Investigating the Implications of Sexual Assaults with Ride-Sharing: A Call for Research

Sexual assault rates are increasing with ride-shares. Sexual violence data are often underestimated due to sexual violence cases going unreported and can lead to negative health outcomes. There is no research on the phenomenon of sexual assaults among ride-share users. This manuscript investigates sexual assaults from two ride-share companies and the policies/procedures in place to prevent sexual assaults. The data from two ride-share companies' previous Safety Reports were compared to see an increase in sexual assaults. The researchers looked at policies and regulations that ride-share companies have to prevent sexual assault. There is a call for research to investigate more in-depth the sexual assaults that have occurred including demographic data, geographic location, global positioning system failure, and the effectiveness of the criminal background checks.

Patients' requests for radiological imaging: A qualitative study on general practitioners' perspectives

BACKGROUND

With the increasing availability of information, patients are becoming more informed about radiology procedures and requesting imaging studies. This qualitative study aims to explore factors that influence general practitioners' (GPs) decisions to fulfil patient requests for imaging studies during clinical consultation.

METHODS

Semi-structured interviews were conducted with 10 GPs working across five private medical centres in Northwest Sydney. Conventional content analysis was used with emergent themes to identify GPs perspectives.

RESULTS

Six themes stood out from the interviews with GPs fulfilling patient requests for imaging studies. They included four pertaining to patient factors: patient expectations, 'therapeutic scans', 'impressive labels' and entitled. Two further themes pertained to the GP perspective and included defensive medicine, and 'new patients'. Requests are fulfilled from anxious or health-obsessed patients, with GPs worrying about litigation if they refuse. However, GPs decline requests from patients with entitlement attitudes or during first visits.

DISCUSSION

The findings suggest that GPs struggle to balance their responsibilities as gatekeepers of imaging with patients' expectations of request fulfilment. Clear guidelines on the appropriate use of diagnostic imaging and its limitations could help patients understand its proper use and ease anxiety. Additionally, education and training for GPs could help them manage patient expectations and provide appropriate care.

PATIENT CONTRIBUTIONS

Patients, service users, caregivers, people with lived experiences or members of the public were not directly involved in the design, conduct, analysis or interpretation of the study. However, our study was conducted in primary care facilities where the GPs were interviewed about patients' requests for diagnostic imaging based on their own initiatives. GPs' perspectives in managing patient expectations and healthcare utilisation were explored within the Australian Medicare system, where medical imaging and image-guided procedures come at little to no cost to the individual. The study findings contribute to a better understanding of the challenges faced by GPs in dealing with patient consumerism and requests for diagnostic imaging, as well as factors influencing request fulfilment or denial. Insights gained from this study may inform future research about delivering patient-centred care within a similar context.

Does healthcare consumerism serve as a barrier or facilitator to the implementation of value-based primary care? Strategies to promote synergy and success

Introduction

Value in health care is described as the measured improvement in a patient's health outcomes for the cost of achieving that improvement. In the United States, value-based care has been heralded by providers, payers, and policymakers alike, as a path to addressing the challenges facing the healthcare system and achieving the aspirational goals of the Quadruple Aim of healthcare. Primary care is often viewed as the foundational cornerstone for implementing value-based care. However, primary care is also considered as ground-zero for the rise in healthcare consumerism.

Methods

In essence, consumerism refers to increasing expectations from patients (consumers) to be more active participants in decisions related to their healthcare. While much of the literature has portrayed the rise in consumerism as a barrier to the implementation of value-based primary care, some have argued that it may have potential to synergize with and facilitate the implementation of value-based primary care. This paper applies an enhanced stepwise implementation framework for value-based (equitable) care, to examine the potential for conflict and synergy between consumerism and value-based care in the emerging retail model of primary care. The application is based on the potential actions of four key stakeholder groups: (1) retail healthcare entities, (2) primary-care providers, (3) consumers (patients), and (4) healthcare payers.

Results

The analysis helps to articulate the responsibilities of each stakeholder group in ensuring synergy between consumerism and value-based primary care. In addition, it helps to identify three drivers of synergy between consumerism and value-based care: (1) trust in the patient-provider relationship, (2) connected consumer-centric technology solutions, and (3) value-based consumer-centric payment models.

Discussion

Overall, the application helps to articulate a comprehensive framework for implementing value-based care that incorporates both the principles of consumerism and active consideration for health equity.

