MSc (Med) (Bioethics and Health Law), Faculty of Health Sciences, University of the Witwatersrand

Thesis advisor: Cherie McGill / Thesis advisor: Marius Stan / Seriously ill newborns are a part of a recent bioethical phenomenon that emerged during the late 1970s. With the rise of new, innovative medical technology, doctors can keep these seriously ill newborns alive, but at monumental financial and psychological costs. This thesis utilizes several economic and ethical frameworks to contextualize these newborns within our healthcare system. After all, our healthcare resources are limited. We must therefore discern between the continuation of an infant’s treatment and conversely, the withdrawal of treatment. / Thesis (BA) — Boston College, 2017. / Submitted to: Boston College. College of Arts and Sciences. / Discipline: Departmental Honors. / Discipline: Philosophy.

Introduction: Short-term medical missions (STMMs) are international service trips of short duration and typically involve teams traveling to provide medical service to low- and middle-income countries. The phenomenon of STMMs is neither well understood nor well defined in the literature. To date, the only published reviews of STMMs focus exclusively on the academic literature. However, these reviews do not capture the characteristics of medical missions conducted by visiting medical teams (VMTs) with no impetus to publish. YouTube, a video sharing platform which launched in 2005, is a novel information source for studying health-related issues. The goal of the present study is to understand the scope of STMMs. Specifically, we aim to characterize the STMMs described in publications listed in PubMed and videos posted to YouTube. We aim to subsequently compare findings from the literature and video review. Methods: We followed PRISMA guidelines to conduct a two pronged search of PubMed-indexed articles and videos posted to YouTube. We created a data extraction form to collect information about short-term medical mission characteristics, including sending and recipient country, sending organization, size of VMT, duration of medical mission, student involvement, and links to the local health system. Additional YouTube video-specific information was extracted including number of views, perspective, quality, operating location of the team, and distribution of medicines and vitamins. The free-text observations of the videos were thematically analyzed. Results: The majority of STMMs described in both PubMed (72%) and YouTube (93%) originate from the USA. The countries receiving the highest number of STMMs identified through literature publications were Haiti, Guatemala, Ethiopia and Peru; among videos, the countries with the highest number of STMMs were Philippines, Haiti, Honduras, and the Dominican Republic. Analysis based on income grouping shows the majority of missions go to lower-middle income countries. Analysis of recipient country based on health workforce density shows that most STMMs go to countries with a health workforce shortage, but this relationship is not linear. The majority of STMMs described in the literature (46%) were organized by secular non-profit organizations whereas the majority of STMMs described in the videos (45%) were organized by faith-based organizations. Out of 49% of articles that specified size, the median was eight members. In comparison, out of 33% videos that specified size, the median was 19 members. Whereas the median size of STMM reported in the literature was 9.5 days, the median duration in videos was 7 days. Student involvement was mentioned in 39% of articles and 18% videos. The majority (87.3%) of articles described a link to the local health system, whereas only 49.8% of videos described any link to the local health system. The median number of views of the videos was 315. Almost all videos (98.6%) were taken from the perspective of the VMT, and 82.2% were of amateur quality (non-professional). Although patients’ faces were shown in 96.1% of videos, only 0.7% of these videos stated that patient consent was obtained. Among the videos that specified the operating location of the STMM, 52.2% took place in a local healthcare facility, 21.5% in a school classroom, and 20.5% in a church. Over half (59%) of the videos portrayed the distribution of medications or vitamins. Of the videos that specified the type of service provided, 80% described STMMs that delivered medical (non-surgical) services. The provision of dental (36%), surgical (29%), and optometric (18%) services was also commonly described. Themes that emerged from the videos included patient privacy issues and long wait times. Discussion/Conclusion: The identified recipient countries of STMMs, when analyzed by income grouping and health workforce density, suggest inadequate distribution of STMMs. Furthermore, the videos highlight aspects of STMMs that have not been clearly explored in the literature including patient privacy, long wait times, and the distribution of medications and vitamins. Additionally, we found considerable variation between STMMs described in the academic literature and in grey data sources, specifically with respect to recipient country, sending organization, size of VMT, duration of STMM, and student involvement. Thus, we recommend caution in using only the academic literature to characterize the scope of medical missions. Future programmatic and policy directions should include improved pre-departure VMT training, rigorous evaluation of STMMs and the creation of a global registry.

