Centre for Public Policy Research, School of Education, Communication and Society, King's College London, Waterloo Bridge Wing, Franklin-Wilkins Building, Waterloo Road, London, SE1 9NH, UK.
Health Services Research Unit and School of Divinity, History and Philosophy, University of Aberdeen, 3rd floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK.
BMC Med Ethics. 2021 Jul 13;22(1):91. doi: 10.1186/s12910-021-00655-x.
Poverty and social deprivation have adverse effects on health outcomes and place a significant burden on healthcare systems. There are some actions that can be taken to tackle them from within healthcare institutions, but clinicians who seek to make frontline services more responsive to the social determinants of health and the social context of people's lives can face a range of ethical challenges. We summarise and consider a case in which clinicians introduced a poverty screening initiative (PSI) into paediatric practice using the discourse and methodology of healthcare quality improvement (QI).
Whilst suggesting that interventions like the PSI are a potentially valuable extension of clinical roles, which take advantage of the unique affordances of clinical settings, we argue that there is a tendency for such settings to continuously reproduce a narrower set of norms. We illustrate how the framing of an initiative as QI can help legitimate and secure funding for practical efforts to help address social ends from within clinical service, but also how it can constrain and disguise the value of this work. A combination of methodological emphases within QI and managerialism within healthcare institutions leads to the prioritisation, often implicitly, of a limited set of aims and governing values for healthcare. This can act as an obstacle to a genuine broadening of the clinical agenda, reinforcing norms of clinical practice that effectively push poverty 'off limits.' We set out the ethical dilemmas facing clinicians who seek to navigate this landscape in order to address poverty and the social determinants of health.
We suggest that reclaiming QI as a more deliberative tool that is sensitive to these ethical dilemmas can enable managers, clinicians and patients to pursue health-related values and ends, broadly conceived, as part of an expansive range of social and personal goods.
贫困和社会剥夺对健康结果有不利影响,并给医疗保健系统带来巨大负担。可以在医疗机构内部采取一些行动来解决这些问题,但寻求使一线服务更能响应健康的社会决定因素和人们生活的社会背景的临床医生可能会面临一系列伦理挑战。我们总结并考虑了一个案例,临床医生使用医疗保健质量改进(QI)的话语和方法,将贫困筛查倡议(PSI)引入儿科实践。
虽然建议像 PSI 这样的干预措施是临床角色的潜在有价值扩展,可以利用临床环境的独特优势,但我们认为,这些环境往往会不断复制更狭窄的规范集。我们说明了如何将倡议框定为 QI 可以帮助为从临床服务内部帮助解决社会目标的实际努力提供资金和保障,但也说明了它如何限制和掩盖这项工作的价值。QI 中的方法重点和医疗机构内的管理主义相结合,导致对医疗保健的有限目标和治理价值观进行优先排序,通常是隐含的。这可能成为真正拓宽临床议程的障碍,强化了实际上将贫困“排除在外”的临床实践规范。我们阐述了寻求在这种情况下进行导航以解决贫困和健康的社会决定因素的临床医生所面临的伦理困境。
我们建议将 QI 重新定义为一种更具审议性的工具,使其对这些伦理困境敏感,可以使管理者、临床医生和患者能够追求广泛意义上的健康相关价值观和目标,作为广泛的社会和个人利益的一部分。