Implications of Extractivism and Environmental Pollution in Mapuche Territories of the Araucania Region

Chile is facing an environmental crisis and the territory of the Mapuche people is no exception. This is largely due to extractivism, which refers to the massive extraction and exploitation of natural resources in an indiscriminate manner. The objective of this study was to reveal the implications of extractivism and environmental pollution in Mapuche territories in the Araucanía region. The methodology used was qualitative, based on constructivist grounded theory. In-depth interviews and participant observation were used to collect data. The participants were 46 kimeltuchefes. The main results revealed extensive monocultures of non-native trees: pine and eucalyptus, which consume large amounts of water. They also revealed environmental pollution and indiscriminate forestry extractivism related to these trees, which generate soil degradation and water pollution. These consequences reduce biodiversity and disturb the ngenh (spiritual beings and protectors of nature). They also affect the Mapuche's agricultural activities and, in turn, their health and subsistence. In addition, non-native tree monocultures, environmental pollution and forestry extractivism transgress the az mapu (Mapuche code of ethics and behaviour), which disturbs the ethical, moral and spiritual relationship between the Mapuche and nature. They also have negative implications for the küme mogen (good living of the Mapuche), since they violate the balance and harmony between the Mapuche and all living beings, elements and spiritual beings that are part of nature. This also violates the reciprocity between the Mapuche and nature. It was concluded that there have been violations of the human rights of the Mapuche people, given that they are exposed to harmful environmental conditions that put their health and subsistence at considerable risk. In this sense, the Mapuche are experiencing a spiritual, physical, cognitive, attitudinal, affective and material imbalance. Ultimately, the state of Chile must generate intercultural environmental public and educational policies aimed at generating environmental awareness and creating actions to solve environmental problems in order to protect Mapuche and non-Mapuche territories.

Cyberdelics in context: On the prospects and challenges of mind-manifesting technologies

The concept of cyberdelics emerged in the 1980s and 1990s as an umbrella term denoting the nexus connecting cybernetic (digital) technologies and psychedelic (mind manifesting) drugs. Cyberdelic technologies, in particular the then newly emerging field of virtual reality, were touted by psychedelic cultural icons including Timothy Leary and Terence McKenna as auguring a new era of digital mind-expansion where psychedelic experiences will be recreated online inside virtual worlds. Cyberdelic culture waned in the 2000s. However, recent years have seen the return of the cyberdelic imaginary, following on the heels of a psychedelic resurgence and a renewed interest in virtual reality technologies and their use in therapy. Cyberdelic advocates speak of the necessity of creating transformative technologies that steer humanity away from mindless consumerism and distractedness, and towards expanded states of awe, presence, and transcendence. Nevertheless, much like psychedelics, cyberdelic technologies are seen as running against the grain of current sociocultural arrangements and economic models which threaten to quell their transformative potential. Research on psychedelics within the humanities over the past decade has emphasized the role of cultural set and setting: the significance of the cultural embeddedness of these psychoactive agents and the dependence of their effects on surrounding sociocultural conditions. Building on the notion of information technologies as mind-manifesting technologies, this paper sets out to consider what psychedelics can teach us about cyberdelics: how the principles of set and setting and current discussions within the psychedelic humanities can inform our understanding of the resurgence of interest in cyberdelic media, its prospects, and challenges.

Analytical psychology and quantum physics in a world in crisis and under transformation

Starting with the current pandemic, a potent symbol of death for all, the author explores the need to transform our vision of, and position in, the world. The author describes the world in which we live in terms of accelerated transformation and extreme imbalance: environmental suicide, consumerism, environmental pollution, global warming and intense polarization brought about by techno-populism. She reflects on the enantiodromia of our current times in which the focus has shifted from extreme spirituality to the opposite extreme of materialism. She returns to the concepts of the psychoid archetype and unus mundus, and analogous concepts in quantum physics, examining the need to review the polarities of psyche and matter in the search for a new synthesis. The author then concludes by highlighting the importance of consciousness in the elaboration and construction of a new way of being in the world.

