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1.
Objective To evaluate the impact of a multi-disciplinary back pain rehabilitation programme using a combination of individual and group
change data.
Methods A total of 261 consecutive patients attending an assessment session for the back pain rehabilitation programme completed the
SF-36 health survey questionnaire. The patients were requested to complete the questionnaires again at programme completion
and at the 6-month follow-up. The Reliable Change Index was used to define ‘clinical significance’ in terms of the assessment
of individual change.
Results Half of those patients considered to be suitable for the programme subsequently completed it. In group terms, non-completers
scored lower than completers on all SF-36 scales. Statistically significant improvements were evident for those completing
the programme (all scales at P < 0.000), with improvement maintained at follow-up. In individual terms, ‘clinical significance’ was exceeded most frequently
in the Physical Functioning and Role Physical scales. Whilst some participants lost previous improvements between completion
and follow-up, others improved over this same time period. The majority of those completing the programme showed improvement
in at least one scale.
Conclusions Adding assessment of individual change to traditional group change measures provides greater insight into the impact a rehabilitation
programme has upon participants’ quality of life. Whilst the programme is clearly effective for those who complete it, work
is required to limit post-programme deterioration and improve uptake. 相似文献
2.
The term ‘altruism’ is often used without definition, leading to contradictions in what we expect from medical students. In
this reflection paper, we critique the concept of ‘altruism’ from the perspective of moral philosophy and social psychology
and challenge its unquestioned usage within the medical education literature, especially that emerging from the USA. We will
argue that ‘altruism’ is a social construction with a particular history, stemming from Kantian philosophy and perpetuated
within newer disciplines such as social psychology. As it currently stands, ‘altruism’ seems to mean utter self-sacrifice—a
position contradictory to recent recommendations by regulatory bodies in the UK, which suggest that graduates should look
after the ‘self’ and achieve a work-life balance. In this article, we argue that it is undesirable to have ‘altruism’ as a
learning outcome for medical students and we also argue that ‘altruism’ is not an observable behavior that can be measured.
Instead, we suggest that medical educators should employ a more balanced term, borrowed from the social psychology literature
i.e. pro-social behavior. We argue that whilst ‘pro-social behavior’ focuses on actions that benefit others, it does not do
so at the expense of the self. In addition, it focuses on students’ observable behaviors rather than their inner motivations,
so is measurable. We conclude our article by discussing the formation of physicians based upon a virtue ethics, where society
and the profession are in dialogue about the telos of medicine and its virtues, and where the character of the young physician is formed within the crucible of that dialogue.
Thus, central to this pro-social behavior is the concept of phronesis or prudence, including the balancing of self-interest such as self-care, and the interests of the other. 相似文献
3.
It is within the context of a person’s lifestory, we argue, that the idea of wearing aprosthesis assumes place and meaning.
Todevelop this argument, a brightly colored hookprosthesis for children is taken as a startingpoint for reflection. The prosthesis
can beseen as fitting this person perfectly, when thebodily difference is understood as positivelyadding to this person’s
identity. The choicefor the prosthesis is normative in a moralsense, in that it is grounded in a person’sfundamental convictions
with respect to hisbeing and living. This understanding of ‘howto live’ can best be grasped – as is suggested– in contrastive
terms of ‘sameness’ and‘otherness’. Striving for conformity andsimilarity would do no justice to theexperiences and ideals
of unique persons, andwould come at great cost. Moreover, society isnot benefited by persons who merely conform,who copy and
imitate others, but by those whowillfully live up to their own unique standards. 相似文献
4.
Greaves D 《Medicine, health care, and philosophy》1998,1(2):133-141
There has been a modern epidemic of heart attacks in the western world, and this paper is concerned with this ‘new’ medical
condition and how it arose. Two competing theories are commonly proposed, relating either to conventional accounts of medical
science, or to social construction. Whilst recognising that aspects of both theories have some validity, it is claimed that
neither is wholly adequate. This issue has particular relevance for heart attacks and is explored in some detail, but it also
points to some more general conclusions. First that medical knowledge cannot be separated into ‘scientific’ and ‘social’ compartments
but is united by its human aspect; and second that although medical knowledge has a special dimension, when understood in
this way, it may also resonate with a more general re-examination of the relationship between scientific and human knowledge.
