Scholarly article on topic 'Vulnerabilities in the Medical Care'

Vulnerabilities in the Medical Care Academic research paper on "Economics and business"

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{vulnerabilities / "right to health" / "medical care"}

Abstract of research paper on Economics and business, author of scientific article — Elena Toader, Dana Damir, Tudorel Toader

Abstract The right to health is a fundamental right whose recovery depends on healthcare providers by providing the required devices and medical equipment, and the states, the circumstances under which you can find health service users. Thus, beyond medical conditions, patients may find themselves vulnerable in certain circumstances, affecting the quality or conduct the medical act. In this sense, it can be considered as having issues: the lack of health education, lack of rights and obligations in the field, consenting to medical experiments for which the patient is not fully informed or whose meaning he/she fails to understand, poor material possibilities, the time factor. A state of vulnerability may exist in the health care providers, while vulnerabilities over possible violations of ethics rules may result even in liability. Prevention or removal of these conditions of vulnerability is likely to contribute to an increased quality of medical care.

Academic research paper on topic "Vulnerabilities in the Medical Care"

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Procedía

Social and Behavioral Sciences

ELSEVIER Procedía - Social and Behavioral Sciences 92 (2013) 936 - 940

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The right to health is a fundamental right whose recovery depends on healthcare providers by providing the required devices and medical equipment, and the states, the circumstances under which you can find health service users. Thus, beyond medical conditions, patients may find themselves vulnerable in certain circumstances, affecting the quality or conduct the medical act. In this sense, it can be considered as having issues: the lack of health education, lack of rights and obligations in the field, consenting to medical experiments for which the patient is not fully informed or whose meaning he/she fails to understand, poor material possibilities, the time factor. A state of vulnerability may exist in the health care providers, while vulnerabilities over possible violations of ethics rules may result even in liability. Prevention or removal of these conditions of vulnerability is likely to contribute to an increased quality of medical care.

©2013 TheAuthors.Publishedby ElsevierLtd.

Selection and/or peer-review under responsibility of Lumen Research Center in Social and Humanistic Sciences, Asociatia Lumen. Keywords: vulnerabilities; right to health; medical care.

1. Introduction

Vulnerability is a human attribute with a universal character of sensibility of the individual who, although intact, is at the same time weak, fragile or biologically ill with an increased predisposition towards supplementary damage (Kottow, 2007). Vulnerability appeared as a new idea in the philosophical debate area of the question is that which is moral in society also just? and was adopted by the bioethical field, where it developed up to a potential through which contested order, became principle and imposed itself as an ethical method applied in the medical domain. The term "vulnerability" comes from the Latin "vulnerare" (i.e. "to hurt"), which further underlines the suspicion of damage (Oxford English Dictionary, 1995). Throughout history, the scientific

* Corresponding author Phone.: +4-074-587-8144. fax: +4-023 -2201-266 E-mail address: toader.elena@yahoo.com

Vulnerabilities in the Medical Care

Elena Toadera' b*, Dana Damira, Tudorel Toaderc

a"Gr.T.Popa", University of Medicine and Pharmacy, Iasi, Romania

a'b Institute of Gastroenterology and Hepatology, Iasi, Romania _c"AL.I. Cuza" University, Faculty of Law, Iasi Romania_

Abstract

1877-0428 © 2013 The Authors. Published by Elsevier Ltd.

Selection and/or peer-review under responsibility of Lumen Research Center in Social and Humanistic Sciences, Asociatia Lumen. doi: 10.1016/j.sbspro.2013.08.780

contribution to the definition of the concept of vulnerability progressed from the empirical observations supported by the internal and external causality of vulnerability to enlargements and refined expressions focused on differences of context. The expansion towards the social environment influences the conceptualization of vulnerability and implies regulations correlated with the adjustment capacity and the potential to react to environmental exposure (Cutter, 2003). In the ethical approach, vulnerability is oriented on arguments related to the consolidation of the concept, the rigorous definition of its status and a better rendition of its meaning. Essentially, the principle of vulnerability is ontological and it states better than all the other ethical principles the finality of the human condition (Kemp and Rendtorff, 2000). In 1974, this concept themed on issues for biomedical research is implemented institutionally in documents correlated with the international ethical directions for the biomedical research on human subjects (National Committee for the Human Protection, Belmont, 1993, CIOMS/WHO (1982, 1993, 2002, 196, WMA, Helsinki Declaration: Ethical principles for medical research involving human subjects (1964, 1975, 1983, 1989, 1996, 2000, 2004) 1997, UNESCO, Universal Declaration of the Human Genome and Human Rights) (The Belmond Report April; 1979) ( Neves, 2011).

