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Malisauskaite G, Nizalova O, Gousia K, Teo H, Forder J. Understanding policy amenable risk factors: Alcohol consumption and long-term care use among people over 65 years old. Soc Sci Med 2024; 347:116746. [PMID: 38471406 DOI: 10.1016/j.socscimed.2024.116746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 02/01/2024] [Accepted: 02/29/2024] [Indexed: 03/14/2024]
Abstract
OBJECTIVES This study aims to explore the effect of past alcohol consumption frequency on formal and informal long-term care (LTC) use in old age and explore the different channels through which it may affect LTC use. MOTIVATION The existing literature has mainly focused on risk factors associated with a nursing home entry, but this evidence is outdated, not UK-focused, and does not look into other types of care, such as informal care. The results of this study will help in modelling the future demand for various types of care and the corresponding public spending. METHODS We use the English Longitudinal Study of Ageing (ELSA) (2002-2017) dataset to conduct longitudinal, individual-level analysis. We explore how the previous frequency of alcohol consumption affects formal and informal care use. We focus on people aged 65 and over with no previous LTC use and run regressions with and without instrumental variables (IV) to estimate how alcohol consumption patterns in the previous wave (2 years before) affect formal and informal care use. For IV regressions, we use the polygenic score for alcohol use, available for a subsample of ELSA respondents, as an instrument while also accounting for sociodemographic characteristics, lifestyle choices, and health conditions. RESULTS The main IV estimates suggest that frequent alcohol consumption has a weakly significant positive effect on the onset of formal LTC care use compared to none/rare drinking. This relationship diminishes and is not statistically significant when we directly control for health status. We find no statistically significant effect towards informal LTC use. These results contrast with the estimates without IV, which suggest that frequent alcohol consumption is negatively associated with informal care use and no or weakly negative association with formal care use. DISCUSSION Our findings suggest that unobserved confounding is important when studying the relationship between alcohol consumption and LTC. We hypothesise that primarily alcohol effects LTC through its adverse effect on health. In addition, unobserved factors like preferences towards seeking care, social behaviour may be related to alcohol consumption and affect access to care. We speculate alcohol may have a damaging effect on personal relationships and could indicate the burden eventually falling on formal care. In as far as the polygenic score IV can account for unobserved preference-behaviour differences, the results (weakly) support the hypothesis that these latter processes are relevant, especially for informal care use.
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Affiliation(s)
- Gintare Malisauskaite
- PSSRU (Personal Social Services Research Unit), University of Kent, Canterbury, CT2 7NF, UK.
| | - Olena Nizalova
- PSSRU (Personal Social Services Research Unit), University of Kent, Canterbury, CT2 7NF, UK.
| | - Katerina Gousia
- PSSRU (Personal Social Services Research Unit), University of Kent, Canterbury, CT2 7NF, UK.
| | - Hansel Teo
- PSSRU (Personal Social Services Research Unit), University of Kent, Canterbury, CT2 7NF, UK.
| | - Julien Forder
- PSSRU (Personal Social Services Research Unit), University of Kent, Canterbury, CT2 7NF, UK.
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Levy N, Savulescu J. The Myth of Zero-Sum Responsibility: Towards Scaffolded Responsibility for Health. JOURNAL OF MORAL PHILOSOPHY 2023; 21:85-105. [PMID: 38623184 PMCID: PMC7615831 DOI: 10.1163/17455243-20233725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Some people argue that the distribution of medical resources should be sensitive to agents' responsibility for their ill-health. In contrast, others point to the social determinants of health to argue that the collective agents that control the conditions in which agents act should bear responsibility. To a large degree, this is a debate in which those who hold individuals responsible currently have the upper hand: warranted appeals to individual responsibility effectively block allocation of any significant degree of responsibility to collective agents. We suggest that a different understanding of individual responsibility might lead to a fairer allocation of blame. Scaffolded agency is individual agency exercised in a context in which opportunities and affordances are structured by others. Appeals to scaffolded agency at once recognize the role of the individual and of the collective agents who have put the scaffolds in place.
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Affiliation(s)
- Neil Levy
- Uehiro Centre for Practical Ethics, University of Oxford, Oxford, United Kingdom
| | - Julian Savulescu
- Centre for Biomedical Ethics, National University of Singapore, Singapore
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Madeira F, Do Bú EA, Freitas G, Pereira CR. Distributive justice criteria and social categorization processes predict healthcare allocation bias. Br J Health Psychol 2022; 28:552-566. [PMID: 36504178 DOI: 10.1111/bjhp.12640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/16/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Drawing on theories of distributive justice and intergroup discrimination, we examined how much distributive justice criterion and racial group membership contribute to bias in healthcare allocation decisions, by testing a theoretical model that specifies perceived stereotypicality and individual responsibility as a serial mediation process in the relationship between disease's contraction controllability (controllable vs. non-controllable) and bias in medical decision-making. METHOD White Portuguese medical students (N = 213) participated in an online experimental study conducted in two phases. In phase 1, we manipulated the cause of disease contagion and the salience of patient's racial categorization, and measured the stereotypicality of behaviour. In phase 2, we assessed perceived responsibility and likelihood of recommending medical treatment. RESULTS Controllable (vs. non-controllable) contraction behaviours in phase 1 were perceived as more stereotypic. As a spillover effect, more stereotypical behaviours in phase 1 predicted more patient's responsibility for their disease in phase 2. Importantly, controllable behaviours of disease contraction in phase 1 negatively affected recommendations for medical treatment in phase 2; and this negative effect was serially mediated by the stereotypicality of behaviour and patient responsibility. Furthermore, patients' skin colour moderated this process, meaning that perceptions of controllable behaviour as more stereotypic were stronger for Black than for White patients. CONCLUSIONS This research shows how stereotyping and social categorization bias allocation decisions through the patient's level of responsibility in decision-making processes. The findings are discussed in light of principles of distributive justice and the literature on intergroup relations with respect to racial disparities in health care.
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Affiliation(s)
- Filipa Madeira
- Institute of Social Sciences University of Lisbon Lisbon Portugal
| | - Emerson Araújo Do Bú
- Institute of Social Sciences University of Lisbon Lisbon Portugal
- Faculty of Psychology University of Lisbon Lisbon Portugal
| | - Gonçalo Freitas
- Institute of Social Sciences University of Lisbon Lisbon Portugal
- Faculty of Psychology University of Lisbon Lisbon Portugal
| | - Cicero Roberto Pereira
- Institute of Social Sciences University of Lisbon Lisbon Portugal
- Department of Psychology Federal University of Paraíba João Pessoa Brazil
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Lünich M, Kieslich K. Exploring the roles of trust and social group preference on the legitimacy of algorithmic decision-making vs. human decision-making for allocating COVID-19 vaccinations. AI & SOCIETY 2022; 39:1-19. [PMID: 35469142 PMCID: PMC9022054 DOI: 10.1007/s00146-022-01412-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 02/14/2022] [Indexed: 11/24/2022]
Abstract
In combating the ongoing global health threat of the COVID-19 pandemic, decision-makers have to take actions based on a multitude of relevant health data with severe potential consequences for the affected patients. Because of their presumed advantages in handling and analyzing vast amounts of data, computer systems of algorithmic decision-making (ADM) are implemented and substitute humans in decision-making processes. In this study, we focus on a specific application of ADM in contrast to human decision-making (HDM), namely the allocation of COVID-19 vaccines to the public. In particular, we elaborate on the role of trust and social group preference on the legitimacy of vaccine allocation. We conducted a survey with a 2 × 2 randomized factorial design among n = 1602 German respondents, in which we utilized distinct decision-making agents (HDM vs. ADM) and prioritization of a specific social group (teachers vs. prisoners) as design factors. Our findings show that general trust in ADM systems and preference for vaccination of a specific social group influence the legitimacy of vaccine allocation. However, contrary to our expectations, trust in the agent making the decision did not moderate the link between social group preference and legitimacy. Moreover, the effect was also not moderated by the type of decision-maker (human vs. algorithm). We conclude that trustworthy ADM systems must not necessarily lead to the legitimacy of ADM systems.
