiasm for slavery" (Washington 2006: 36).

Ota Benga

1906, missionary-explorer Samuel Phillips Verner brought African Pygmies to America for display at the St. Louise World's Fair. In exchange for a financial gift, Verner sold Ota Benga to the Bronx Zoological Gardens. Benga was caged with a gorilla and orangutan, given a bow and arrow, and paraded every afternoon for show. Show eventually closed. He committed suicide in 1916.

medical apartheid in history

AD 160, Roman physician Galen (129-c.199) described African men as having oversized sexual organs, inferior intelligence 1 775, Swedish naturalist Carl von Linné (Carolus Linnaeus) categorized Africans as Homo sapiens afer, a different species and different evolutionary track than white men Monogenists of the 17th and 18th centuries instead explained that characteristics were dictated by climate 1839, physician-scientist Samuel George Morton determined that Caucasians had the largest skulls, and therefore the largest brains, and blacks the smallest 1851, Louisiana's Samuel A. Cartwright, M.D., discovered a host of imaginary "black" diseases "whose principle symptoms seemed to be a lack of enthusiasm for slavery" (Washington 2006: 36). ppl who are authoritative get to decide major scientific categories: continents-geologically speaking Europe is not a peninsula context extremely important-if not concerned with marketplace of ideas circulating around you not remembering history racialization of poverty is racialization but be conscious of how using it for whom is the decision unethical

Galen

AD 160, Roman physician described African men as having oversized sexual organs, inferior intelligence

Human Genetic Engineering

ALD stem cell virus injection

Communitarian Ethics

About communities-if you define yourself as part of a community you will have an ethical standing in that community

6 traits of current international milieu

Absence of consensus (?) New balance of power (?) Traditional influences focused on security; modern era of economic interdependence Truly global economy (though states were never islands, uninfluenced by neighbors) National Sovereignty is a "Constituent Principle" Colonialism and old-fashioned aggression are still occasions for intervention 7. International Law is "thinly institutionalized" and constantly evolving. 8. Collective intervention is our current model for checking power.

Parkland CEO

Anderson Dand and Mayer

Lackoff

Argentina: neoliberal forms of aid and development; we just need to get to know each other better, talk more; one issue is if one country gets too dependent on another country economically, they're essentially held hostage price-wise: neoliberalism is an economic theory that in theoretical circumstances have demand informing supply-when do we create that perfect circumstance? No where but a book; freedom of access to goods and information; problem is assumes free market space which doesn't exist; what did this do to the health market in Argentina?-neoliberal reform often brings with it privatization=positive side that encourages entrepeneurial work inside-creates space for new businesses and individuals in the nation to engage in new markets, you as a single person can now develop relationships to build up your local corner store; particular type of state created-marginalized in longterm markers of development-education doesn't come up-upper class rises through entrepeneurship but not all of society forward; market flooded with a lot of new medications and advertisements for medications so consumers putting pressures on physicians to prescribe what they saw through marketing-how markets can flood a system and bypass medical expertise

Budget Reduction to HHS

Arlene

Three metaphorical spaces of Mattingly as ethical project

Artisan's workshop, courtroom, and lab

Dunkelberg

Associate Director of Center for Public Policy priorities- a liberal think tank in Austin research institute/center and organisation that performs research and advocacy concerning topics such as social policy, political strategy, economics, military, technology, and culture Dand and Mayer

How does Kleinman's explanatory model (8 questions) framework make more ethical care possible?

Authoritative knowledge (challenge to) Cultural relativism Clinical narrative (challenge to) Cultural competency Hippocratic Oath Informed Consent Moral dilemmas

Review DeVries an Rott "Principalism is not an easy fit in most developing countries." (p.8) What principles were identified as particularly problematic?

Autonomy: there are familial and communal ideas of autonomy; autonomy is meaningless where patients have no power to act on it; Christian assumptions behind principalism oblate other religious viewpoints.

gendered ethics

BC say women speak in a different voice

Andrena and Belinda

Belinda has brain cancer and Andrena joins collective group dynamic and keeps hope-then works with families to make feel better

Margaret Sanger

Birth control to decrease black babies "is usually lauded as a powerful birth-control pioneer and as a feminist" but is described by Washington as "the most famous American populizer of eugenics" (2006: 195).

sickle cell anemia test-example of genetic perdition with Herrick and Irons

Cardiologists James B. Herrick and Ernest E. Irons first identified the sickle cell trait. Affects Mediterranean, Middle Easter, and West African people, but not South African and East Asian people. Failures to see or acknowledge scientific facts: Despite broader ethnic patterns, only African American pilots were grounded (or lost jobs); Ortho Pharmaceutical Company sold the so-called sickle-cell screening test, though it did not differentiate between sickle-cell carriers (heterozygote) and people with sickle-cell disease (homozygote).