The trouble with personhood and person-centred care

The phrase 'person-centred care' (PCC) reminds us that the fundamental philosophical goal of caring for people is to uphold or promote their personhood. However, such an idea has translated into promoting individualist notions of autonomy, empowerment and personal responsibility in the context of consumerism and neoliberalism, which is problematic both conceptually and practically. From a conceptual standpoint, it ignores the fact that humans are social, historical and biographical beings, and instead assumes an essentialist or idealized concept of personhood in which a person is viewed as an individual static object. From a practical standpoint, the application of such a concept of personhood can lead to neglect of a person's fundamental care needs and exacerbate the problems of social inequity, in particular for older people and people with dementia. Therefore, we argue that our understanding of PCC must instead be based on a dynamic concept of personhood that integrates the relevant social, relational, temporal and biographical dimensions. We propose that the correct concept of personhood in PCC is one in which persons are understood as socially embedded, relational and temporally extended subjects rather than merely individual, autonomous, asocial and atemporal objects. We then present a reconceptualization of the fundamental philosophical goal of PCC as promoting selfhood rather than personhood. Such a reconceptualization avoids the problems that beset the concept of personhood and its application in PCC, while also providing a philosophical foundation for the growing body of empirical literature that emphasizes the psychosocial, relational, subjective and biographical dimensions of PCC.

How to maintain mental health in today's world?

Consumerism favours the culture of the disposable, excessive extroversion, and superficiality. Data manipulation, the shadow of information technology, harms individual and collective lives. In a world filled with prejudice, intolerance, violence and social inequality, nature is neglected putting our survival at risk. The lack of appreciation for subjectivity and self-knowledge and the demand for greater performance foster physical and emotional problems expressed through anxiety, depression, anguish and burnout. It is thus urgent to develop a pattern of consciousness that allows us to overcome polarization and cope with the opposites by the means of dialogue and an appreciation of the dialectical and symmetrical relationship between the polarities. Carlos Byington, in his symbolic psychology, named this the archetypal pattern of alterity, and considered it the basis of solidarity, respect for difference, democracy and sustainability.

Technoscientific control of nature: The ultimate paradox

The current interlinked environmental and socioeconomic global crises constitute the gravest threat to humanity's well-being, indeed survival, today. Studies of the historical roots and contemporary manifestations of the various elements of these crises-including accelerating environmental degradation, unfettered capitalist technoscientific/industrial expansion, overpopulation, and overconsumption-are plentiful. Also well-known is the influence of Francis Bacon's writings, particularly The Advancement of Learning (1605), Novum Organon (1620), and the utopian New Atlantis (1627), on the development of empiricism and the modern scientific method as well as the reform and organization of scientific research. Bacon's significance for the founding of the Royal Society of London (1660) and for the plan and structure of the Encyclopedie (1751-1772), coupled with his oft-cited aphoristic injunctions to study nature to control/dominate it, are staples in the lore and justification of technoscience. I argue that the enduring appeal of so-called Baconianism derives, in part, from a fundamental misappropriation of certain of Bacon's original ideas. Specifically, the complex ethical and religious framework within which Bacon situated his vision of scientific and technological development was discarded (or ignored) so that, by the early decades of the 18th century, Baconianism had come to be understood almost exclusively for its utilitarian role in society. This deracinated version became the familiar trope of technoscience's unlimited potential to transform nature (including human nature and behavior) in the service of an ideology of industrial/consumerist expansion since then. Linkage between the history of science/technology and addictive consumerism, apparent by the close of the 19th century, has been insufficiently examined. Such addictive consumerist behavior and continued virtually unregulated industrialization and production, were effectively removed from ethical scrutiny and a high degree of material acquisition and personal/societal rapaciousness became the norm rather than the exception in most countries. I suggest that further historical deconstruction of this denuded Baconianism will yield important insights in the search for viable solutions to the present global socioenvironmental crises.

Professionalism - A Medico-Legal Perspective

This article examines the issue of professionalism in relation to dental practitioners, and how it impacts upon the range of medico-legal challenges they might face. It provides an overview of professionalism in a healthcare context and explores some of the characteristics that different parties would associate with it.The mismatch between these different perspectives and the relative importance that each party attaches to different aspects of professionalism, can often sit at the heart of complaints and litigation.The article also questions whether or not traditional professional values and behaviours are still relevant in a modern healthcare environment that is increasingly digital, consumerist and competitive - or conversely in such a fast-changing world, whether the need for a modern professionalism is greater than ever.