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Affiliation(s)
- Marco Lünich
- Department of Social Sciences, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Kimon Kieslich
- Department of Social Sciences, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Greenberg R, Goldberg A, Anthony S, Buchman DZ, Delaney S, Gruben V, Holdsworth S, Le Foll B, Leung M, Lien D, Lynch MJ, Selzner N, Chandler JA, Fortin MC. Canadian Society of Transplantation White Paper: Ethical and Legal Considerations for Alcohol and Cannabis Use in Solid Organ Listing and Allocation. Transplantation 2021; 105:1957-1964. [PMID: 33587429 PMCID: PMC8376271 DOI: 10.1097/tp.0000000000003618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 11/16/2020] [Accepted: 11/20/2020] [Indexed: 11/26/2022]
Abstract
Alcohol and cannabis use as a contraindication to organ transplantation is a controversial issue. Until recently, patients in Canada with alcohol-associated liver disease were required to demonstrate abstinence for 6 mo to receive a liver transplant. There is no equivalent rule that is applied consistently for cannabis use. There is some evidence that alcohol and cannabis use disorder pretransplant could be associated with worse outcomes posttransplantation. However, early liver transplantation for patients with alcohol-associated liver disease in France and in the United States has led to challenges of the 6-mo abstinence rule in Canada in the media. It has also resulted in several legal challenges arguing that the rule violates human rights laws regarding discrimination in the provision of medical services and that the rule is also unconstitutional (this challenge is still before the court). Recent legalization of cannabis use for adults in Canada has led to questions about the appropriateness of limiting transplant access based on cannabis use. The ethics committee of the Canadian Society of Transplantation was asked to provide an ethical analysis of cannabis and alcohol abstinence policies. Our conclusions were as follows: neither cannabis use nor the 6-mo abstinence rule for alcohol use should be an absolute contraindication to transplantation, and transplant could be offered to selected patients, further research should be conducted to ensure evidence-based policies; and the transplant community has a duty not to perpetuate stigma associated with alcohol and cannabis use disorders.
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Affiliation(s)
- Rebecca Greenberg
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Mount Sinai Hospital, Toronto, ON, Canada
| | - Aviva Goldberg
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Samantha Anthony
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, ON, Canada
| | - Daniel Z. Buchman
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | | | - Vanessa Gruben
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Faculty of Law, University of Ottawa, Ottawa, ON, Canada
| | - Sandra Holdsworth
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Bernard Le Foll
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | | | - Dale Lien
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Marie-Josee Lynch
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Research Institute, Toronto, ON, Canada
| | - Nazia Selzner
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Toronto General Research Institute, Toronto, ON, Canada
| | - Jennifer A. Chandler
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Faculty of Law, University of Ottawa, Ottawa, ON, Canada
| | - Marie-Chantal Fortin
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Centre de recherche du CHUM, Montreal, QC, Canada
- Faculty of Medicine, University of Montreal, QC, Canada
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Knotz CM, Gandenberger MK, Fossati F, Bonoli G. A Recast Framework for Welfare Deservingness Perceptions. SOCIAL INDICATORS RESEARCH 2021; 159:927-943. [PMID: 34456449 PMCID: PMC8378786 DOI: 10.1007/s11205-021-02774-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 06/02/2023]
Abstract
UNLABELLED Many important societal debates revolve around questions of deservingness, especially when it comes to debates related to inequality and social protection. It is therefore unsurprising that a growing body of research spanning the social and political sciences is concerned with the determinants of deservingness perceptions. In this contribution, we engage with the currently central theoretical framework used in deservingness research and point out an important weakness: Partly ambiguous definitions of the framework's central concepts, the criteria for perceived deservingness. We also highlight the negative consequences this has for empirical research, including notably varying and overlapping operationalizations and thereby a lacking comparability of results across studies. Our main contribution is a redefinition of the criteria for perceived deservingness and a demonstration of the empirical implications of using this new set of criteria via original vignette survey experiments conducted in Germany and the United States in 2019. Our results provide a clearer image of which criteria drive deservingness perceptions. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s11205-021-02774-9.
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Affiliation(s)
- Carlo Michael Knotz
- Department of Media and Social Sciences (IMS), University of Stavanger, Elise Ottesen-Jensens Hus, Kjell Arholms Gate 37, 4021 Stavanger, Norway
| | - Mia Katharina Gandenberger
- Swiss Graduate School of Public Administration (IDHEAP), University of Lausanne & NCCR - on the move, Quartier UNIL-Mouline, Bâtiment IDHEAP, 1015 Lausanne, Switzerland
| | - Flavia Fossati
- Swiss Graduate School of Public Administration (IDHEAP), University of Lausanne, NCCR - on the move & NCCR - LIVES, Quartier UNIL-Mouline, Bâtiment IDHEAP, 1015 Lausanne, Switzerland
| | - Giuliano Bonoli
- Swiss Graduate School of Public Administration (IDHEAP), University of Lausanne, NCCR - on the move & NCCR - LIVES, Quartier UNIL-Mouline, Bâtiment IDHEAP, 1015 Lausanne, Switzerland
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Knotz CM, Gandenberger MK, Fossati F, Bonoli G. Public attitudes toward pandemic triage: Evidence from conjoint survey experiments in Switzerland. Soc Sci Med 2021; 285:114238. [PMID: 34364159 PMCID: PMC8417366 DOI: 10.1016/j.socscimed.2021.114238] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/28/2021] [Accepted: 07/15/2021] [Indexed: 11/23/2022]
Abstract
The question of how to implement medical triages has become highly salient during the COVID-19 pandemic and continues to be actively discussed. It is important to know how members of the general public think about this issue. For one, knowledge about the public's standpoint can help resolve important questions where ethical considerations are by themselves not sufficient, for instance whether the patient's age should matter. It can also help identify if more communication with the public about medical ethics is needed. We study how members of the Swiss public would allocate intensive medical care among COVID-19 patients using data from two original conjoint survey experiments conducted in Switzerland in the context of the first and second pandemic waves in 2020 (N = 1457 & N = 1450). We find that our participants would not base triage decisions on the patient's age. However, they do give much importance to the patient's behavior prior and during illness, discriminate against non-nationals, and assign only a relatively small and inconsistent role to medical considerations. Our findings suggest that there is a need for more communication with the public about the ethics of medical triage.