Texas Comptroller and what stated in Dand and Mayer

Carol Strayhorn said it cost 3X more in ER if not insured

Discuss two majors aspects of the culture of biomedicine: first, the 'culture of no culture' described by Janelle Taylor; and second, the specific cultural values that attend commercialized pharmaceutical trials. What roles do medicalization, authority, and The Four Principles play in these dilemmas?

Clinical narrative Culture of No Culture Standardization Institutionalization of bioethics (and institutional ecology of global pharm) Divisible body/bioavailability Definitions of death Standard of care Informed consent After the trial Experimental imperative Free market (& dilemmas) Body parts as commodities IRBs and Ethics Committees (regulation)

Janelle Taylor What is it about the culture of medicine that makes it appear, to its members, to be so devoid of culture?

Clinical narratives; creating a "medically meaningful argument"; bracketing off questions of the patient's life experience (p.557)

Taylor

Culture of no culture: how to shed biomedicine's culture; there is a professional culture that is a subset; trained to view people's cultural context as separate from situation; physician's medical knowledge is no less cultural/real than a patient's knowledge is one-sided

Kleinman's 8 Questions

Descriptive Level: How would you describe the problem that has brought you to me? Conceptual Level: What does the illness do to you? How does it work? Why do you think it started when it did? What are the results you hope for? What will happen if you don't get treatment? Apart from me, who else can help you get better? How can they help? Personal: Why did you in particular get sick?

Bioethics as secularizing movement

Devries and Rott strips away anything biomedicine says isn't important; science should not be questioned-authoritative knowledge

Hyper-individualized healthcare (PLK 7,8)

Diminished negative force of collective problems Micro-standardization that ignores local moral worlds Non-medical forms of influence Doctors become gatekeepers

Characteristics of capitalist medicine

Direction of public funds: to construction of centralized medical centers, pharmaceutical remedies, medical technology, and specialization (e.g., PLK). Health care and research tied closely to the economic market (primacy of profit); health not a social good; market goals affect science (PLK Ch.8, p.225-230; Rylko-Bauer & Farmer). Direction of public funds to individualized goals (fee-based care, specialized services) (PLK Ch.8, p.222-225) Marketplace priorities do not match public health priorities (Rylko-Bauer & Farmer; Welch). Loss of traditional and lay knowledge (lower cost); de-valuation of these models (e.g., childbirth). Non-medical forms of influence (e.g., pharmaceutical company access/gifts to doctors - PLK Ch. 5, p.115 & p.128; "normalcy" defined by market - Welch)

Dotty and Betsy Dotty's moral tragedy

Dotty wanted to be a nurse but had to take care of Betsy with sickle cell anemia becomes superstrong black woman whose attitude she would reject if not in that kind of situation

FILM: Race: The Power of an Illusion, 2003. IDD 05326 (168 minutes)

Episode 1 - The Difference Between Us1. What is genetic variation? How are biological explanations used to justify inequalities?2. What are some of the complex ways in which genes and environment interact.3. Do visual traits correspond to other genetic differences in the body? What does the answer mean for questions of social race?4. How much genetic variation falls within, and how much between, the groups we regard as (social) races?5. How does a race/species develop? What is required? What evidence of this exists for humans?Episode 2 - The Story We Tell1. How are terms like "assimiliation", "civilization", and racial "superiority" or "inferiority" used and justified in history? In particular, how have we relied on "science" or "medicine" to justify these social priorities? Identify examples from throughout the film.2. Summarize the "American" concept of race and how it has evolved over time.3. What was Thomas Jefferson's theory of race in the U.S.? How did we move from a "fluid" theory of race to one that is more rigid?4. What is the difference between "African slavery" and "European indentured servitude"? How and when did this difference emerge?5. What is White Man's Burden?6. What is the World's Fair? How does this showcase of "science" and "progress" institutionalize cultural and economic ideas?Episode 3 - The House We Live In1. What cultural traits and policies made up the context of early 20th century immigration to the U.S.?2. What was the Ozawa case and its implications for race?3. What was the Thind case, and how did the Supreme Court contradict its own reasoning here?4. Explain the WWII housing crunch and the racial logic behind home loans.5. What is the dual housing market and how is this constructed? What institutions are involved? What mechanisms of culture, authoritative knowledge, and marketing are at play?

