Everyday moral reasoning in the governmentality of HIV risk

Drawing on the sociology of morality, this article analyses the social contexts, discourses and ethno‐methods of everyday life that shape real‐world decisions of gay men around HIV prevention. Through an analysis of the predominant narratives in an online public forum created for an HIV prevention campaign, this article explores the ways in which homosexually active men engage in everyday moral reasoning and challenge a neoliberal moral order of risk and responsibility. The article concludes that gay and bisexual men engage in forms of practical morality with their sexual partners and imagine larger communities of interest, love, companionship and pleasure. At the same time, they draw heavily from discourses on individual and rational responsibility, as well as narratives of romance and community, that shape forms of moral selfhood. Risk management techniques that are grounded in notions of rational choice and that are insensitive to the emotional worlds that these men inhabit create situations of risk avoidance but also inadvertently open them to new forms of vulnerability.     

Corporate moral responsibility in health care

The question of corporate moral responsibility – of whether it makes sense to hold an organisation corporately morally responsible for its actions,rather than holding responsible the individuals who contributed to that action – has been debated over a number of years in the business ethics literature. However, it has had little attention in the world of health care ethics. Health care in the United Kingdom(UK) is becoming an increasingly corporate responsibility, so the issue is increasingly relevant in the health care context, and it is worth considering whether the specific nature of health care raises special questions around corporate moral responsibility. For instance, corporate responsibility has usually been considered in the context of private corporations, and the organisations of health care in the UK are mainly state bodies. However, there is enough similarity in relevant respects between state organisations and private corporations, for the question of corporate responsibility to be equally applicable. Also, health care is characterised by professions with their own systems of ethical regulation. However, this feature does not seriously diminish the importance of the corporate responsibility issue, and the importance of the latter is enhanced by recent developments. But there is one major area of difference. Health care, as an activity with an intrinsically moral goal, differs importantly from commercial activities that are essentially a moral, in that it narrows the range of opportunities for corporate wrongdoing, and also makes such organisations more difficult to punish This revised version was published online in July 2006 with corrections to the Cover Date.     

Moral reasoning as a catalyst for cultural competence and culturally responsive care

The importance of developing cultural competence among healthcare professionals is well recognized. However, the widespread reports of insensitivity and deficiencies in care for culturally diverse patients illuminate the need to review how cultural competence development is taught, learnt and applied in practice. Unless we can alter the ‘hearts and minds’ of practising nurses to provide the care that they know they should, culturally insensitive care will continue operating in subtle ways. This paper explores the ideas behind nurses’ actions and omissions when caring for culturally diverse patients and proposes the need to examine cultural competence development through a moral reasoning lens. Examining cultural competence development through a moral reasoning lens can help empower nurses, whilst nurturing commitment and courage to providing quality care that meets the needs of culturally diverse patients. The model of morality provides a framework that explores how moral motivation and behaviour occur and can provide a vehicle for critically examining the knowledge, skills and attitudes required to provide culturally responsive care.     

Changes in moral reasoning and the teaching of medical ethics

Courses in medical ethics are becoming an integral part of many medical school curricula in Europe. At the medical school of the University of Copenhagen, a course on philosophy of medicine has been compulsory for all medical students since 1988. The effect of such courses on the ethical awareness and reasoning of medical students is not well understood and we have therefore found it of interest to study the effects of the Copenhagen course. For the study, we used a Danish version of the Defining Issues Test (DIT) which measures development in moral reasoning (Rest J R, 1979 Development in Judging Moral Issues. University of Minnesota Press, Minneapolis).
The study was conducted as a pre- and post-test study without a control group, and the subjects were all medical students attending the course in the autumn of 1993.
The results show that moral reasoning scores measured by the DIT increase significantly, and we argue that this increase can only be explained as an effect of the course.     

Evaluation of teaching medical ethics by an assessment of moral reasoning

This study assessed the hypothesis that the formal teaching of medical ethics promotes a significant increase in the growth and development of moral reasoning in medical students. Results indicated a statistically significant increase (P less than or equal to 0.0005) in the level of moral reasoning of students exposed to a medical ethics course compared to the control group that was not exposed to the medical ethics course. When the posttest scores were adjusted by subtracting the pretest scores, the differences were even more significant (P less than or equal to 0.0002). This study confirmed similar findings of another study using a different instrument of assessment. Brief discussion is given of the fundamental premise that the appropriate function of teaching medical ethics in our modern pluralistic society is to improve students' moral reasoning about value issues regardless of what their particular set of moral values happens to be.     