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Affiliation(s)
- Carlo Michael Knotz
- Department of Media & Social Sciences (IMS), University of Stavanger, Elise Ottesen-Jensens hus, 4036, Stavanger, Norway.
| | - Mia Katharina Gandenberger
- Swiss Graduate School of Public Administration (IDHEAP), University of Lausanne & NCCR - on the move, Quartier UNIL-Mouline, Bâtiment IDHEAP, 1015, Lausanne, Switzerland.
| | - Flavia Fossati
- Swiss Graduate School of Public Administration (IDHEAP), University of Lausanne, NCCR - on the move & NCCR - LIVES, Quartier UNIL-Mouline, Bâtiment IDHEAP, 1015, Lausanne, Switzerland.
| | - Giuliano Bonoli
- Swiss Graduate School of Public Administration (IDHEAP), University of Lausanne, NCCR - on the move & NCCR - LIVES, Quartier UNIL-Mouline, Bâtiment IDHEAP, 1015, Lausanne, Switzerland.
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DiSantostefano RL, Terris-Prestholt F. Using Societal Values to Inform Public Health Policy During the COVID-19 Pandemic: The Role of Health Preference Research. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 14:303-307. [PMID: 33886102 PMCID: PMC8060338 DOI: 10.1007/s40271-021-00516-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 04/02/2021] [Indexed: 01/16/2023]
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Avanceña ALV, Prosser LA. Examining Equity Effects of Health Interventions in Cost-Effectiveness Analysis: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:136-143. [PMID: 33431148 DOI: 10.1016/j.jval.2020.10.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 09/09/2020] [Accepted: 10/06/2020] [Indexed: 05/10/2023]
Abstract
OBJECTIVE This systematic review aims to catalogue and describe published applications of equity-informative cost-effectiveness analysis (CEAs). METHODS Following PRISMA guidelines, we searched Medline for English-language, peer-reviewed CEAs published on or before August 2019. We included CEAs that evaluated 2 or more alternatives; explicitly mentioned equity as a consideration or decision-making principle; and applied an equity-informative CEA method to analyze or examine at least 1 equity criterion in an applied CEA. We extracted data on selected characteristics and analyzed reporting quality using the CHEERS checklist. RESULTS Fifty-four articles identified through a search and bibliography reviews met the inclusion criteria. All articles were published on or after 2010, with 80% published after 2015. Most studies evaluated primary prevention interventions in disease areas such as cancer, infectious diseases, and cardiovascular disease. Equity impact analysis alone was the most common equity-informative CEA (56%), followed by equity impact analysis with financial protection effects (30%). At least 11 different equity criteria have been used in equity-informative CEAs; socioeconomic status and race/ethnicity were used most frequently. Seventy-eight percent of studies reported finding "greater value" in an intervention after examining its distributional effects. CONCLUSION The number of equity-informative CEAs is increasing, and the wide range of equity criteria, diseases, interventions, settings, and populations represented suggests that broad application of these methods is feasible but will require further refinement. Inclusion of equity into CEAs may shift the value of evaluated interventions and can provide crucial additional information for decision makers.
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Affiliation(s)
- Anton L V Avanceña
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA.
| | - Lisa A Prosser
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA; Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics, Medical School, University of Michigan, Ann Arbor, Michigan, USA
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Notini L, Vasileva D, Orchanian-Cheff A, Buchman DZ. Ethical issues associated with solid organ transplantation and substance use: a scoping review. Monash Bioeth Rev 2020; 37:111-135. [PMID: 31749129 DOI: 10.1007/s40592-019-00100-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
While solid organ transplantation for patients with substance use issues has attracted ethical discussion, a typology of the ethics themes has not been articulated in the literature. We conducted a scoping review of peer-reviewed literature on solid organ transplantation and substance use published between January 1997 and April 2016. We aimed to identify and develop a typology of the main ethical themes discussed in this literature and to identify gaps worthy of future research. Seventy articles met inclusion criteria and underwent inductive content analysis. Four main ethical themes were identified: (1) personal responsibility; (2) utility; (3) moral character; and (4) fairness. Each theme had multiple sub-themes and there was substantial overlap between themes. This scoping review identified a disproportionate emphasis in the literature regarding personal responsibility, which was referenced by each of the other themes, and a narrow focus on alcohol and liver. We recommend future research further investigate these connections between ethical themes and focus on ethical issues associated with transplants from organ groups other than liver for patients who use substances other than alcohol.
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Affiliation(s)
- Lauren Notini
- Joint Centre for Bioethics, University of Toronto, 155 College Street, Suite 754, Toronto, ON, M5T 1P8, Canada.,Melbourne Law School, The University of Melbourne, 185 Pelham Street, Carlton, VIC, 3053, Australia.,Biomedical Ethics Research Group, Murdoch Children's Research Institute, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | | | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | - Daniel Z Buchman
- Joint Centre for Bioethics, University of Toronto, 155 College Street, Suite 754, Toronto, ON, M5T 1P8, Canada. .,Bioethics Department, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada. .,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. .,Krembil Research Institute, Toronto, ON, Canada.
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Traina G, Martinussen PE, Feiring E. Being Healthy, Being Sick, Being Responsible: Attitudes towards Responsibility for Health in a Public Healthcare System. Public Health Ethics 2019; 12:145-157. [PMID: 31384303 PMCID: PMC6655377 DOI: 10.1093/phe/phz009] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Lifestyle-induced diseases are becoming a burden on healthcare, actualizing the discussion on health responsibilities. Using data from the National Association for Heart and Lung Diseases (LHL)’s 2015 Health Survey (N = 2689), this study examined the public’s attitudes towards personal and social health responsibility in a Norwegian population. The questionnaires covered self-reported health and lifestyle, attitudes towards personal responsibility and the authorities’ responsibility for promoting health, resource-prioritisation and socio-demographic characteristics. Block-wise multiple linear regression assessed the association between attitudes towards health responsibilities and individual lifestyle, political orientation and health condition. We found a moderate support for social responsibility across political views. Respondents reporting unhealthier eating habits, smokers and physically inactive were less supportive of health promotion policies (including information, health incentives, prevention and regulations). The idea that individuals are responsible for taking care of their health was widely accepted as an abstract ideal. Yet, only a third of the respondents agreed with introducing higher co-payments for treatment of ‘self-inflicted’ conditions and levels of support were patterned by health-related behaviour and left-right political orientation. Our study suggests that a significant support for social responsibility does not exclude a strong support for personal health responsibility. However, conditional access to healthcare based on personal lifestyle is still controversial.