The doctor meets the bioethcist

Ethicist says human is just one species among many Doctor religious argument central to ethics rational-multiple forms of rationality

Legal focus on patient autonomy (B&C)

Four Principles Approach

use moral reasoning to discuss global transplant medicine and its relevance to the field of health ethics; give specific examples from santillan case and lecture materials to justify moral priorities; which state, institutional, moral perspectives are best guides for this topic?

Global transplant medicine compassion-give to all medicical care loyalty to citizens that are legal resourceful thoughtful discernent a death retold- illegal vs legal chavez, compassion to a young girl best guides-Hippocratc oath, EMTALA, Alma Ata, UDHR: perspectives of UN, of citizens, of physicians

Fannie Lou Hamer

Granddaughter of a slave, daughter of sharecroppers, Fannie Lou Hamer sought help in 1961 for a "knot on her stomach". The doctor removed her uterus, without explanation or consent. Became a lifelong opponent of birth control.

Native Ethics/Priorities

Greater importance of collectivism (esp. for reservation-based care) Values that encompass genealogy and historical links Relationships and sharing between individuals, families, and communities Cooperation and coexistence with environments and sources of food The recognition that some tribal knowledge is not accessible to all.

Role of belief in healing-strauss

Healers believe in effectiveness of their technique patients believe in healer's powers social groups believe in healers' powers

2-3 examples of hyperindividualism from Smith-Morris and Sargent

Helman, a physician and anthropologist, notes that biomedicine focuses on the individual patient, or even the individual organ, while ignoring wider familial, social, and economic issues that render consensus or problem resolution difficult to achieve Individual versus family (collective) focus of decisions There are two main critiques we make: that the individual is so prioritized and central as to become an unquestioned presumption of care and that the notion of a common morality is a false, if not a culturally imperialist, idea that justifies the devaluation of locally meaningful moralities.

Why is medicine unique according to ethicists? Why are health care professionals held to a higher standard of ethics?

Hippocratic Oath and changes conflictscreating a straing on our safety net explicit rationing-health maintenance of organizations is an insurance product was never intended as an equity measure never intended as another option in the marketplace-like said to woman in clinic-if choose to leave lose help from service sounds fair but not if think of responsibility ends of medicine unique becausee linked to individual trust and common good-conclude argument with a statement that it is a false belief that efficiency will solve proble of common good

Hoffman, Beatrix. 2006 "Sympathy and Exclusion: Access to Health Care for Undocumented Immigrants in the U.S." WLG

Hoffman talks about the different issues with illegal immigrant health care over the decades and particularly in the Santillan case-the santillan case was no ordinary case-the family came for the purpose of medical care, mother prodvided insurance by job, Jessica got donors-Mahoney-Jessica'sHope Chest; laws relating to illegal immigrant care in past included IRCA 1986 restricted immigrants' access to healthcare futher made harder for legal immigrants to find jobs that provieded health insurance Welfare reform passed by Clinton dramatically cut back access to health care Guerrerro v copper queen with burning kids in arizona said cannot deny health care to illegal immigrants if emergency sometimes we search for a better life only to find death

HB 2292 Texas

House Bill 2292, passed by the 78th Texas Legislature, requires each CRCG serving children and youth to evaluate the provision of systems of care services in the community that the CRCG serves. The Health and Human Services Commission, in conjunction with the State Texas Integrated Funding Initiative Consortium, will develop and implement an assessment instrument and process for use by local CRCGs. The assessment instrument and additional instruction will be sent to CRCG chairpersons and coordinators in January, 2004. CRCG chairpersons and coordinators can plan their CRCG meetings in February or March to include discussion and information-gathering in order to complete and return the assessment survey by March 31, 2004

additions in contemporary version of Hippocratic Oath

I do not treat a fever chart, or a ncancerous growth, but a human being i will prevent disease wherever i can i will remember that I remain a member of society, with special obligations to all my fellow human beings

Hippocratic Oath Intro

I swear to fulfill, to the best of my ability and judgment, this covenant. I will respect the hard-won scientific gains (science=religion) of those physicians in whose steps I walk and gladly share such knowledge as is mine with those who are to follow

Main parts of Hippocratic Oath Body

I will apply for the benefit of the sick all measures required I will remember that there is art to medicine, and that warmth and understanding may outweigh the knife/drug I will not be ashamed to say Idk or call in colleagues when I need help I will respect the privacy of my patients, their problems are not mine to share I must not play God I do not treat a fever chart, cancerous growth, but a sick human being-illness may affect econ, family-my responsibility includes those I will prevent disease when possible I am a member of society and leader of society where I have great responsibility and morality