This revised version was published online in July 2006 with corrections to the Cover Date. 相似文献
5.
Tyreman S 《Medicine, health care, and philosophy》2005,8(2):153-157
This paper critiques particular aspects of the published UK government Department of Health’s proposal to promote ‘The Expert
Patient’ as a way of enhancing patient autonomy and reducing reliance on limited health care resources. Although the broad
aims of the report are supported the detail is criticised on the basis that lack of clarity over key terms, including ‘expert’
‘illness’ and ‘disease’, means that there is no clear focus for action and threatens to undermine the effectiveness of the
proposals. 相似文献
6.
Krahn T 《Medicine, health care, and philosophy》2009,12(2):187-202
The identification and avoidance of disease susceptibility in embryos is the most common goal of preimplantation genetic diagnosis
(PGD). Most jurisdictions that accept but regulate the availability of PGD restrict it to what are characterized as ‘serious’
conditions. Line-drawing around seriousness is not determined solely by the identification of a genetic mutation. Other factors
seen to be relevant include: impact on health or severity of symptoms; degree of penetrance (probability of genotype being
expressed as a genetic disorder); potential for therapy; rate of progression; heritability; and age of onset. In the original
applications of PGD, most, if not all of these factors were seen as necessary but none was seen as sufficient for determining
whether a genetic condition was labelled ‘serious’. This, however, is changing as impact on health or severity of symptoms
is coming to eclipse the other considerations. This paper investigates how age of onset (primarily in the context of the United
Kingdom (UK)) has become considerably less significant as a criterion for determining ethically acceptable applications of
PGD. Having moved off the threshold of permitting PGD testing for only fatal (or seriously debilitating), early-onset diseases,
I will investigate reasons for why age of onset will not do any work to discriminate between which adult-onset diseases should
be considered serious or not. First I will explain the rationale underpinning age of onset as a factor to be weighed in making
determinations of seriousness. Next I will challenge the view that later-onset conditions are less serious for being later
than earlier-onset conditions. The final section of the paper will discuss some of the broader disability concerns at stake
in limiting access to PGD based upon determinations of the ‘seriousness’ of genetic conditions. Instead of advocating a return
to limiting PGD to only early-onset conditions, I conclude that the whole enterprise of trying to draw lines of what is to
count as a ‘serious’ condition is itself problematic and in certain ways morally misleading.
相似文献
Timothy KrahnEmail: |
7.
The expressions ‘high quality care’ and ‘low quality care’ are cognitive and linguistic artefacts that help to structure people’s lives and thinking; for example, moves are now afoot internationally to pay bonuses to health professionals for delivering high quality care. United States programmes, most conspicuously, are assuming that high quality care can be validly distinguished from low quality care, and incentivised through bonuses. This distinction is always at least implicit, for high quality care has no meaning without low quality care. Through a ‘deconstructionist reading,’ this article discusses limitations of categorising the quality of care as either high or low. The limitations of this ‘binary opposition’ can include a lack of defining attributes; vagueness and fuzziness at the ‘boundaries’ between high quality care and low quality care; concealment of quality as a continuum; and use of the binary opposition to effect social order and control. Health policy implications of our analysis are discussed. Drawing upon the general medical services contract in the United Kingdom, we suggest an approach to overcoming the oversimplification and imprecision that categorisation tends to produce. 相似文献
8.
This paper is a response to Henk ten Have's “Genetics and Culture: The Geneticization thesis”. In it, I refute Ten Have's
suggestion that geneticization is not the sort of process that can be measured and commented on in terms of empirical evidence,even
if he is correct in suggesting that it should be seen as part of ‘philosophical discourse’. At the end, I relate this discussion
to broader debates within bioethics between the social science and philosophy, and suggest the need for philosophical approaches
to take the social sciences seriously.
This revised version was published online in July 2006 with corrections to the Cover Date. 相似文献
9.