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Affiliation(s)
- Gloria Traina
- Department of Health Management and Health Economics, University of Oslo
| | - Pål E Martinussen
- Department of Sociology and Political Science, Norwegian University of Science and Technology (NTNU)
| | - Eli Feiring
- Department of Health Management and Health Economics, University of Oslo
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Systematic Review of Public Preferences for the Allocation of Donor Organs for Transplantation: Principles of Distributive Justice. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2019; 12:475-489. [DOI: 10.1007/s40271-019-00363-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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O'Dell HW, McMichael BJ, Lee S, Karp JL, VanHorn RL, Karp SJ. Public attitudes toward contemporary issues in liver allocation. Am J Transplant 2019; 19:1212-1217. [PMID: 30582275 DOI: 10.1111/ajt.15227] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 01/25/2023]
Abstract
Allocation of scarce livers for transplantation seeks to balance competing ethical principles of autonomy, utility, and justice. Given the history and ongoing dependence of transplantation on public support for funding and organs, understanding and incorporating public attitudes into allocation decisions seems appropriate. In the context of the current controversy around liver allocation, we sought to determine public preferences about issues relevant to the debate. We performed multiple surveys of attitudes around donation and evaluated these using conjoint analysis and clarifying follow-up questions. We found little public support that allocation decisions should be based solely on risk of waiting-list mortality. Strong public sentiment supported maximizing outcomes after transplantation, prioritizing US citizens or residents, keeping organs local, and considering cost in allocation decisions. We then present a methodology for incorporating these preferences into the Model for End-Stage Liver Disease (or MELD) priority score. Taken together, these findings suggest that current allocation schemes do not accurately reflect public preferences and suggest a framework to better align allocation with the values of the public.
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Affiliation(s)
- Heather W O'Dell
- Vanderbilt Transplant Center, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Suzie Lee
- Vanderbilt Transplant Center, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - R Lawrence VanHorn
- Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee
| | - Seth J Karp
- Vanderbilt Transplant Center, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
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Reckers-Droog V, van Exel J, Brouwer W. Who should receive treatment? An empirical enquiry into the relationship between societal views and preferences concerning healthcare priority setting. PLoS One 2018; 13:e0198761. [PMID: 29949648 PMCID: PMC6021057 DOI: 10.1371/journal.pone.0198761] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/24/2018] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Policy makers increasingly need to prioritise between competing health technologies or patient populations. When aiming to align allocation decisions with societal preferences, knowledge and operationalisation of such preferences is indispensable. This study examines the distribution of three views on healthcare priority setting in the Netherlands, labelled "Equal right to healthcare", "Limits to healthcare", and "Effective and efficient healthcare", and their relationship with preferences in willingness to trade-off (WTT) exercises. METHODS A survey including four reimbursement scenarios was conducted in a representative sample of the adult population in the Netherlands (n = 261). Respondents were matched to one of the three views based on their agreement with 14 statements on principles for resource allocation. We tested for WTT differences between respondents with different views and applied logit regression models for examining the relationship between preferences and background characteristics, including views. RESULTS Nearly 65% of respondents held the view "Equal right to healthcare", followed by "Limits to healthcare" (22.5%), and "Effective and efficient healthcare" (7.1%). Most respondents (75.9%) expressed WTT in at least one scenario and preferred gains in quality of life over life expectancy, maximising gains over limiting inequality, treating children over elderly, and those with adversity over those with an unhealthy lifestyle. Various background characteristics, including the views, were associated with respondents' preferences. CONCLUSIONS Most respondents held an egalitarian view on priority setting, yet the majority was willing to prioritise regardless of their view. Societal views and preferences concerning healthcare priority setting are related. However, respondents' views influence preferences differently in different reimbursement scenarios. As societal views and preferences are heterogeneous and may conflict, aligning allocation decisions with societal preferences remains challenging and any decision may be expected to receive opposition from some group in society.
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Affiliation(s)
- Vivian Reckers-Droog
- Erasmus University Rotterdam, Erasmus School of Health Policy & Management, Rotterdam, the Netherlands
| | - Job van Exel
- Erasmus University Rotterdam, Erasmus School of Health Policy & Management, Rotterdam, the Netherlands.,Erasmus University Rotterdam, Erasmus School of Economics, Rotterdam, the Netherlands
| | - Werner Brouwer
- Erasmus University Rotterdam, Erasmus School of Health Policy & Management, Rotterdam, the Netherlands
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Leon M, Varon J, Surani S. When a liver transplant recipient goes back to alcohol abuse: Should we be more selective? World J Gastroenterol 2016; 22:4789-4793. [PMID: 27239105 PMCID: PMC4873871 DOI: 10.3748/wjg.v22.i20.4789] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/02/2016] [Accepted: 05/04/2016] [Indexed: 02/06/2023] Open
Abstract
Alcoholic liver disease (ALD) is one of the most common indications for liver transplantation (LT). However, it has always remained as a complicated topic from both medical and ethical grounds, as it is seen for many a “self-inflicted disease”. Over the years, the survival rate of transplanted patients has significantly improved. The allocation system and the inclusion criteria for LT has also undergone some modifications. Early LT for acute alcoholic hepatitis has been subject to recent clinical studies with encouraging results in highly selected patients. We have learned from studies the importance of a multidisciplinary evaluation of candidates for LT. Complete abstinence should be attempted to overcome addiction issues and to allow spontaneous liver recovery. Risk factors for relapse include the presence of anxiety or depressive disorder, short duration of sobriety pre-LT and lack of social support. The identification of risk factors and the strengthen of social support system may decrease relapse among these patients. Family counseling of candidates is highly encouraged to prevent relapse to alcohol. Relapse has been associated with different histopathological changes, graft damage, graft loss and even decrease in survival among some studies. Therefore, each patient should be carefully selected and priority is to continue to lean on patients with high probability of success. The ethical issue remains as to the patient returning to drinking after the LT, hindering the way for other patients who could have received the same organ.
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Mathurin P. Therapeutic management of alcoholic hepatitis. Clin Res Hepatol Gastroenterol 2015; 39 Suppl 1:S41-5. [PMID: 26189979 DOI: 10.1016/j.clinre.2015.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 05/18/2015] [Indexed: 02/04/2023]
Abstract
Several investigators have given priority to treatment of AH, as this entity is associated with significant early mortality. Patients at significant risk of early death are identified by the use of prognostic models. The Lille model highlights the benefits obtained from strategy integrating the impact of treatment upon the evaluated endpoint. Survival impact of corticosteroids is significant in complete and partial responders, whereas it appeared negligible in null-responders. Infection screening is warranted, but should not contraindicate steroids. In terms of mechanisms, non-response to steroids is the key factor in development of infection and prediction of survival. For patients with severe alcoholic hepatitis failing to medical therapy can be identified earlier and have a 6-month survival around 30%; early liver transplantation in those patients is attractive but highly controversial as it challenges the 6-month abstinence rule prior to LT.
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Affiliation(s)
- Philippe Mathurin
- Service d'hépato-gastroentérologie, hôpital Claude-Huriez, 1(er) étage est, avenue Michel-Polonovski, 59037 Lille, France.
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Abstract
Abstract:This article discusses the notion of social responsibility for personal health and well-being in bioethics. Although social responsibility is an intrinsic aspect of bioethics, and its role is increasingly recognized in certain areas, it can still be claimed that bioethics in general is committed to an individualistic theoretical framework that disregards the social context in which decisions, health, and well-being are situated. The philosophical premises of this framework regard individuals as rational decisionmakers who can be held accountable for their health conditions and who should be the primary objects of intervention in attempts to reduce lifestyle-associated chronic diseases. There are, however, social determinants of health that challenge this conclusion. Because their impact can be controlled, to a certain extent, by social and public policy decisions, their existence shows the inadequacy of the purely individualistic approach. I suggest, accordingly, that bioethics would benefit, both academically and societally, from a more social perspective. Bioethical studies that acknowledge, from the start, the social determinants of health would be more amenable to constructive multi- and interdisciplinarity, and a more balanced account of responsibility would further the contribution of sound bioethical work to sensible public policies.