Management ethics for the health care supervisor

Someone once described the difference between ethical and unethical behavior in these terms: After doing something ethical you feel good; after doing something unethical you feel bad. Not quite. Feelings have something to do with ethics but not everything. Feelings may legitimately play into the moral reasoning associated with senses of guilt and guiltlessness, but moral reasoning demands critical thinking if it is to be honest. The ability to think critically on moral issues, it is argued here, is a competence that must be exercised by all professionals.     

Exploring parkrun as a social context for collective health practices: running with and against the moral imperatives of health responsibilisation

Critiques of public health policies to reduce physical inactivity have led to calls for practice‐led research and the need to reduce the individualising effects of health promotion discourse. The purpose of this paper is to examine how parkrun – an increasingly popular, regular, community‐based 5 km running event – comes to be understood as a ‘health practice’ that allows individuals to enact contemporary desires for better health in a collective social context. Taking a reflexive analytical approach, we use interview data from a geographically diverse sample of previously inactive parkrun participants (N = 19) to explore two themes. First, we argue that parkrun offers a space for ‘collective bodywork’ whereby participants simultaneously enact personal body projects while they also experience a sense of being ‘all in this together’ which works to ameliorate certain individualising effects of health responsibilisation. Second, we examine how parkrun figures as a health practice that makes available the subject position of the ‘parkrunner’. In doing so, parkrun enables newly active participants to negotiate discourses of embodied risk to reconcile the otherwise paradoxical experience of being an ‘unfit‐runner’. Findings contribute to sociological understandings of health and illness through new insights into the relation between health practices and emerging physical cultures, such as parkrun.     

试论医疗经济活动中的伦理道德标准和价值取向

该文从医疗资源分配，交换以及医院的市场经营等三个方面对医疗经济活动中涉及的伦理道德标准和价值取向进行分析，并对市场中如何获得相应伦理道德标准和价值取向进行探讨。     

Uncertainty in the economic evaluation of health care technologies: The role of sensitivity analysis

Given the increased use of economic evaluation to inform decision making in the health service, it is particularly important that the research methods used are critically assessed and, where possible, improved. The systematic handling of uncertainty in economic evaluation is an important area that remains methodologically underdeveloped. With the increased use of the clinical trial as a vehicle for economic evaluation, there has been recent interest in how the statistical methods routinely employed to handle uncertainty in clinical research might be applied to economic evaluation. This paper reviews the types of uncertainty that exist in economic evaluation and argues that some forms of uncertainty are not amenable to statistical methods. Sensitivity analysis is not a single approach but can take a number of different forms. The different types of sensitivity analysis are reviewed, with an indication of their strengths and weaknesses in relation to the different types of uncertainty in economic evaluation.     

Facilitating the development of moral insight in practice: teaching ethics and teaching virtue

Abstract The teaching of ethics is discussed within the context of insights gleaned from ancient Greek ethics, particularly Aristotle and Plato and their conceptions of virtue (arete, meaning excellence). The virtues of excellence of character (moral virtue) and excellence of intelligence (intellectual virtue), particularly practical wisdom and theoretical wisdom, are considered. In Aristotelian ethics, a distinction is drawn between these intellectual virtues: experience and maturity is needed for practical wisdom, but not for theoretical wisdom. In addition to this, excellence of character is acquired through habitual practice, not instruction. This suggests that there is a need to teach more than theoretical ethics and that the ethics teacher must also facilitate the acquisition of practical wisdom and excellence of character. This distinction highlights a need for various educational approaches in cultivating these excellences which are required for a moral life. It also raises the question: is it possible to teach practical wisdom and excellence of character? It is suggested that virtue, conceived of as a type of knowledge, or skill, can be taught, and people can, with appropriate experience, habitual practice, and good role models, develop excellence of character and become moral experts. These students are the next generation of exemplars and they will educate others by example and sustain the practice of nursing. They need an education which includes theoretical ethics and the nurturing of practical wisdom and excellence of character. For this purpose, a humanities approach is suggested.     