Cardona B 《Medicine, health care, and philosophy》2008,11(4):475-483
This paper explores how the exercise of the ethics of ‘responsibility’ for health care advanced through ‘healthy ageing’ and
‘successful ageing’ narratives in Western countries animates an array of ‘authorities’, including the ‘anti-ageing medicine’
movement as a strategy to address the anxieties of growing old in Western societies and as a tool to exercise the ethos of
‘responsibility’. The choice of this type of authority as a source of guidance for self-constitution and the exercise of the
‘responsible self’, this paper will argue, enables the enactment of a type of late modernity notion of citizenship for ageing
individuals based on principles of agelessness, health, independence and consumption power. Through interviews with anti-ageing
consumers, however, it is also possible to argue the existence of tensions and contradictions that such a rigid model of self-constitution
in later life produces, and the potential forms of resistance and contestations that may emerge as a result. In this way the
current ‘war on anti-ageing medicine’ (Vincent 2003) becomes also symptomatic of bigger ‘wars’ taking place not only between
institutions competing for control over knowledge and management of ageing, but between those in favour and against the homogenisation
of life under the language of universal science, reason and market rationality. 相似文献
10.
Tigelaar DE Dolmans DH Meijer PC de Grave WS van der Vleuten CP 《Advances in health sciences education : theory and practice》2008,13(3):289-308
Teachers’ reflections are often narrowly focused on technical questions (‘how to’) and less on the underlying moral, political
and emotional aspects of their functioning. However, for a better understanding of teaching practice it is important to uncover
beliefs and values that usually remain implicit. Meeting with others is considered crucial for enhancing the quality of teachers’
reflections. However, little is known about how any beneficial effects of such meetings are brought about. We explored the
relationship between medical teachers’ interactions and collaborative reflection processes during peer meetings. Five experienced
teachers and a teacher trainer participated in the study. Three peer meetings were videotaped and transcribed. Teachers’ interactions
and collaborative reflective processes were analysed. The interactions promoted reflection not only on technical questions
but also on moral, political, and emotional issues. ‘Guiding/directing’, ‘proposing an alternative’ and ‘exploring an alternative’
appeared to be the principal interactions. The results may be useful for teachers and trainers who are considering organising
and/or improving peer meetings. 相似文献
11.
Marianne Boenink 《Medicine, health care, and philosophy》2010,13(1):11-23
Although it is now generally acknowledged that new biomedical technologies often produce new definitions and sometimes even
new concepts of disease, this observation is rarely used in research that anticipates potential ethical issues in emerging
technologies. This article argues that it is useful to start with an analysis of implied concepts of disease when anticipating
ethical issues of biomedical technologies. It shows, moreover, that it is possible to do so at an early stage, i.e. when a
technology is only just emerging. The specific case analysed here is that of ‘molecular medicine’. This group of emerging
technologies combines a ‘cascade model’ of disease processes with a ‘personal pattern’ model of bodily functioning. Whereas
the ethical implications of the first are partly familiar from earlier—albeit controversial—forms of preventive and predictive
medicine, those of the second are quite novel and potentially far-reaching. 相似文献
12.
Thomas BC Carlson LE Bultz BD 《Journal of immigrant and minority health / Center for Minority Public Health》2009,11(4):237-248
Variations in access to care, utilization of available resources and treatment outcomes in the context of ethnicity have been
recognized, but very little research of this nature exists in the oncology context. The present paper is an in-depth analysis
of data on a large representative sample of Canadian cancer patients with a focus on the role of ‘ethnicity’, its association
to psychological distress, and its impact on the cancer experience. Because of a heterogeneous representation of ethnic self-identifications
which were not easily grouped or classified, English as a second language was considered as a surrogate marker to ethnicity.
People who self-reported to be from an English-speaking country were grouped together and compared to those hailing from countries
which do not have English as a primary language. In a hierarchical logistic regression model (n = 2,402) the demographic and cancer-related variables associated with significant clinical distress in the first block were
gender (male, except those with prostate cancer), age less that 68 years, less than a year since diagnosis, diagnosis of lung
cancer, and recurrent disease. In the second block, after controlling for the influence of these factors, patient-reported
ethnicity (being originally from a non-English speaking country) added significantly to the prediction of patient distress.