Discourses on human "rights" (source documents)

IDHR, ICESCR, ICCPR Institutionalization of ethics (Harris)

the committee charged with review of huamn subject research protocols is named the

IRB

according to the maryland office for human research protections developing a new checklist for recording research events _______ something that requires IRB review

IS

Transplant specific challenges with common morality

Individual orientation Linear time Universality of truth-telling Informed consent Definitions of personhood Ownership and transplantation of body parts Withholding or withdrawing life-sustaining treatments gave us our definition of brain death, launched us into these gruesome new challenged, launched an entire economy of biotechnology, vast new areas for potential product if you can convince them to take off part of their body then it's ok-carve off portions of self inorder to survive is that autonomy or an infringement on justice that person really does want to sell their kidney bc can get money-only thing that makes that informed condition valid is ability to address justice if some of the highest paid do not address these moral obligations, then who will truth telling-deliver diagnosis if they don't want it-think also about lecturing-physicians who are dealing with obese patients who are smoking and asking for transplant-truths that that physician must tell America has morbidly obsese, poor folk who don't want to sit through lecture with respect to transplant-linear times suggests a particular outcome or length of life most of people who give up kidneys are ppl who have plenty of other folks in their family who need help people who are donors tend to be ppl with larger families and lower incomes individual orientation-individual is recipient of care and can make a position on what want regardless of family obligation

collective consent

Individual versus family (or collective) focus of decisions

What does ethnography add to health ethics?

Individual versus family (or collective) focus of decisions Religious interpretations Discussions of death Truth-telling norms Norms of "fair" access to resources Relations of power and authority Gender roles Cultural constructs of illness The meanings of diagnoses (e.g., "epilepsy") The purpose and value of medicine Norms of "care" Legal and institutional frameworks Forms of structural violence

ICCPR

International Covenant on Civil and Political Rights

ICESCR

International Covenant on Economic, Social and Cultural Rights

State Representative from Flower Mound

Jane Nelson

Pharmeceutical Governance

Joao Biel-Brazil-National free distribution of medicine for AIDs-AZT social activism in country helped:GAPAS APIA recognition of disease as country problem 35% lower number of AIDs deaths in first three months in Sao PaoloSaved $500 million with increase in self-reporting and ppl getting treatment patent issues

What is the difference between justice and equity? What lessons can be drawn from course materials on this difference, and how is it applied to health or health care?

Justice: the moral obligation to act on the basis of fair adjudication between competing claims; it is linked to fairness, entitlement and equality. Equity: "Equity is no part of the law, but a moral virtue, which qualifies, moderates, and reforms the rigor, hardness and edge of the law, and is a universal truth. It is the office of equity to protect and support the common law from shifts and contrivances against the justice of the law."Sir John, Trevor, M.R. Dudley v. Dudley, Preced. in Ch. 241, 244; 1 Wooddeson, Lect. VII. 192; 1 Story, Eq. Jur. 13.

Fink, Sheri. August 30, 2009. Strained by Katrina, a Hospital Faced Deadly Choices. The New York Times Magazine.

Katrina marooned Memorial Medical Center in Uptown New Orleans-hurricane knocked out power and water, , well-regarded doctor and two respected nurses had hastened the deaths of some patients by injecting them with lethal doses of drugs (Anna Pou) defended herself on national television-help patients through pain, more medical professionals were involved in teh decision to inject patients-long awaited rescues, might not have survived evacuations

REmedy to issues of transplant ethics

Kleinman's 8 Qs: OBJECTIVE: for clinicians and patients to negotiate treatment and expected outcomes, as therapeutic allies. ADDRESS: etiology onset of symptoms pathophysiology course of illness treatment REFLECT: social class, cultural beliefs, education, occupation, religious affiliation, past experience with illness and health care.

Patricia, Delores, Marcy, Leroy

Leroy hip problem Marcy drugs Delores gave up job for kids Patricia PT

Jeff Brennaer

MD who works with Atul Ganande in hotspotting video to see the inequality in his area-healthcare cost super high with ER treating chronic illness, 1percent of Camden accounting for 30% of Hospital charges

Rouse, Carolyn. 2006. "Jessica Speaks?: Adolescent Consent for Transplantation and Ethical Uncertainty" WLG

Mahoney wanted custody for jessica's story what did jessica want is the question? Mack-controlling make him a saint and jessica an angel institutions look at finanace and sybol while physicians look at patients' costs and benefits parrents accept over rest more than actual patient 4 beliefs Jess shaped by body and medicine- preserve body, reduce suffering, adults know better, physician=authority

Who had authority over Jessica Santillan's body?