Private Services and the Fragmentation of Maternity Care in Poland

As a result of reforms aimed at adjusting it to the market economy, the Polish health care system has become a complicated mix of public and private services. Using as an example maternity services, I show how private services allow a subtle process of patient selection to emerge, contributing to the fragmentation of public care. The process of selection is based on social relations formed between health care providers and patients through the use of private services. This has a negative impact on women who do not have the social or financial resources to engage in private services.W wyniku reform mających na celu dostosowanie do gospodarki rynkowej, opieka zdrowotna w Polsce przekształcona została w skomplikowaną mieszaninę usług publicznych i prywatnych. Na podstawie świadczeń położniczych, pokazuję, w jaki sposób prywatne usługi zdrowotne stały się "oknami" pozwalającymi na subtelną selekcję pacjentów. Selekcja ta oparta jest na relacjach społecznych nawiązywanych pomiędzy lekarzem/położną a pacjentką przy okazji korzystania z prywatnych usług i prowadzi do fragmentaryzacji opieki publicznej. Proces ten szczególnie negatywnie wpływa na kobiety, których zasoby społeczne i finansowe nie pozwalają na korzystanie z prywatnych usług zdrowotnych.

Dentists' Perspectives on Commercial Practices in Private Dentistry

BACKGROUND

Dentistry is predominantly provided in a commercial context in Australia. Despite this, little is known about how dentists navigate potential tensions that may arise between commercial and professional obligations in private dental practice. This analysis uses a qualitative approach to explore dentists' perceptions and attitudes toward the commercialized nature of private dental practice and how these affect their professional role in providing care.

METHODS

Participants were recruited by advertising on social media, as well as through a professional association and a corporate dental group's graduate training program. Data were collected from participants through interviews and written reflections. The data were subjected to thematic analysis to reveal deeper meanings and linkages between different emergent themes.

RESULTS

Twenty dentists who worked in private practice environments were recruited to take part. The analysis revealed the following themes within the data: dentistry devalued, commercial influences on professional behavior, the effect of advertising and competition on dentistry, ethical selling, and the impacts of commercialism on consumers of dentistry.

CONCLUSIONS

Consumers of dentistry may only be superficially empowered by the commercialized context of private dental practice. Empowerment to decide which services to access and from whom does not address the inherent disparities that exist within the dentist-patient clinical relationship. Advertising and the active "selling" of oral health services are all designed to create dental consumers, not to empower them. While advertising might assist patients to understand available treatments, the primary objective of marketing is not health education. Increasing competition and consumer choice within dentistry may help to empower consumers of dental services but only if the dentist-patient relationship remains founded in altruistic intent, with the doctrine of "caveat emptor" (buyer beware) having no place within dentistry.

KNOWLEDGE TRANSFER STATEMENT

This research provides novel insights into how dentists experience the commercial context of private dental practice and how this is perceived to be both beneficial and detrimental to the consumers of dental services. This work will help to guide policy development to address the commercial determinants of oral health generated by the nature of commercialized dental practice environments.

Consumer-Facing Data, Information, And Tools: Self-Management Of Health In The Digital Age

Consumers have greater access to data, information, and tools to support the management of their health than ever before. While the sheer quantity of these resources has increased exponentially over the past decade, the accuracy of consumer-facing resources is variable, and the value to the individual consumer remains uncertain. In general, the quality of these resources has improved, mostly because of improvements in web and mobile technologies and efforts to restructure health care delivery to be more patient centered. We describe the major initiatives that have led to consumers' increased access to both their own health data and performance data for health care providers and hospitals. We explore how search engines and crowdsourced review websites help and hinder the dissemination of medically accurate information. We highlight emerging examples of websites and apps that enable consumers to make medical decisions more in concert with their preferences. We conclude by describing key limitations of consumer-facing resources and making recommendations for how they may best be curated and regulated.

The Engaged Patient: The Relevance of Patient-Physician Communication for Twenty-First-Century Health

The patient-doctor interaction has changed profoundly in the past decades. In reaction to paternalistic communication patterns, health policy makers have advocated for patient-centered care and shared decision-making. Although these models of medical communication remain still aspirational, patients have become more engaged in advocating for their own health in encounters with physicians. I argue that the engaged patient is a more accurate conceptualization of the changing role of the patient than patient consumerism, the empowered, or expert patient. I examine how the emergence of engaged patients influences the autonomy of health professionals, relates to the rise of the internet as an alternative source of medical information, centers the role of the patient-doctor interaction in public health epidemics, and contributes to health inequities.