Though compelling, there is a need to understand the relationship between the ethnic features and language (English versus
non-English language). A hypothesis is presented as an attempt to understand an individual’s ‘ethnicity’ within the framework
of a multicultural society. 相似文献
13.
Tyreman S 《Medicine, health care, and philosophy》2011,14(2):209-217
In recent years so-called Complementary and Alternative Medicine (CAM) practices have made significant political and professional
advances particularly in the United Kingdom (UK): osteopathy and chiropractic were granted statutory self-regulation in the
1990s effectively giving them more professional autonomy and independence than health care professions supplementary to medicine;
the practice of acupuncture is widespread within the National Health Service (NHS) for pain control; and homoeopathy is offered
to patients by a few General Practitioners alongside conventional treatments. These developments have had a number of consequences:
one is that both CAM and Conventional and Orthodox Medical (COM) professions have had to reappraise their professional identity.
In manual therapy for example, questions have been asked about the differences between physiotherapy, osteopathy and chiropractic,
and what the justification is for having separate professions. A wider question concerns the relationship between CAM and
COM; are CAM distinct professions or should they, as has happened to a limited extent in the UK, be absorbed into the broader
field of ‘Medicine’ or ‘Health Care’ as adjunctive therapies. CAM professions have also had to develop, implement and enforce
codes of practice for practitioners and clarify the scope of practice within a profession. At the heart of these issues lies
the need to identify and clarify professional values. A key claim of CAM professions is that their practice is distinct and
the outcome of treatment at least as effective and in many cases more effective than with conventional therapies. In addition,
what counts as effective outcome is often different from conventional medical understanding, involving more subtle humanitarian
considerations, for example. Three values are identified as being commonly held across CAM professions. These are: offering
‘natural’ treatment; being patient rather than disease focussed; and being holistic. However, these may not be as distinctive
of CAM as is claimed either because the meaning is unclear or because COM professions claim similar values. The paper argues
that the values that inform ‘good practice’ and ‘effective outcome’ should be seen as distinct components of professional
competence. This has implications for establishing professional identity and codes of practice. 相似文献
14.
Experiences of moral distress encountered in psychiatric practice were explored in a hermeneutic phenomenological study. Moral
distress is the state experienced when moral choices and actions are thwarted by constraints. Psychiatrists describe struggling
‘to do the right thing’ for individual patients within a societal system that places unrealistic demands on psychiatric expertise.
Certainty on the part of the psychiatrist is an expectation when judgments of dangerousness and/or the need for coercive treatments
are made. This assumption, however, ignores the uncertainty and complexity of reality. Society entrusts psychiatrists to care
for and treat those among its most vulnerable members: persons deemed to have a severely diminished capacity for autonomy
due to a mental disorder. Simultaneously, psychiatrists are held accountable by society for the protection of the public.
Moral distress arose for psychiatrists in their efforts to fulfill both roles. They described an ‘outsider/insider’ status
and the ways in which they attempted to cope with moral distress. 相似文献
15.
This paper is in three parts. In Part One we briefly explain that an unsophisticated form of utilitarianism—economic rationalism
(ER)—has become dominant in many health systems. Its proponents argue that one of ER’s most important effects is to increase
consumer choice. However, evidence from New Zealand does not support this claim. Furthermore, the logic of ER requires the
construction of systems which tend to restrict individual participation.
In Part Two we argue that although some have advocated an ‘ethic of care’ in an attempt to counteract ER’s utilitarianism,
two decades of campaigning have had little influence on health policy. ER’s pro-care adversaries have failed to make an impact
because they have not developed a taxonomy of care—they have not established a language compatible with, or as powerful as,
ER’s.