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Rustad JK, Stern TA, Prabhakar M, Musselman D. Risk factors for alcohol relapse following orthotopic liver transplantation: a systematic review. PSYCHOSOMATICS 2014; 56:21-35. [PMID: 25619671 DOI: 10.1016/j.psym.2014.09.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 09/03/2014] [Accepted: 09/04/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Each year, 5000-6000 individuals undergo orthotopic liver transplantation (OLT) in the United States, and of these, nearly 18% have alcoholic liver disease. Relapse to alcohol occurs in more than 40% of patients with OLT for alcoholic liver disease. OBJECTIVES We sought to identify factors that predict relapse to alcohol or medication nonadherence following OLT in patients with alcoholic liver disease and to review what randomized clinical interventions have addressed these factors following OLT. Our hypothesis was that there would be factors before and after OLT that predict relapse to alcohol following OLT, and that these, if targeted, might improve sobriety and associated outcomes of adherence with medications and appointments. METHODS We performed a review (focusing on articles published since 2004) with PubMed and MEDLINE searches using the following search terms: liver transplantation, recidivism, alcohol relapse, and predictors of alcohol relapse. We supplemented the online searches with manual reviews of article reference lists and selected relevant articles for further review by author consensus. RESULTS In largely white populations, prospective studies document that shorter length of pretransplantation sobriety is a significant predictor of time to first drink and time to binge use. Presence of psychiatric comorbidity, high score on standardized High-risk Alcoholism Relapse Scale, and diagnosis of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) alcohol dependence are predictive of posttransplantation alcohol relapse. Pretransplantation alcohol use history variables (e.g., family history of alcoholism) reliably discriminate between complete abstainers and those who drink, while medical and psychosocial characteristics at early post-liver transplantation period (e.g., more bodily pain) maximally discriminate patterns of alcohol use. Alcoholic individuals with early-onset, rapidly accelerating moderate use and early-onset, continuously increasing heavy use have more than double the prevalence of steatohepatitis or rejection on biopsy and graft failure and more frequent mortality resulting from recurrent alcoholic liver disease than late-onset (i.e., peak of heaviest drinking at 6y posttransplantation) alcohol users do. Fortunately, pretransplantation screening combined with a structured pretransplantation management program and a 12-step program attendance reduced recidivism. No randomized clinical trials have been performed that target pretransplantation risk factors in individuals with alcoholic liver disease before or after OLT to improve post-OLT outcomes. CONCLUSIONS Recent research findings suggest that screening can reveal individuals who are vulnerable to alcohol relapse and targeted intervention can prevent their relapse to alcohol. Based on existing addiction treatments (e.g., relapse prevention plan construction), randomized clinical trials tailored to post-OLT patients should be conducted to improve their survival and quality of life.
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Affiliation(s)
- James K Rustad
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida Morsani College of Medicine, Tampa, FL (JKR).
| | - Theodore A Stern
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA (TAS)
| | - Maithri Prabhakar
- Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL (MP)
| | - Dominique Musselman
- Department of Psychiatry and Behavioral Sciences, University of Miami Leonard H. Miller School of Medicine, Miami, FL (DM)
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Stafinski T, McCabe C, Menon D. Determining social values for resource allocation decision-making in cancer care: a Canadian experiment. J Cancer Policy 2014. [DOI: 10.1016/j.jcpo.2014.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Hyde MK, Chambers SK. Information Sources, Donation Knowledge, and Attitudes toward Transplant Recipients in Australia. Prog Transplant 2014; 24:169-77. [DOI: 10.7182/pit2014799] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Context Knowledge is linked consistently with organ donation attitudes, willingness, and consent. Negative information about donation and the recipients of donation can affect public opinion and donation willingness. However, it is unclear which information sources are most important in forming knowledge, particularly in Australia where little prior research exists. Objectives To identify information sources that may inform Australians' organ donation knowledge and attitudes toward transplant recipients. Participants 1487 Australian residents aged 18 years or older who completed an online survey. Main Outcome Measures Self-reported knowledge, information sources, and attitudes toward transplant recipients. Results Participants felt fairly well informed about organ donation, particularly if they registered donation wishes, were female, and were older. More than half reported their driver's license, television news, and discussion with family/friends as donation information sources. However, information sources contributing to knowledge were personal experience, online, hospital, government campaign, discussion with family/friends, Medicare, doctor's surgery, and the newspaper. Differences based on registration status, sex, and age, were found. Discussion with family/friends and movies or television shows, as well as not having seen information in a newspaper or doctor's surgery, contributed to positive attitudes toward recipients, although the variance explained was small. Conclusions People felt more informed by personal, medical, and government information sources than by mass media. Family discussion was not only a common information source but also contributed significantly and positively to both donation knowledge and attitudes toward recipients. Further exploration of information sources contributing to donation knowledge and community attitudes toward transplant recipients among young men is needed.
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Ali NF, Qureshi A, Jilani BN, Zehra N. Knowledge and ethical perception regarding organ donation among medical students. BMC Med Ethics 2013; 14:38. [PMID: 24070261 PMCID: PMC3856467 DOI: 10.1186/1472-6939-14-38] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 09/18/2013] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND To determine the knowledge and ethical perception regarding organ donation amongst medical students in Karachi- Pakistan. METHODS Data of this cross sectional study was collected by self administered questionnaire from MBBS students of Ziauddin University from 2010 to 2011. Sample size of 158 (83 First years and 75 Fourth years) were selected by convenient sampling and those students who were present and gave consent were included in the study. The data was analyzed by SPSS version 20. RESULTS A total of 158 participants from Ziauddin Medical University filled out the questionnaire out of which 83(52.5%) were first years and 75(47.5%) were fourth year medical students. Mean age of sample was 20 ± 1.7. Majority of students were aware about organ donation with print and electronic media as the main source of information. 81.6% agreed that it was ethically correct to donate an organ. In the students' opinion, most commonly donated organs and tissues were kidney, cornea, blood and platelet. Ideal candidates for donating organ were parents (81%). Regarding list of options for preference to receive an organ, most of the students agreed on young age group patients and persons with family. Willingness to donate was significantly associated with knowledge of allowance of organ donation in religion (P = 0.000). CONCLUSION Both 1st year and 4th year students are aware of Organ Donation, but there is a significant lack of knowledge regarding the topic.