2. Vulnerability - knowledge background

From the point of view of knowledge, the terms that define vulnerability are extracted from the wide framework offered by the opportunities of medical care. Vulnerability is a comprehensive concept used at a large scale to identify persons, groups or populations whose autonomy is damaged, in order to understand the intrinsic or extrinsic nature of the concept and also to explain the manner in which certain macrosocial phenomena generate the vulnerability state. For the medical care, vulnerability and the significations attached to the term promote an ethical determinism, recognizing the need to be defined in measurable and operational terms. The ethical essence of the concept is given by autonomy, non-maleficence, well-doing, justice, principles that confer an idea on the meaning of the term for different social categories and healthcare systems to which medical care relates. In the European approach the ethical content of vulnerability steps towards biological law, justified by the interpretation of the concept together which principles such as autonomy, dignity and integrity (Goodin, 2004). Another meaning of the concept refers to a general recalibration of the consent to use vulnerability in medical care. The attempts to elaborate an exhaustive definition of vulnerability in a domain where the autonomy and consent ability of the patient cross paths with the system of healthcare policies required supplementary elaborations, specific for the context and also for the approach strategies distinctive for medical research and practice. It is worth underlining the fact that the wide range of usage of vulnerability issued a series of term derivatives, which, through their individualization partitioned the concept, given that this term refers equally to persons, groups and populations vulnerable involved in the medical care from the medical practice, research and healthcare policies, which are complementary domains (Flaskerud, 1998).

The definition of vulnerability in the limited context of the access to fundamental research and clinical studies develops an interpretation with a tendency to understand the concept in a restricted manner. This restrictive approach, characteristic for some authors in Western countries is used as selection criterion of the participants involved in research on human subjects. From the perspective of the authors who prefer the more detailed definitions focused on the underlining of the condition of "recognition and respect", the concept of vulnerability appears to be understood with a broader meaning that may be applied to every domain of human activity. From the perspective of this approach, representative for the developing countries, a balance is achieved, with a consideration typical for the medical field that vulnerability must not signify the basis of differentiation between those who have access to the medical act within research and those who do not (Neves, 2011).

3. Vulnerable populations - ethical and medical considerations

From the differences between the proposed definitions we can notice that together with the multiple connotations the term also reflects the way in which the word vulnerability itself is used, in the sense of its usefulness as an instrument for the determination of those who are vulnerable. The term "vulnerable populations" included in the terminological thesaurus of bioethics in 1997 will undergo developments up to the clarifications on the vulnerability involved in the healthcare system (Morawa, 2003). Moreover, bioethics implements the concept in major projects with the commitment to identify the vulnerable populations in order to ensure and guarantee their autonomy and dignity according to the principles of well-doing and justice. One distinction upon which bioethics insists is the usage of the term in the sense of anthropologically facilitated vulnerability or as an ethical principle. Thus, vulnerability as "human fragility" applied for everyone is deemed an approach that generates a meaning believed to be too large, because if everyone is vulnerable than the concept becomes too vague to become significant (Levine, 2004). Vulnerability as a sensibility to be harmed and predisposed is narrower connotation centred on the group characteristics of vulnerable populations with an emphasis on the ability to consent i.e. those who are exposed to certain conditions of injustice, distress or, from various reasons, are culpable of their situations (Brock, 2002, Kottow, 2007, Schramm, 2011). Furthermore, the most important concern for vulnerability is embodied by the recruitment for clinical research of the individuals who cannot consent or are exposed to constraint or coercion. Although the term of vulnerable populations has its detractors, bioethics, in its efforts of identification, definition and classification, reveals significant aspects of the marginalized groups including children, prisoners, pregnant women, handicapped persons, mentally handicapped persons, individuals economically or educationally underprivileged, high risk persons, mothers, chronic or HIV/AIDS patients, alcohol or drug abuse, persons predisposed to suicide or murder, domestic violence, homeless persons, immigrants, refugees etc. It is to be noticed the open character of the common norm list for vulnerable populations, emphasized by the fact that almost everyone, at a certain point in their lifetime will be confronted with an illness, which represents also a vulnerability state (Blacksher, Stone, 2002).

4. Vulnerability in healthcare and medical research

Vulnerability through stigmatization and marginalization has an impact on the health status, its instability being frequently the consequence of public policies and practices without just cause. Therefore, for guarantees regarding the respect for the human dignity of the vulnerable persons the intervention of bioethics is necessary, at the three levels of medical care: human experiment, medical care, biomedical research policies.