Students' moral reasoning, Machiavellianism and socially desirable responding: implications for teaching ethics and research integrity

OBJECTIVE: To investigate the relationship between psychological constructs related to professional and research integrity and moral reasoning among medical students. METHODS: Medical students, 2nd-year (n = 208, 85.6% of 243 enrolled students), answered the moral reasoning test-defining issues test 2 (DIT2) and the Machiavellianism and Paulhus socially desirable responding (SDR) scales. RESULTS: Students had the highest score on the post-conventional schema of moral reasoning (mean +/- standard deviation, 35.2 +/- 11.6 of a possible 95) compared with personal interest (27.2 +/- 12.3) and maintaining norms schemae (29.2 +/- 11.5; P < 0.001, repeated-measures anova). Female students scored higher than their male collegues on post-conventional moral reasoning (37.6 +/- 11.0 versus 31.2 +/- 22.4, P < 0.001, independent-sample t-test). Of all 4 Machiavellianism subscales students scored highest on deceiving, where female students scored higher than their male colleagues (24.5 +/- 4.2 versus 22.9 +/- 5.1 of a possible 30; P = 0.037, independent-sample t-test). Female students also scored higher on the impression management subscale, whereas their male colleagues scored higher on the self-deception subscale of the Paulhus SDR scale. Moral reasoning scores were associated with cynicism, deceiving and flattering Machiavellianism scores, but not with Paulhus SDR scores. Multiple regression analysis showed the Machiavellianism amorality score as a significant negative predictor (beta = -0.183, P = 0.017) and female sex as a positive predictor (beta = 0.291, P < 0.001) for the post-conventional schema score on the DIT2. The Machiavellianism flattering score was a significant negative predictor for the personal interest schema score (beta = -0.215, P = 0.006). CONCLUSIONS: Although moral reasoning is generally seen as independent of variables related to personality, our study indicated that Machiavellianism, especially its amorality and flattering subscales, were associated with moral reasoning. These results have important implications for teaching ethics and the responsible conduct of research in different cultural and socio-economic settings.     

The government and ethics of health promotion: the importance of Michel Foucault

A debate about the ethics of health promotion recently appearedin this journal. While the papers involved provided a numberof new insights into this area, they appeared to stop shortof many possibilities. In particular, the dismissal of the relevanceof the work of Foucault in this area prevented another lineof inquiry opening up. This paper provides a fuller explicationof Foucault's relevance of ethics and health promotion. It drawsattention to the way health promotion produces subjects, especiallychoosing subjects. Using nutrition promotion as an example,it highlights the way that various positions in health promotion—whichon the surface appear to be at odds with each other—canin fact be seen to be part of the same project: that of producingself-regulating subjects. The paper concludes by stressing thathealth promotion provides an ethics, in a Foucauldian sense,by producing the means by which subjects assess their own desires,attitudes and conducts in relation to those set out by healthpromotion expertise.     

Testing for selection bias and moral hazard in private health insurance: Evidence from a mixed public-private health system

Separating selection bias from moral hazard in private health insurance (PHI) markets has been a challenging task. We estimate selection bias and moral hazard in Australia's mixed public-private health system, where PHI premiums are community-rated rather than risk-rated. Using longitudinal cohort data, with fine-grained measures for medical services predominantly funded by PHI providers, we find consistent and robust estimates of advantageous selection among hospitalized cardiovascular disease (CVD) patients. Specifically, we show that in addition to their risk-averse attributes, CVD patients who purchase PHI use fewer services that are not covered by PHI providers (e.g., general practitioners and emergency departments) and have fewer comorbidities. Finally, unlike previous studies, we show that ex-post moral hazard exists in the use of specific “in-hospital” medical services such as specialist and physician services, miscellaneous diagnostic procedures, and therapeutic treatments. From the perspective of PHI providers, the annual cost of moral hazard translates to a lower bound estimate of $707 per patient, equivalent to a 3.03% reduction in their annual profits.     

Applying ethics to health care: the role of continuing education

The study of ethics will not provide health care professionals with specific answers to specific ethical dilemmas they as individuals may face. it will not provide specific rules of conduct. The ability to examine ethical dilemmas sets forth practical wisdom that provides guidance when making decisions. The study of ethics helps to define problems and establishes basic principles to be used in solving these problems. It can help health care professionals identify appropriate goals and give them direction in achieving those goals. Health care supervisors have an obligation to provide the educational opportunity that will enable professionals to emerge with a perspective that allows them to take an ethical stand and to support that position with sound, rational thinking. In fulfilling this obligation, individuals working within health care facilities can significantly contribute to their profession and to society.     

浅谈健康教育在儿童保健护理工作中的重要意义

目的提高全民健康意识,培养儿童良好的生活习惯和心理素质,强化儿童预防保健工作。方法强化教育的规范化管理,通过各种直观形象教育,开设卫生保健知识课,开办家长学校由专家教授专题讲授保健知识。结果提高了幼儿健康文明的心理素质,强化了儿童自我保健意识和安全保护意识,促使儿童身心健康的正常发育。结论健康教育在医疗服务工作中起着重要的作用,尤其在儿童预防保健工作中,相当于又给儿童增加了另一种疫苗。