Media and public commentary Malpractice laws (and medical error) Justice and (medical) citizenship laws Jesica herself Her physicians Also relevant: authoritative knowledge, clinical narrative, cultural competency

Coughlin, S. S. (2006). Ethical issues in epidemiologic research and public health practice. Emerging themes in epi 3(1)

Moral reasoning & deliberation Principalism, casuistry, and other approaches Issues specific to public health reducing risks across the public privacy, confidentiality surveillance, emergency response, regulation, monitoring ethics of screening deontological theories (Kant, sanctity of all persons) and utilitarian (maximizing benefit across all persons) We can certainly argue weather people deserve four heart transplants or weather you can have access to organs but everyone tends to agree get a variety of infectious threats that ignore state governments cffman article begins with moral reasoning any set of rules you supply has been thrown at various sides of any debate declaration of human rights can be very damaging when used inappropriately state laws being used on both sides of arguments law lags behind social process issue with 4 principals approach-cannot be used by all cultures bc autonomy is different everywhere and beneficence and nonmalevocance are very arbitrary and vague especially if morally serious persons Coughlin ()()()() Hard part of question-who gets to make judgment of life insists that physicians or moral agents engage in justice global marketplace much harder than indiviual physician relationships obligations to communities (pg 5)-these are the harder issues these are public health issues screening-who would not want this (don't want bad news if can't afford care-not a staright win-win: these are the harder ethical questions)

market dilemmas for transplant

Nacy Shepherd Hughes-free market requires divisible body and has taken advantage of divisible body inspired and fueled by these advances-further ethical challenges-market dilemmas-healthcare can now be sep from a healthcare market physicians like to believe they can make casuist ethical decisions but cannot because they are highest trained, highest paid, and have obligation to accept market dilemmas-unequal position that donors and recipitents have In the market particularly across countries and that laws are always outdated bc always lag behind culture laws immediately outdated even when we work so hard to get our laws as good as we can-still have to fund regulation

biological citizenship

Nation-state enforcement boundaries medical resources provided only to (documented) citizens

Why need IRB?

No one onjective about own work ppl underestimate risks involved in things they are familiar with ppl overestimate benefits of things that are important to them

Two principles that not much good for class

Nonmaleficence, beneficence

Action, and the perspective on care as "cultivating virtues" The family as a primary moral site The trope of the laboratory Experimentation Narrative and the "enduring self" Narrative re-envisioning

P.6 - Andy has cerebral palsy P.15, 17-19 (continuity, Becker) 65-Leroy has a congenital hip problem

New medicine video

Pregnancy stress reductionWound healing (married couple team; sniderman or another jewish name; round wounds with matched stressed care-givers to onon-stressed)Disc disease surgery, guided imageryPediatric pain (no mind-body split), chronic painCerebral palsy Jonathan McNabb's broken ankleRheumatoid arthritis - the emotions that make pain worseTibetan meditation (e.g., compassion) and flu shots

The Declaration of Helsinki

Prior to the 1947 Nuremberg Code there was no generally accepted code of conduct governing the ethical aspects of human research, although some countries, notably Germany and Russia, had national policies [3a]. The Declaration developed the ten principles first stated in the Nuremberg Code, and tied them to the Declaration of Geneva (1948), a statement of physicians' ethical duties. The Declaration more specifically addressed clinical research, reflecting changes in medical practice from the term 'Human Experimentation' used in the Nuremberg Code. A notable change from the Nuremberg Code was a relaxation of the conditions of consent, which was 'absolutely essential' under Nuremberg. Now doctors were asked to obtain consent 'if at all possible' and research was allowed without consent where a proxy consent, such as a legal guardian, was available

Wit Movie

Professor Vivian Bearing (Emma Thompson), an expert on the work of 17th-century British poet John Donne, has spent her adult life contemplating religion and death as literary motifs. Diagnosed with advanced ovarian cancer, she consents to an aggressive and experimental form of chemotherapy administered by Dr. Kelekian (Christopher Lloyd) and his assistant, Dr. Posner (Jonathan M. Woodward), her former student. Facing death on a personal level, she reflects on her life and work.