4.1. In the human experiment field the vulnerability of each human being may be exploited intrinsic or inherent in a subtle and even accidental manner. Circumstances such as the neutrality of the information in the clinical studies, volunteering versus benefits, submit to ethical debate the recruitment method of the volunteers and also the fact that a series of the healthcare benefits for the volunteers are in fact mandatory prerequisites for participation. Moreover, the public release of the success is confronted with the illusion and hope that all biomedical accomplishments lead definitely to success. In medical care, the application of the human experiment must not regard consent as less important or place autonomy on a secondary position. Consequently, the aims intended and followed in medical care are to protect vulnerable individuals, but also to make the more powerful persons in this relationship more responsible (Stacy, 2007).

4.2. Vulnerability in medical care starts from the boundary created by the lack of a unique approach in the definition of vulnerability, which makes the usage of the concept incomplete and inappropriate and the criteria for the designation of vulnerable populations are vague, situational, influenced by personal perception and stratified according to risk degree. An integrative approach of the concept oriented on the cultural formation of relationships that humans have in the social environment tries to take into consideration the manner in which

financial status, social support, education, income, life changes according to age, sex, race and ethnicity play a role in the social construction of the vulnerability of the health status (Turner, 2003). If at the social level vulnerabilities are mostly ignored, mainly because quantification difficulties in medical care a reconfiguration of vulnerability is necessary, with the translation of the meaning from "weakness" to "possibility to become fully responsible in autonomous choices and to compel those that have the power, influence and authority (society, state institutions) to protect individuals from potential abuse". Similar to the human experiment, the exploitation in medical practice in a subtle and even accidental manner of the vulnerability of each human being through deviation from signification and distancing from meaning has as ethical consequences the narrowing of the "normality" concept (Sandu, 2012). Among relevant examples there are those referring to the neglect of the psychological structure and life experience, which can sometimes determine persons to feel obligated to volunteer as organ donors for their family members. Also, the medicalization of the society contributes to the illusion that medicine has solutions for everything and has an impact on the concept of "disease". Another example is given by publicity for medication and medical procedures that create unrealistic expectations in the patient and places a tension between the vulnerability and the autonomy of those who lost their ability to make informed choices. In this context, the efforts to protect vulnerable patients who do not dispose of their ability to make informed choices may be regarded as paternalist and autonomy risks to become a principle with totalitarian attitude (Ruof, 2004). From the point of view of the moral values in medical practice it is required a deontological attitude of support for the balance between autonomy and the protection of vulnerable patients.

4.3. Vulnerability in patient-doctor relationship, as indication of professional integrity, illustrates by the appreciation of the trust in the medical act and medical personnel the need of the patient to investigate his health status and to be taken care of. In this relationship, the doctor, through professional and social legitimacy, through knowledge power, abilities and resources must act moral in the final choice and not profit from the vulnerability of patients. In this context, ethics intervenes moderately in order to balance the asymmetry of this relationship (Benner, 2008).

In the field of application of the healthcare and biomedical research policies a series of "patient lobbies" take place, with benefits obtained through the power of demand or by the progress recorded in the genetics domain, which by the identification of new aberrations widens the disease range. The biopolitical concept must be concentrated on the creation of circumstances for the bioethics to act correctly as an analytical and normative morality instrument regarding of the aims submitted for medical research (Schramm, 2010). One objective must be the warning of institutions and states about the fact that biomedical progress does not always yield the decrease and/or suppression of vulnerability but, on the contrary, successes recorded by biotechnologies may be factors of injustice and discrimination which can create and/or aggravate vulnerabilities (The Current State of Health Care for People with Disabilities (2009)).

In conclusion, the theoretical challenges and practical accomplishments at the three levels of ethical analysis enforce the respect for the vulnerability of the individual and for the personal integrity and dignity. In all endeavours of medical practice and research as well as the level of healthcare policies we must constantly be aware of the human vulnerability, which has to be taken into consideration as an obligation to not take advantage from the frailty of others (negative action) but also to consolidate through affirmative actions the social and institutional guarantees of protection for those who for various reasons are more vulnerable. Vulnerability represents a commitment towards morality, which in the medical act leads to a logical action of care, solicitude, solidarity and responsibility. Vulnerability, through orientation and adjustment, looks at the same time for complementary alternatives of freedom and attempts through change and self-determination to make strong and just that which is moral in society.

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