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Affiliation(s)
- Nisreen Feroz Ali
- Fifth year medical students, Ziauddin Medical University, ST-16, Block B, North Nazimabad, Karachi, Pakistan
| | - Amal Qureshi
- Fifth year medical students, Ziauddin Medical University, ST-16, Block B, North Nazimabad, Karachi, Pakistan
| | - Basmah Naser Jilani
- Fifth year medical students, Ziauddin Medical University, ST-16, Block B, North Nazimabad, Karachi, Pakistan
| | - Nosheen Zehra
- Department of Community Health Sciences, Ziauddin Medical University, ST-4/B, Block 6, Clifton, Karachi, Pakistan
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Abstract
AbstractDocumentation of the patient encounter is a traditional component of health care practice, a requirement of various regulatory agencies and hospital oversight committees, and a necessity for reimbursement. A disaster may create unexpected challenges to documentation. If patient volume and acuity overwhelm health care providers, what is the acceptable appropriate documentation? If alterations in scope of practice and environmental or resource limitations occur, to what degree should this be documented? The conflicts arising from allocation of limited resources create unfamiliar situations in which patient competition becomes a component of the medical decision making; should that be documented, and, if so, how?In addition to these challenges, ever-present liability worries are compounded by controversies over the standards to which health care providers will be held. Little guidance is available on how or what to document. We conducted a search of the literature and found no appropriate references for disaster documentation, and no guidelines from professional organizations. We review here the challenges affecting documentation during disasters and provide a rationale for specific patient care documentation that avoids regulatory and legal pitfalls. (Disaster Med Public Health Preparedness. 2013;0:1–7)
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Bobinac A, van Exel NJA, Rutten FFH, Brouwer WBF. Inquiry into the relationship between equity weights and the value of the QALY. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:1119-26. [PMID: 23244815 DOI: 10.1016/j.jval.2012.07.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2011] [Revised: 06/14/2012] [Accepted: 07/07/2012] [Indexed: 05/07/2023]
Abstract
BACKGROUND A commonly held view of the decision rule in economic evaluations in health care is that the final incremental cost-effectiveness ratio needs to be judged against some threshold, which is equal for all quality-adjusted life-year (QALY) gains. This reflects the assumption that "a QALY is a QALY" no matter who receives it, or the equity notion that all QALY gains are equally valuable, regardless of the context in which they are realized. If such an assumption does not adequately reflect the distributional concerns in society, however, different thresholds could be used for different QALY gains, whose relative values can be seen as "equity weights." AIM Our aim was to explore the relationship between equity or distributional concerns and the social value of QALYs within the health economics literature. In light of the empirical interest in equity-related concerns as well as the nature and height of the incremental cost-effectiveness ratio threshold, this study investigates the "common ground" between the two streams of literature and considers how the empirical literature estimating the incremental cost-effectiveness ratio threshold treats existing distributional considerations.
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Affiliation(s)
- Ana Bobinac
- Department of Health Policy & Management and Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands.
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Stafinski T, Menon D, Marshall D, Caulfield T. Societal values in the allocation of healthcare resources: is it all about the health gain? PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2012; 4:207-25. [PMID: 21815706 DOI: 10.2165/11588880-000000000-00000] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Over the past decade, public distrust in unavoidable value-laden decisions on the allocation of resources to new health technologies has grown. In response, healthcare organizations have made considerable efforts to improve their acceptability by increasing transparency in decision-making processes. However, the social value judgments (distributive preferences of the public) embedded in them have yet to be defined. While the need to explicate such judgments has become widely recognized, the most appropriate approach to accomplishing this remains unclear. The aims of this review were to identify factors around which distributive preferences of the public have been sought, create a list of social values proposed or used in current resource allocation decision-making processes for new health technologies, and review approaches to eliciting such values from the general public. Social values proposed or used in making resource allocation decisions for new health technologies were identified through three approaches: (i) a comprehensive review of published, peer-reviewed, empirical studies of public preferences for the distribution of healthcare; (ii) an analysis of non-technical factors or social value statements considered by technology funding decision-making processes in Canada and abroad; and (iii) a review of appeals to funding decisions on grounds in part related to social value judgments. A total of 34 empirical studies, 10 technology funding decision-making processes, and 12 appeals to decisions were identified and reviewed. The key factors/patient characteristics addressed through policy statements and around which distributive preferences of the public have been sought included severity of illness, immediate need, age (and its relationship to lifetime health), health gain (amount and final outcome/health state), personal responsibility for illness, caregiving responsibilities, and number of patients who could benefit (rarity). Empirical studies typically examined the importance of these factors in isolation. Therefore, the extent to which preferences around one factor may be modified in the presence of others is still unclear. Research that seeks to clarify interactions among factors by asking the public to weigh several of them at once is needed to ensure the relevance of elicited preferences to real-world technology funding decisions.
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Affiliation(s)
- Tania Stafinski
- School of Public Health, University of Alberta, Edmonton, AB, Canada.
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Mathurin P, Moreno C, Samuel D, Dumortier J, Salleron J, Durand F, Castel H, Duhamel A, Pageaux GP, Leroy V, Dharancy S, Louvet A, Boleslawski E, Lucidi V, Gustot T, Francoz C, Letoublon C, Castaing D, Belghiti J, Donckier V, Pruvot FR, Duclos-Vallée JC. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med 2011; 365:1790-800. [PMID: 22070476 DOI: 10.1056/nejmoa1105703] [Citation(s) in RCA: 598] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND A 6-month abstinence from alcohol is usually required before patients with severe alcoholic hepatitis are considered for liver transplantation. Patients whose hepatitis is not responding to medical therapy have a 6-month survival rate of approximately 30%. Since most alcoholic hepatitis deaths occur within 2 months, early liver transplantation is attractive but controversial. METHODS We selected patients from seven centers for early liver transplantation. The patients had no prior episodes of alcoholic hepatitis and had scores of 0.45 or higher according to the Lille model (which calculates scores ranging from 0 to 1, with a score ≥ 0.45 indicating nonresponse to medical therapy and an increased risk of death in the absence of transplantation) or rapid worsening of liver function despite medical therapy. Selected patients also had supportive family members, no severe coexisting conditions, and a commitment to alcohol abstinence. Survival was compared between patients who underwent early liver transplantation and matched patients who did not. RESULTS In all, 26 patients with severe alcoholic hepatitis at high risk of death (median Lille score, 0.88) were selected and placed on the list for a liver transplant within a median of 13 days after nonresponse to medical therapy. Fewer than 2% of patients admitted for an episode of severe alcoholic hepatitis were selected. The centers used 2.9% of available grafts for this indication. The cumulative 6-month survival rate (±SE) was higher among patients who received early transplantation than among those who did not (77 ± 8% vs. 23 ± 8%, P<0.001). This benefit of early transplantation was maintained through 2 years of follow-up (hazard ratio, 6.08; P = 0.004). Three patients resumed drinking alcohol: one at 720 days, one at 740 days, and one at 1140 days after transplantation. CONCLUSIONS Early liver transplantation can improve survival in patients with a first episode of severe alcoholic hepatitis not responding to medical therapy. (Funded by Société Nationale Française de Gastroentérologie.).
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Affiliation(s)
- Philippe Mathurin
- Hôpital Claude Huriez, Services Maladies de l'Appareil Digestif and INSERM Unité 995, Centre Hospitalier Universitaire, de Lille and Université Nord de France, Lille
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Abstract
In this article the epidemiology of substance use and substance disorders in the United States and their association with liver disease are reviewed. The relevance of tobacco use and issues of candidacy as it pertains to substance use are discussed. The use of alcohol while on the waitlist and short sobriety are also addressed. The merits of monitoring of patients are discussed, and the outcomes of these patients after liver transplantation are examined. The article concludes with a summary of recommendations for clinicians working with these patients and possible future directions for both clinical care and research.
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Affiliation(s)
- Andrea DiMartini
- Consultation Liaison to the Liver Transplant Program, Starzl Transplant Institute, University of Pittsburgh Medical Center, PA 15213, USA.