Smith's view of liberalism

Puts sovereignty subordinate to human rights claims A view of liberalism that seeks the conditions in which individuals can fulfill themselves, their vision of the good, while respecting the personhood of others (communalism through individualism) Persons are social beings, so society must protect the ability to come together for common purposes, including a safe, sovereign framework to enforce their rights to autonomy Thus, this liberal ethics subordinates the principle of state sovereignty to the recognition of human rights. Liberalism (particularly Smith's expression) recognizes best of statist and communitarian approaches, but insists on value-based ethical engagement rather than sovereignty-based engagement

Smith's view on liberalism

Puts sovereignty subordinate to human rights claims A view of liberalism that seeks the conditions in which individuals can fulfill themselves, their vision of the good, while respecting the personhood of others (communalism through individualism) Persons are social beings, so society must protect the ability to come together for common purposes, including a safe, sovereign framework to enforce their rights to autonomy Thus, this liberal ethics subordinates the principle of state sovereignty to the recognition of human rights. value-based ethical engagement

quinlan

Quinlan: differentiating death from brain death, legal definition of brain death-how do we decide someone is dead-, death no longer in realm of religion or faith or God, not even very clearly in the human body, emerged into new space where can keep organism alive under extreme circumstances, doctors afraid of getting sued, forced to act in ways not comfortable with, new education of patients abt technologies, ethics and authoritative knowledge of physicians in question whether or not to take her off her respirator, court had to decide between family and docor who moderately protected by hospital; give technology authority to decide between MUST be save and can be allowed to die, example: DNR order (don't want to stay alive on respirator), If doctors agree no life being sustained then can turn off technology, Last october TX passed new bill that said you can't-hospitals required to act and if there is disagreement between a phyiscian and a family member or even a legal DNR cannot work, courts de cide where to give authority and where to draw the line, want a legal spokesperson for a patient to weigh in , should inform all of your doctors and all of your family members (best you can hope for), we can keep a person a life, but the cost is hugee pg 125-doctor's job not to make moral judgments

Sasha and Delores

Sasha is Delores' friend and becomes a mirror for what Sasha does-shows her the truth behind what she is doing about Willy's burn, how she is treating it, how Willy is a fine kid and she is babying hima nd making him a monster because of disfigurement and only talking of his intelligence and not what he does to defend self-wit

James Marion Sims

South Carolinian doctor: Performed craniotomy (removal of portion of skull) on sick black infants to compensate for what was deemed the premature hardening of the cranial sutures; Un-anesthetized removal of bone segments to prevent spread of an infection. Botched use of obstetrical forceps, causing profound fistula.

3 things that limit our perceptions of what is ethical:

Standardization Nonmedical forms of influence Monopolies over strategic knowledge

Paul Farmer

Structural violence

Tuskegee

Studies done 1932-1972 that looked at black men with syphilis then did not let them receive care they believed in doctors as highest form of authoritative knowledge

Titanji

Sub Saharan Africa AIDS trials informed consent ethical review standard of care residual obligations integrity professsionalism

Western/Industrialized cultural assumptions:

The target of care is the patient alone, reification of the individual Limited responsibilities of the provider Limited responsibilities of institutions Poorly suited to multi-cultural settings (Marshall 2004; Sargent and Smith-Morris 2006)

Race in heath research

Thomas Jefferson, lawyer, politician, and scientist: Enthusiastic researcher of vaccination Tested his theories on his slaves Included tests on Edward Jenner's new technique of vaccination (cowpox for smallpox) Jefferson vaccinated 200 of his own and his neighbors' slaves, and waited for results, before injection his own family at Monticello. James Marion Sims, South Carolinian doctor: Performed craniotomy (removal of portion of skull) on sick black infants to compensate for what was deemed the premature hardening of the cranial sutures; Un-anesthetized removal of bone segments to prevent spread of an infection. Botched use of obstetrical forceps, causing profound fistula. Daughter of a socialist, Margaret Sanger, "is usually lauded as a powerful birth-control pioneer and as a feminist" but is described by Washington as "the most famous American populizer of eugenics" (2006: 195). 1920's was researching birth patterns, published on "The Negro Number" and recruited black leaders to contribute articles in support W.E.B. Du Bois (NAACP founder) wrote, "The mass of ignorant Negroes still breed carelessly and disastrously...." 28% of blacks surveyed in the late 1960's agreed that "encouraging blacks to use birth control is comparable to trying to eliminate this group from society".

Statists

Those who look at states as the source of values Realists Arguments Traditionally hostile to ethical intervention on the grounds that such interventions are not disinterested (although they also say that, to work, they must have "real" interests at stake). The goal of creating a more orderly international system may justify intervention for realists. Believe that the government should take an active role in controlling the economy.