In Part Three, in an attempt to raise the conceptual and practical status of caring in contemporary health systems, we distinguish
four different forms of care. In opposition to those who believe the ‘ethic of care’ can adequately direct health care practice,
we demonstrate that care is a secondary notion. We show that in order for a carer to decide which form of care to adopt in
different situations she requires a more powerful idea. We contend further that health care ought to be governed by a theory
of health, and suggest that ‘the foundations theory of health’ should be adopted by planners searching for a more humane alternative
to ER. We conclude that ER’s dominance can and must be challenged. However, only those arguments which offer detailed theoretical
analyses of health care, as well as meticulously derived practical policies, have any chance of success. 相似文献
16.
Eating behaviour depends partly on food preference, which may be determined by different types of emotions. Among the emotions
generated by food, disgust and pleasure are common and can lead to increased and reduced food consumption. We tested the hypothesis
that (1) elderly men and women felt different emotions towards food, and (2) low energy intake is related to negative emotions
towards food. In February 2004, a convenience sample of elderly participants was recruited locally by telephone. Food intake
of 52 elderly people, aged 63–80 years, was monitored throughout each day for one week and made it possible to assign the
elderly people to two groups (low and high energy intake from food consumption data). One month later, each of them assessed
their likes or dislikes towards 30 food pictures (vegetables, cheeses, fruits, starchy foods, sweets, meat, fish, offal and
eggs) using 19 emotional words (eight words with a positive valence: ‘to like’, ‘thrilled’, ‘satisfaction’, ‘surprise’, ‘serene’,
‘amused’, ‘pride’, ‘interest’, and 11 other words with a negative valence: ‘disgust’, ‘indifference’, ‘guilt’, ‘uneasiness’,
‘nostalgia’, ‘impatience’, ‘doubt’, ‘frustration’, ‘embarrassment’, ‘disappointment’ and ‘lassitude’. The emotional intensities
experienced with the different pictures were analysed by ANOVA for each group (men and women, small and big eaters). There
were differences in likes and dislikes between men and women. Both guilty and liking scores towards food were generally higher
in women than in men. Small eaters felt more doubt, unease, disappointment and indifference towards food than big eaters.
In conclusion, the report of low food intake was related to more negative emotions towards foods that might be associated
with the willingness to restrict food intake or to undernutrition. 相似文献
17.
Paul Joseph Tranter 《Journal of urban health》2010,87(2):155-166
Road safety experts understand the contribution of speed to the severity and frequency of road crashes. Yet, the impact of
speed on health is far more subtle and pervasive than simply its effect on road safety. The emphasis in urban areas on increasing
the speed and volume of car traffic contributes to ill-health through its impacts on local air pollution, greenhouse gas production,
inactivity, obesity and social isolation. In addition to these impacts, a heavy reliance on cars as a supposedly ‘fast’ mode
of transport consumes more time and money than a reliance on supposedly slower modes of transport (walking, cycling and public
transport). Lack of time is a major reason why people do not engage in healthy behaviours. Using the concept of ‘effective
speed’, this paper demonstrates that any attempt to ‘save time’ through increasing the speed of motorists is ultimately futile.
Paradoxically, if planners wish to provide urban residents with more time for healthy behaviours (such as exercise and preparing
healthy food), then, support for the ‘slower’ active modes of transport should be encouraged. 相似文献
18.