[The specificity of moral aspects of activity of medical workers in Health Care of Russia]

The transformation of values and dissemination of consumerism ideology, associated with active implementation of market mechanisms of functioning in the Russian health care system, significantly affected processes of implementing moral aspects of activities of medical workers. The transition of physician and patient to buying and selling relationships initiated the situation when the life and health maintenance is considered not as an ultimate purpose of medical profession, but as a service supplied for particular fee. Moreover, quality of medical care supplied is considered as directly proportional to its cost. This fact results, from one hand, in corruption in health care system initiated by patients themselves because unofficial fee is significantly lower than the established one. From the other hand, it results in the fact that service supplied to patient for free in state polyclinics is provided untimely and not always is has needed quality due to lacking of necessary resources. As a result, the moral purpose of medical profession becomes minor, yielding to commercial relationships. However, these occurrences do not disprove the fact that the patient, in case of visiting physician, remains completely dependent on one's professionalism and responsibility, despite the abundance of private medical institutions and the formal freedom of choosing type of medical service and medical specialist providing it. The high moral culture was and continue to be an obligatory characteristic of successfulness and professionalism of physician. In the new economic conditions, it can become a competitive advantage, since every patient wishes to see in physician not only competent specialist, but also a person capable to empathize and responsibly treat with responsibility another life that was trusted to him.

Health Promotion That Saves People and the Planet and an Interview With Dr Sara Singer

Recently the Business Roundtable released a "Statement on the Purpose of a Corporation" which pronounced that alongside increasing shareholder value, businesses need to play a role in environmental and consumer protection. These stated "commitments" signed by 181 CEOs of leading companies include "supporting the communities in which we work," "investing in our employees," and "embracing sustainable practices." Skeptics will take a wait and see attitude about these business leaders' words and await more deeds, but others view this as an affirmation of an employer leadership philosophy that many have been championing for decades. For example, the book Building a Culture of Health: A New Imperative for Business examined the interface of social and business trends and argues that 4 pillars are needed if business is to accrue the advantages of leading with a culture of health. These pillars are community, consumer, employee, and environmental health. This editorial summarizes current initiatives and studies relating to these pillars and the Business Roundtable's commitments and includes an interview with Dr Sara Singer. Singer is an organizational development expert, business scholar, and coinvestigator of a national study that examines business engagement in the 4 pillars and sets a baseline for how involved businesses are in addressing social and health issues.

The patient-doctor relationship in the transnational healthcare context

Moving away from paternalism to more equal forms of interaction in the patient-doctor relationship has been seen in positive light by policymakers, patients' rights advocates and scholars alike. Nonetheless, against the background of commercialisation and consumerism, empirical research showcases how reduced asymmetries bring in tensions and friction between patients and doctors (Greenfield et al. 2012). This paper contributes to the discussion through the examination of the patient-doctor relationship in the niche setting of private transnational healthcare markets which involve patients travelling overseas for care and where commodification, consumerism and care go hand-in-hand. It is geographically focused on two large cities in South-Eastern Europe as settings where health care is provided to foreign patients - Athens and Istanbul - and empirically draws on qualitative interviews with doctors who run small/medium practices. The findings highlight that, despite excessive consumerism, power asymmetries are not mitigated but patient vulnerability shapes the patient-doctor relationship. In the transnational context, the patient faces an additional source of vulnerability: a condition of foreignness. As such, the findings stress that one relationship model (the consumerist) does not, per se, replace an older one (e.g. the Parsonian). Instead, the consumer-provider dimension co-exists with the client-expert, patient-doctor and, finally, host-guest relation.

Epigenetics in the public sphere: interdisciplinary perspectives

Despite the high public interest in epigenetics, few scholars have empirically investigated the forms, reasons and consequences of the public circulation of epigenetics. Using an original database focusing on 'lifestyle' or 'everyday' epigenetics, this article aims to promote an open-minded and interdisciplinary dialogue between the public appropriation of epigenetics and the current scientific state of the art. It raises three main questions: Are there any specific modes of circulation of epigenetics in the general public? Why does epigenetics seem so appealing to the public? Within the public repertoire of epigenetics, is it possible to identify some specific knowledge claims and, if so, given the current state of the art, what is their degree of accuracy? The article argues that the social diffusion of epigenetics frequently carries on beliefs and misconceptions about genetics and epigenetics. The social life of epigenetics fuels a collective 'illusion' of control and empowerment on the basis of which new markets expand. More unexpectedly, this article underlines the emergence of a new scientific culture, i.e. the 'scientifization' of the cultural appropriation of epigenetics. Our analysis can inform the scientific community about the current and evolving state of the public representation of epigenetics and help it frame outreach activities.