Aristotelian ethics - virtue ethics

To create a good and "happy" life, a "life worth living". Moral thriving Morality as moral reasoning and discernment.

Das and Das

Treatment through dispensation rather than diagnosis

Pfizer

Trovan testing 100 children get medication-one never been tested on human and other, others given lower dose of standard of care for meningitis parents had no idea what children being given protocal approved under Abacha Military dictatorship in Nigeria chain of complicity=Nigeria rulers, ministry of health, local health admin, US FDA, Pfizer researchers-all involved in violations argument_massive epidemic killing more than 11,000 ppl

Article 25

UDHR Everyone has the right to a standard of living adequate for health and well-being of himself and his family, including food, clothing, housing, and medical care, and necessary social services, ad the right to security in the event of unemployment, sickness, disability, widowhood, old age, or other lack of livelihood in circumstances beyond his control Mother and childhood are entitled to special care and assistance. All children whether born in or out of wedlock, shall enjoy the same social protection

cosmopolitanists

Universalists Liberalist Arguments Traditionally value self-determination, community, and shared history; may also include a more universal conception of "human rights" in which sovereignty has subsidiary and conditional value. Individual autonomy in a community of tolerance (see next slide - Smith's liberalism) Noninterventionists here value community itself, shared values should be respected prima facie by outsiders. tend to be noninterventionalist just like the states do cosmopolitanists say let's not get involved if there is agreement and a respectful process-let them decide their way of doing things very similar statements/responses but very different outcomes-names most important obligations very differently statists give authority to state cosmopolitianists give it to the process

Life in the Balance:The Healthcare Crisis in Texas

Veronica Scavetti waiting since 7am to get mamogram and req to pay 300 dollars in cash that does not have; afraid has cancer (waited 5 hrs), doesn't qualify for federal healthcare (no social security); has to make a new appt and wait 3 months for mamogram; better to die she thinks because no one takes care of (1 of 34 million uninsured in US) hospital administrators cutting services just to stay in business; get crowded or because of demands exceed cppacity in Texas problem is worse with 1 in 4 uninsured; Republican party holds in Texas; medicaid cancelled in 2003 causing more uninsured uninsured patients often in ER where care is most expensive-costs are going up and ppl are increasing charges-these ddays it costs about 9000 dollars to insure a family of 4 deceptively simple question-what is dollar value of human life Scafeti waiting for care in one of busied hospitals in nation (Parkland)-seeing more patients than ever-trying to contend with extreme population growth without new resources; trauma is put first because not enough resources so other issues like mamograms [ut in the back Houston's Ben Todd hospital-overcrowded-when come into an ER here you're in crisis - like a triage on a battlefield; doctors and nurses ration space federal law required doctors to treat everyone in the emergency room but 1/3 will not pay long waiting time (5.5 hours or more wait) life or death situations Ben Todd debating-do we stop providing geriatrics? pediatrics? impossible to take care of all people of Texas who need care it's ration or close to survive, cut services and raise prices

Health Systems and the right to Health-an assessment of 194 countries

WHO identifies six essential building blocks that make up health systems: health services, health workforce; health information system; medical products, vaccines, and technologies; health financing, leadership and governance Peruvian hospital accepted indigenous community customs to encourage reproduction within hopsital research on right to health care and how in diff countries: UDHR, propose 72 indicators of features right to health requires all countries to have an effective, national, comprehensive, harm reduction policy and plan, delivering essential services Features that should be part of any health system: legal recognition, standards, participation transparency, equity, equality, and non-discrimination, respector for cultural difference , quality, planning, referral systems, coordination, international cooperation, legal obligation, monitoring and accountability aim was to assess how much the health systems of all countries include some of the features that arise from the right to health indigenous and alternative health care systems confusing so not in system, research also difficult to indicate final selecton of 72 indicators divded into 15 groups among recgintion of right to highest attainable standard of health, nondiscrimination, health information, national health plan, particpation, underlying determinants of health, access to health services, medicines, etc

Sargent SM main point

We suggest that incorporating an ethnographic approach in ethical analysis would challenge ethicists to pay greater attention to how moral concepts are embedded in social practice and how biomedical practitioners and institutional patterns shape the production and experience of ethical dilemmas

The nocebo of social death

When society no longer recognizes a person's existence as a person When a disease, or diseased person, is socially ostracized When diagnosis can lead to negative health outcomes/death