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Gollust SE, Lantz PM, Ubel PA. Images of illness: how causal claims and racial associations influence public preferences toward diabetes research spending. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2010; 35:921-959. [PMID: 21451158 PMCID: PMC3856194 DOI: 10.1215/03616878-2010-034] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Despite the salience of health disparities in media and policy discourse, little previous research has investigated if imagery associating an illness with a certain racial group influences public perceptions. This study evaluated the influence of the media's presentation of the causes of type 2 diabetes and its implicit racial associations on attitudes toward people with diabetes and preferences toward research spending. Survey participants who viewed an article on genetic causation or social determinants of diabetes were more likely to support increased government spending on research than those viewing an article with no causal language, while participants viewing an article on behavioral choices were more likely to attribute negative stereotypes to people with diabetes. Participants who viewed a photo of a black woman accompanying the article were less likely to endorse negative stereotypes than those viewing a photo of a white woman, but those who viewed a photo of a glucose-testing device expressed the lowest negative stereotypes. The effect of social determinants language was significantly different for blacks and whites, lowering stereotypes only among blacks. Emphasizing the behavioral causes of diabetes, as is common in media coverage, may perpetuate negative stereotypes. While drawing attention to the social determinants that shape these behaviors could mitigate stereotypes, this strategy is unlikely to influence the public uniformly.
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Hyde MK, White KM. A comparison of registered and unregistered organ donors’ perceptions about transplant recipients. Clin Transplant 2010; 25:444-9. [DOI: 10.1111/j.1399-0012.2010.01257.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Community preferences for the allocation of solid organs for transplantation: a systematic review. Transplantation 2010; 89:796-805. [PMID: 20090570 DOI: 10.1097/tp.0b013e3181cf1ee1] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Organs for transplantation are a scarce community resource but community preferences and how they are incorporated into allocation policies are unclear. This systematic review aimed to ascertain community preferences for organ allocation and the principles underpinning these preferences. METHODS Medline, Embase, PsycINFO, EconLit, and gray literature databases were searched. Quantitative data were extracted, and a qualitative textual synthesis of the results and conclusions reported in each included study was performed. RESULTS Fifteen studies involving more than 5563 respondents were included. Seven themes describing community preferences for organ allocation were identified: (1) maximum benefit, to achieve maximum health gain in recipient survival and quality of life; (2) social valuation, to base preferences on societal gain; (3) moral deservingness, to consider the "worthiness" of recipients based on their social standing and lifestyle decisions; (4) prejudice, to make a judgement based on personal ideologic viewpoints; (5) "fair innings," to provide an organ preferentially to the younger recipient giving opportunity for a "normal" life span and to those waiting for a first organ rather than a retransplant; (6) "first come, first served," to allocate the organ to recipients wait-listed the longest; and (7) medical urgency, to allocate based on illness severity and saving life. CONCLUSIONS Community preferences for organ allocation hinge on a complex balance of efficiency, social valuation, morality, fairness, and equity principles. Being a community-held resource, effective ways to identify and incorporate community preferences into allocation algorithms for solid organ transplantation are warranted.
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Hyde MK, White KM. Exploring donation decisions: beliefs and preferences for organ donation in Australia. DEATH STUDIES 2010; 34:172-185. [PMID: 24479180 DOI: 10.1080/07481180903492604] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The authors explored common beliefs and preferences for posthumous and living organ donation in Australia where organ donation rates are low and little research exists. Content analysis of discussions revealed the advantage of prolonging/saving life whereas disadvantages differed according to donation context. A range of people/groups perceived to approve and disapprove of donation were identified. Barriers for posthumous donation included a family's objection, with the type of organ needed important for living donation. Motivators included knowledge about potential organ recipients. Donation preferences favored loved ones, with weaker preferences for recipients who were perceived as morally questionable or responsible for their illness.
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Affiliation(s)
- Melissa K Hyde
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, Queensland, Australia.
| | - Katherine M White
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, Queensland, Australia
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Pageaux GP, Faure S, Chermak F, Bismuth M, Bouyabrine H. [Liver transplantation in a patient with alcoholic cirrhosis: discussion about nonabstinence]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2009; 33:F44-F49. [PMID: 19747790 DOI: 10.1016/j.gcb.2009.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Liver transplantation is the recognized treatment for serious cases of alcoholic cirrhosis. However, due to their poor image within society, patients with alcoholic cirrhosis are often less referred to transplant centres. This is even more surprising since in terms of patient' and graft's survival, the results of transplantation are comparable, if not better, than in other indications. Transplantation is the treatment for the liver disease, not a treatment for alcoholism. In the case of severe alcoholic disease, a relapse is neither surprising nor unacceptable or insignificant if severe. In this case, it has an impact on the long-term survival, notably due to mortality by cancer. All the medical teams carrying out transplants agree that abstinence is necessary when a patient is being evaluated for liver transplantation. However, it is not proven that a set period of 6 months' abstinence prior to the transplantation can modify the results. The problem of alcoholism must be treated specifically in terms of addiction both before and after transplantation.
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Affiliation(s)
- G-P Pageaux
- Pôle digestif, service d'hépatogastroentérologie et transplantation hépatique, CHU Saint-Eloi, 80 rue Augustin-Fliche, Montpellier cedex 5, France.
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Lucas T, Lakey B, Alexander S, Arnetz B. Individuals and illnesses as sources of perceived preventability. PSYCHOL HEALTH MED 2009; 14:322-30. [DOI: 10.1080/13548500802705914] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
1. In the absence of treatment, 50% of patients with severe alcoholic hepatitis (AH) [Maddrey function (DF) >or= 32] die 2 months later. Among patients with severe AH treated by corticosteroids, 80% had 2-month survival. Pentoxifylline is considered by some investigators to be an alternative option to corticosteroids. 2. Non-responders to corticosteroids (NRCs) have poor survival and require new strategies. Liver transplantation should be considered in order to improve survival of non-responders to therapeutic agents. 3. Prognostic models such as the Model for End-Stage Liver Disease (MELD) and DF are useful tools for predicting short-term mortality of patients with severe AH. Specific models taking into account the particular settings of treated patients are warranted. 4. In an era of organ shortage, use of liver transplants in patients with severe AH may negatively affect the public attitude on transplantation and organ donation, and may cause reluctance on the part of clinicians to modify guidelines for alcoholic patients. 5. Therefore, a reasonable approach would be to carry out only pilot studies on only a small cohort of patients to determine whether transplantation improves survival in patients with severe AH.
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Affiliation(s)
- Philippe Mathurin
- Service d'Hépatogastroentérologie Hôpital Claude Huriez and Equipe mixte INSERM 0114, CHU Lille, France.
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35
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Abstract
Patients with end-stage alcoholic liver disease should be considered for liver transplantation. A careful pretransplant evaluation must be undertaken to assess for both medical and psychiatric factors that will continue to require attention following transplantation. Although most programs require at least 6 months of ethanol abstinence before consideration of liver transplantation, there is little evidence that this conclusively predicts a reduction in recidivism. Most programs continue to exclude those with alcoholic hepatitis. Postoperatively, attention to psychiatric issues, recidivism, compliance, and assessment for tumors, especially squamous cell carcinomas, should be undertaken.