K. KozŁowska PhD A. Szczecińska W. Roszkowski A. Brzozowska C. Alfonso C. Fjellstrom C. Morais N. A. Nielsen C. Pfau A. Saba B. Sidenvall A. Turrini M. Raats M. Lumbers 《The journal of nutrition, health & aging》2008,12(10):728-733
Objectives: To determine (i) the extent to which recommended lifestyle healthy behaviors are adopted and the existence of positive attitudes
to health; (ii) the relative influence of socio-demographic variables on multiple healthy lifestyle behaviors and positive
attitudes to health; (iii) the association between healthy lifestyle behaviors and positive attitudes to health.Design: two distinct healthy behavioral measures were developed: (i) healthy lifestyles based on physical activity, no cigarette
smoking, no/moderate alcohol drinking, maintaining a “healthy” weight and having no sleeping problems and (ii) positive health
attitudes based on having positive emotional attitudes, such as: self-perceived good health status, being calm, peaceful and
happy for most of the time, not expecting health to get worse and regular health check-ups. A composite healthy lifestyle
index, ranging from 0 (none of behaviors met) to 5 (all behaviors met) was calculated by summing up the individual’s scores
for the five healthy lifestyle items. Afterwards, each individual’s index was collapsed into three levels: 0–2 equivalent
to ‘level 1’ (subjectively regarded as ‘too low’), a score of 3 equivalent to ‘level 2’ (‘fair’) and 4–5 as ‘level 3’ satisfactory
‘healthy lifestyle’ practices. The same procedure was applied to the positive health attitudes index. Multinomial logistic
regression analyses by a forward selection procedure were used to calculate the adjusted odds ratio (OR) with 95% confidence
interval (95% CI).Participants: a multi-national sample consisting of 638 older Europeans from 8 countries, aged 65–74 and 75+, living alone or with others.Results and conclusions: maintaining a “healthy” weight was the most frequently cited factor in the healthy lifestyles index and therefore assumed
to be the most important to the older Europeans in the study; positive attitudes to health were relatively low; participants
achieved a ‘satisfactory’ level for healthy lifestyles index (level 3) more frequently than a satisfactory level for positive
attitudes to health; having a satisfactory ‘healthy lifestyle’ was directly related to having a satisfactory level of positive
attitudes to health based on the positive health attitudes index; income and geographical location in Europe appeared to be
key predictors for meeting both the recommended healthy lifestyle factors in the index and having positive health attitudes
however, the composition and nature of the study sample should be taken into consideration when considering the impact of
the location on healthy lifestyles and attitudes to health across Europe.
more details at www.foodinlaterlife.org. 相似文献
19.
Conley EC Owens DR Luzio SL Subramanian M Ali AS Hardisty A Rana O 《Health care management science》2008,11(2):152-166
The research aim underpinning the Healthcare@Home (HH) information system described here was to enable ‘near real time’ risk analysis for disease early detection and prevention.
To this end, we are implementing a family of prototype web services to ‘push’ or ‘pull’ individual’s health-related data via an system of clinical hubs, mobile communication devices and/or dedicated home-based network computers. We are examining
more efficient methods for ethical use of such data in timeline-based (i.e. ‘longitudinal’) data analysis systems. A consistent
data collation infrastructure is being created for use along the ‘patient path’—accessible wherever patients happen to be.
This ‘patient-centred’ infrastructure can be applied in the evaluation of disease progression risk (in the light of clinical
understanding of disease processes). In this paper we describe the requirements for making multi-data trend management ‘scale-up’,
together with some requirements of an ‘end-to-end’ functioning data collection system. A Service-Oriented Architecture (SOA)
approach is used to maximise benefits from (1) clinical evidence and (2) computational models of disease progression that
can be made available elsewhere on the SOA. We discuss the implications of this so-called ‘closed loop’ approach for improving
healthcare intervention outcomes, patient safety, decision support, objective measurement of service quality and in providing
inputs for quantitative healthcare (predictive) modelling.
To aid understanding, a concise glossary is provided for italicized technical or common ‘jargon’ terms that are not defined
in the text. 相似文献
20.
Lemoine M 《Medicine, health care, and philosophy》2009,12(3):355-362
If the healthy and the pathological are not merely judgments qualifiers, but real phenomena, it must be possible to define
both of them positively, which, in this context, means as factual contraries. On the other hand, only a privative definition, either of the pathological as ‘non-healthy’, or of the healthy
as ‘non-pathological’, can rationally circumscribe all possible states of an organism. This fluctuation between two meanings of the ‘healthy’–‘pathological’ opposition,
factual vs. rational, characterizes the ordinary usage of these concepts and puts all philosophical definitions in a hopeless situation. Although
a scientific definition may conceal this equivocation by adequately setting out the terms of the problem of discriminating
between the ‘healthy’ and the ‘pathological’, it could explain some of the difficulties met in determining ‘gold standards’,
in the choice of separators, and in the assessment of the diagnostic qualities of tests. 相似文献