Explanatory model for transplant decision making

Who else, if anyone, has been or should be involved in your care? In cases like yours, what family or friends usually are involved in decisions? How are decisions about health care made in your family/culture/neighborhood? What do you feel doctors/hospitals should provide in these cases? (What are your expectations?) Would you like to express any preference for who is involved? - for how decisions are made? How do you want me to handle information about your health?

a biomedically meaningful argument which brackets off questions and issues in the patient's life experience is what janelle taylor calls

a clinical narrative

dotty is able to produce one of these about her daughter's condition, earning respect from her clinicians

a clinical narrative

according to B and C the set of norms that all morally serious persons re said to share is

a common morality

healthcare hotspotting

a data-driven process for the timely identification of extreme patterns in a defined region of the healthcare system. It is used to guide targeted intervention and follow-up to better address patient needs, improve care quality, and reduce cost. Most often the data in question are hospital reimbursement claims that are continuously produced, standardized by an operational imperative, and bring together high-stakes diagnostic, temporal, financial, spatial, and demographic data in a single set of records. Through hotspotting, claims data can help reveal both a community's healthcare problems and their solutions.

beneficence

a group of norms of doing good but also balancing with risks and costs

medicaid

a joint federal state program initiated in 1965 that provides health coverage or nursing home coverage to certian categories of low asset ppl including children pregnant women parents of eligible childre ppl with disabilities and elderly needing nurising homes care

nonmaleficence

a norm of avoiding the causation of harm

respect for autonomy

a norm of respecting the decision-making capacities of individual persons

a ghostwriter is

a person who writes a research manuscript for payment, but will not receive authorship or credit

Ethics

a shared, formalized code of behavior of a group, based on ideas about tright and wrong; a generic term covering several different ways of examining and understanding moral life; understanding what is right and wrong

Virtues

a trait of character that is socially and or morally valuable; virtue ethics are character-based and fairly non-prescriptive, allowing the community to specify the traits valued and how to demonstrate them

mattingly talks about the narrative as

a way for us to imagine or play out different moral possibilities, linked to lived experiences, a way f experimenting, not as coherent and linear as critics suggest

hyperindividualism

a withdrawing into individual private shells

Normative Ethics

about a norm; something that a culture believes in

Nonnormative ethics

about what people actually do

Standardizing niches

adaptation; do you adapt at an an individual strictly at an individual level? not relaly not in genetic adaptation of Charles Darwin-pop level movemnts should have your thinking of standardization across populations

Rylko-Bauer, Barbara & Paul Farmer. 2002. "Managed Care or Managed Inequality: A Call for Critiques of Market-Based Medicine". Medical Anthropology Quarterly 16(4): 4726-502. http://www.jstor.org/stable/25487792?seq=1#page_scan_tab_contents

allowing market forces to dictate that shape of health care delivery in this country insures that inequalities grow and modern medicine will become increasingly adept at managing inequality rather than managing (providing) care-article challenges anthropologists to expand on and contextualize debates surrounding the market's role in medicine, here and abroad

precautionary principle

always proceed responsibly and expose communities to least danger

free market medicine

an economic system in which prices are determined by unrestricted competition between privately owned businesses.

Multi-disciplinary approach

anthropology, public health, medicine, journalism, epidemiology, psychology, law

Singer "Medical Papers by Ghostwriters"

articles that weigh large body of research and offer judgment and how to treat ailment-Wyeth paid for people to write well about their hormones you don't know which articles are tainte dby bias and which are not

US MONEY HEALTH

as a percentage of gross domestic product-commodifiable productivity US spends far more than any other country on health US is not the biggest spender of public money; have a lot of private money being spent public is health as a right but we also see it as a commodity and people can spend privately on many different things quality of care though so much money is spent on it is not the best

Ethically neutral model

asking questions to patients in a way that accepts ethnography and shows them the legal obligations

Peer review

assess research quality (validity, significance, and originality), double blind, anonymous

when more than one knowledge system exists, and one gains greater power and acceptance leading to the devaluation of all other ways of knowing, we cll that dominant system

authoritative knowledge

what are four principles in the approach to bioethics espoused by B and C

autonomy, beneficence, justice, and nonmaleficence

after her ______ baby fae's life was extended for twenty days entailing tremendous postoperative pain and discomfort

baboon heart transplant

WWII and Nuremberg War Crime Trial

based on events of 1939-1945 as crimes for benefit o Ger Air Force and treating war injuries plus trauma, impetus for UDHR, led to Code 1947

4 principles

beneficence, nonmaleficence, autonomy ,justice