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Affiliation(s)
- Rowen K Zetterman
- Nebraska-Western Iowa VA Health Care System, 4101 Woolworth Avenue, Omaha, NE 68105, USA.
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Dolan P, Shaw R, Tsuchiya A, Williams A. QALY maximisation and people's preferences: a methodological review of the literature. HEALTH ECONOMICS 2005; 14:197-208. [PMID: 15386656 DOI: 10.1002/hec.924] [Citation(s) in RCA: 239] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
In cost-utility analysis, the numbers of quality-adjusted life years (QALYs) gained are aggregated according to the sum-ranking (or QALY maximisation) rule. This requires that the social value from health improvements is a simple product of gains in quality of life, length of life and the number of persons treated. The results from a systematic review of the literature suggest that QALY maximisation is descriptively flawed. Rather than being linear in quality and length of life, it would seem that social value diminishes in marginal increments of both. And rather than being neutral to the characteristics of people other than their propensity to generate QALYs, the social value of a health improvement seems to be higher if the person has worse lifetime health prospects and higher if that person has dependents. In addition, there is a desire to reduce inequalities in health. However, there are some uncertainties surrounding the results, particularly in relation to what might be affecting the responses, and there is the need for more studies of the general public that attempt to highlight the relative importance of various key factors.
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Affiliation(s)
- Paul Dolan
- Sheffield Health Economics Group, School of Health and Related Research, University of Sheffield, UK.
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de la Mata M, Barrera P, Fraga E, Montero JL, de la Torre J, López-Cillero P, Briceño J, Solórzano G, Alonso M. [Liver transplantation in patients with HIV infection]. GASTROENTEROLOGIA Y HEPATOLOGIA 2004; 27:425-8. [PMID: 15461943 DOI: 10.1016/s0210-5705(03)70492-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- M de la Mata
- Unidad de Trasplante Hepático, Hospital Universitario Reina Sofía, Córdoba, Spain.
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Lim JK, Keeffe EB. Liver transplantation for alcoholic liver disease: current concepts and length of sobriety. Liver Transpl 2004; 10:S31-8. [PMID: 15382288 DOI: 10.1002/lt.20267] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
1. The 1-year and 5-year actuarial survival rates following liver transplantation for patients with alcoholic liver disease are 82% and 68%, respectively, in the United States and 85% and 70%, respectively, in Europe. These survival rates are similar to the outcomes of patients who undergo transplantation for other types of chronic liver disease. 2. Posttransplant improvements in health-related quality of life are similar in patients who undergo transplantation for alcoholic liver disease compared to those who undergo transplantation for other causes of end-stage liver disease. 3. Approximately 20% of patients who undergo transplantation for alcoholic liver disease use alcohol posttransplant, with one-third of these individuals exhibiting repetitive or heavy drinking. Surprisingly, little evidence exists to document a significant detrimental effect on graft or patient survival associated with resumption of drinking. 4. There are few reliable predictors of relapse in alcoholic patients after liver transplantation. Although not supported by all studies, abstinence of fewer than 6 months prior to transplantation may be a reasonable predictor of recidivism and is widely employed as a criterion for listing for liver transplantation. There are no good data to determine if some patients with sobriety fewer than 6 months might benefit from liver transplantation.
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Affiliation(s)
- Joseph K Lim
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Abstract
OBJECTIVE To investigate the nature of public preferences in the allocation of donor liver grafts for transplantation. DESIGN A qualitative study based upon the transcripts of four focus groups. SETTING Derby, Derbyshire, UK. PARTICIPANTS Twenty-two members of the public in the Derby locality, recruited to one of four focus groups through local community groups. MAIN OUTCOME MEASURES The views of focus group members as to the importance (or otherwise) of several potential discriminating factors which could be used in the prioritization of patients on the waiting list for liver transplantation were ascertained. The factors included were expected posttransplantation prognosis, the age of the patient, whether the patient was personally responsible for their illness, the time spent on the waiting list, re-transplantation or primary transplant and the social background of the patient. RESULTS AND CONCLUSIONS Group members explored the criteria from a number of perspectives, and made some unexpected linkages between the criteria and wider moral principles. They did not come to firm conclusions about the relative desirability of the criteria, but their approach was notably flexible and thoughtful, with the exception of a few instances where they appeared to resort to arguments based on what is 'obvious' and 'natural'. The results of these discussions suggest that members of the public would be able and willing to respond positively to a more open and consultative system of donor liver prioritization than exists presently within the UK.
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Affiliation(s)
- Mira Johri
- Department of Health Administration, Faculty of Medicine, University of Montreal, Canada.
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Wittenberg E, Goldie SJ, Fischhoff B, Graham JD. Rationing decisions and individual responsibility for illness: are all lives equal? Med Decis Making 2003; 23:194-211. [PMID: 12809318 DOI: 10.1177/0272989x03023003002] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This survey measured individuals' rationing allocation choices for situations in which patients are deemed to hold personal responsibility for their diseases and the influence of different arguments on such choices. METHODS The association between allocation decisions for liver disease and asthma and the belief that a patient was responsible for his or her illness was modeled using multivariable regression analysis, controlling for the effect of arguments on choices. RESULTS In data from 310 returned surveys (43% response rate), respondents were 10 to 17 times more likely to allocate liver transplants or asthma treatment to patients they deemed not responsible for their illnesses than to patients they deemed responsible for their conditions (liver transplants: odds ratio [OR] = 10.3, 95% confidence interval ([CI] = 2.5-42.1; asthma: OR = 16.8, 95% CI = 2.1-136.6). CONCLUSIONS Personal responsibility for illness was an important consideration in respondents' rationing allocation decisions. These choices appeared to be stable although possibly influenced by respondents' interpretations of the survey scenarios and decision tasks.
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Affiliation(s)
- Eve Wittenberg
- MGH Institute for Technology Assessment, Massachusetts General Hospital, Boston 02114, USA.
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Criterios de priorización para el acceso al trasplante. El caso del trasplante hepático en España. Med Clin (Barc) 2003. [DOI: 10.1016/s0025-7753(03)73710-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Affiliation(s)
- Scott D Halpern
- University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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Olbrisch ME, Benedict SM, Ashe K, Levenson JL. Psychological assessment and care of organ transplant patients. J Consult Clin Psychol 2002; 70:771-83. [PMID: 12090382 DOI: 10.1037/0022-006x.70.3.771] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Organ transplant has been developed in animal models over the past 100 years. The major limiting factor in transplant medicine is the shortage of donor organs. This shortage creates pressure for fair and efficient allocation of organs, with expectations that those involved in transplantation will strive to achieve optimal outcomes and ensure just access. This article reviews the major types of transplants and the illnesses and behavioral comorbidities that lead to these procedures, the psychological assessment of transplant candidates, the adaptive tasks required of the transplant recipient at various stages of the transplant process, and relevant psychological interventions. Liaison with others on the transplant team and ethical issues of concern to psychologists who work with transplant patients, including living organ donors, are also discussed. Finally, new developments in transplant and suggestions for future psychological research in organ transplant are presented.
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Affiliation(s)
- Mary Ellen Olbrisch
- Department of Psychiatry, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298-0268, USA.
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