Concierge medicine is a model of care in which patients pay an upfront annual membership fee to belong to the practice. In return for the fee the doctor is contracted to give the patient a more dedicated and individualized model of patient care. Concierge medicine was created out of the frustrations primary care physicians felt towards the restrictions place on them by insurance companies. Physicians want to be able to practice good medicine and not be buried in tedious paperwork that restricts the amount of time they can spend with patients. Physicians benefit because they able to spend more time with their patients, allowing them to establish relationships with their patients. Physicians are actually able to practice medicine and worry less about restrictions placed on them by insurance companies. They can practice preventative care which is a crucial part of their job. Their incomes are also protected because their salary is not regulated by the number of patients they see a day and the number of tests and labs they may run. Most importantly, physcian’s are much more satisfied with their jobs because of the time they are able to spend with the patients. Patients benefit even more than physicians. They can have long conversations with their physicians, rather than being rushed. When they need to see the doctor, patients are able to make same day appointments and avoid long wait times in the waiting room. Patients have 24/7 access to their physicians, so whenever a question or issue comes up, it can be addressed. Patients receive preventative care, to be proactive in preventing bad health outcomes for the future and undergo less unnecessary testing. There is much controversy with concierge medicine because many feel it is not ethical to provide better care for those who can afford concierge medicine. Proponents of concierge medicine argue that it is affordable to people from all socioeconomic statuses. Critics believe that concierge physicians are denying care to people of lower socioeconomic status, but most concierge physicians have a form of scholarship care in place for people who cannot afford the fee. While there is much controversy surrounding concierge medicine, there is not concrete evidence that is benefits patients or causes harm to the health care system. Many studies need to be done to determine its benefits. It is known that it does leave patients feeling much more satisfied with the quality of care, than when they received care in non-concierge practices. The real issue that needs to be addressed in the health care system is how to provide a quality of care similar to that provided by concierge physicians for everyone.

This study examines the visibility of moral agency in the daily work and production of healthcare in emergency medicine at an urban emergency medical center in the United States. Through detailed ethnographic research, this study investigates how the work of paramedics, nurses and physicians within their professional practice spheres of emergency medicine constantly resolve challenges that make their moral agency visible. Several themes emerge from this study by examining and closely noting how these individuals interact and express less a principled bioethical script, but instead a personal one that is or is not explained by their professional role in treating patients. This study follows the daily conversations and interactions that embody the local moral worlds of emergency medicine in paramedics, nurses and physicians and how each of these professional groups work through and around medical and patient care issues to create care. As these individuals within their professional role address challenges in emergency care, it is their interactions and conversations that make visible the moral agency of the individual healthcare worker. By examining the domain of these work lives this study investigates the ongoing and new conflicts and resolutions for the healthcare workers and how they assert moral agency; the intersubjective local moral worlds of care; use of technology to mediate care; and the structure of medicine in emergency medical care.

Members of the biomedical community justify biomedical research on sentient beings by depicting the benign results which are regarded as necessary for scientific and medical progress, which in turn is absolutely necessary for maintaining human health, well being, and life. Rather than take for granted that the burden of biomedical research should rest only on nonhuman animals, I will explore whether or not there is a more appropriate class of sentient beings that we should conduct our biomedical research on. I will argue, based on utilitarian principles, that if we can maximize overall happiness by conducting our research on a different group of beings, then we should opt to conduct our biomedical experiments on these beings. My central proposal is that our decision to experiment on nonhuman animals is not the best alternative available; rather, if we were to experiment on violent criminals, we would increase overall happiness. Since conducting biomedical research on this particular group of prisoners would fulfill the aims of retributive punishment, deter violent crime, and procure optimal scientific results, we would produce the maximal amount of benefits by experimenting on these transgressors. Thus when faced with the choice to experiment on either violent criminals or nonhuman animals, the morally commendable decision would be to perform research on violent criminals.

Thesis (Ph. D.)--University of Chicago, Dept. of Anthropology, June 1999. / Includes bibliographical references. Also available on the Internet.

Thesis (M.Sc.)--Flinders University, School of Medicine, Dept. of Speech Pathology and Audiology. / Typescript bound. Includes bibliographical references: (leaves 237-249) Also available electronically.

Project Thesis (D. Min.)--Denver Seminary, 1988. / Includes bibliographical references (leaves 313-329).

Thesis (Ph. D.)--University of Washington, 2001. / Vita. Includes bibliographical references (leaves 212-216).