Kaposy Chris, Greenspan Nicole R, Marshall Zack, Allison Jill, Marshall Shelley, Kitson Cynthia
Faculty of Medicine, Health Sciences Centre, Memorial University, St. John's, NL, A1B 3V6, Canada.
Present Address: St. Michael's Hospital, 30 Bond St., Toronto, ON, M5B 1W8, Canada.
BMC Med Ethics. 2017 Feb 6;18(1):9. doi: 10.1186/s12910-017-0171-3.
This is a study involving three HIV clinics in the Canadian provinces of Newfoundland and Labrador, and Manitoba. We sought to identify ethical issues involving health care providers and clinic clients in these settings, and to gain an understanding of how different ethical issues are managed by these groups.
We used an institutional ethnographic method to investigate ethical issues in HIV clinics. Our researcher conducted in-depth semi-structured interviews, compiled participant observation notes, and studied health records in order to document ethical issues in the clinics, and to understand how health care providers and clinic clients manage and resolve these issues.
We found that health care providers and clinic clients have developed work processes for managing ethical issues of various types: conflicts between client-autonomy and public health priorities ("treatment as prevention"), difficulties associated with the criminalization of nondisclosure of HIV positive status, challenges with non-adherence to HIV treatment, the protection of confidentiality, barriers to treatment access, and negative social determinants of health and well-being.
Some ethical issues resulted from structural disadvantages experienced by clinic clients. The most striking findings in our study were the negative social determinants of health and well-being experienced by some clinic clients - such as experiences of violence and trauma, poverty, racism, colonization, homelessness, and other factors affecting well-being such as problematic substance use. These negative determinants were at the root of other ethical issues, and are themselves of ethical concern.
这是一项涉及加拿大纽芬兰与拉布拉多省以及曼尼托巴省三家艾滋病诊所的研究。我们试图确定这些机构中涉及医疗服务提供者和诊所患者的伦理问题，并了解这些群体如何处理不同的伦理问题。
我们采用机构民族志方法来调查艾滋病诊所中的伦理问题。我们的研究人员进行了深入的半结构化访谈，汇编了参与观察记录，并研究了健康记录，以便记录诊所中的伦理问题，并了解医疗服务提供者和诊所患者如何管理和解决这些问题。
我们发现，医疗服务提供者和诊所患者已经制定了处理各类伦理问题的工作流程：患者自主权与公共卫生优先事项之间的冲突（“治疗即预防”）、与将未披露艾滋病毒阳性状态定为刑事犯罪相关的困难、与不坚持艾滋病毒治疗相关的挑战、保密保护、治疗获取障碍以及健康和福祉的负面社会决定因素。
一些伦理问题是由诊所患者所经历的结构性劣势导致的。我们研究中最显著的发现是一些诊所患者所经历的健康和福祉的负面社会决定因素——例如暴力和创伤经历、贫困、种族主义、殖民化、无家可归以及其他影响福祉的因素，如问题性物质使用。这些负面决定因素是其他伦理问题的根源，其本身也关乎伦理。