Community-consumerism: negotiating risk in online drug communities

This study explores the social organisation of risk within online drug-related communities. Drawing on in-depth interviews with participants from two Norwegian Internet drug forums, the paper illustrates how participation in such forums influenced notions of risk, and how it supported notions of participants as being informed, responsible and empowered. First, the forums facilitated an easy exchange of user-generated drug information, which helped members present themselves as informed and competent. Second, members used the communal resources on the forums to negotiate their drug-using identities, in which they resisted stigma and argued for a responsible drug-using identity. Third, the social inclusion and sense of community within the forums formed the basis for collective support, which helped empower those involved. Conceptualised as community-consumerism, these findings highlight the social mechanisms involved in the information self-sufficiency and decentralisation of authority on the Internet, in which members created an alternative frame of reference for drug use and associated health. The concept of community-consumerism offers a perspective on the social organisation of risk within online communities and ought to be of relevance for future studies on online health-related discourses, not only those related to drugs.

Mindful Eating (Not the Kind You Think) and an Interview With Dr Kevin Walker

Could it be that self-help concepts like mindfulness meditation have a short shelf life because they're just that, too much about the self and not enough about something far more important? This editorial describes Kevin Walker's research and his new book, "The Grand Food Bargain and the Mindless Drive for More." Walker's book shows why the dozens of federal and state agencies with a slice of accountability for food health and safety are predictably and routinely outgunned by the food industry with respect to influencing the public's health. Describing the dozens of interagency agreements relating to agriculture policies, Walker writes that "food safety in America is held together using the policy equivalent of baling wire and duct tape." Most health promotion professionals who consider the term mindful eating likely first think about principles that relate to being present and techniques that put you in closer touch with the flavors, colors, or textures of your food. In addition to focusing on how creamy a texture feels on our tongues, might advocacy for "mindful eating" have a more abiding impact if it brought with it a deep appreciation for how our food choices affect the health and sustainability of our communities and our Mother Earth? Changing food from an afterthought to a daily reminder about environmental sustainability is a multidimensional challenge that will require multisectoral partnerships and solutions.

The Possibilities and Limits of "Co-producing" Research

In this perspective paper, we explore the growing enthusiasm for "co-produced" research, focusing in particular on the United Kingdom's National Institute for Health Research's (NIHR) recent adoption of the term co-production. We consider how this interest in co-production is driven by concerns that patient and public involvement (PPI) in health research tends to be "tokenistic" and to reproduce power imbalances between researchers and lay contributors. We argue that these apparent implementation "barriers" or "inconsistencies" need to be understood in relation to the various elements that the institutionalisation of PPI brings together. We show how these elements are articulated in such a way that consumer, managerial, and performative logics and practices are dominant, resulting in limits being placed on the scope and forms of PPI, and the emergence of acts of recalcitrance and impression management. By considering the alternative discursive repertoires made available through co-production, we point to the possibilities co-production presents for moving beyond these dominant tendencies. We argue, however, that such possibilities need to be understood in relation to the constraints of the present. In doing so, we draw attention to the tenacity of the articulations that have historically constituted the institutionalisation of PPI.

Beyond Dr. Google: the evidence on consumer-facing digital tools for diagnosis

Over a third of adults go online to diagnose their health condition. Direct-to-consumer (DTC), interactive, diagnostic apps with information personalization capabilities beyond those of static search engines are rapidly proliferating. While these apps promise faster, more convenient and more accurate information to improve diagnosis, little is known about the state of the evidence on their performance or the methods used to evaluate them. We conducted a scoping review of the peer-reviewed and gray literature for the period January 1, 2014–June 30, 2017. We found that the largest category of evaluations involved symptom checkers that applied algorithms to user-answered questions, followed by sensor-driven apps that applied algorithms to smartphone photos, with a handful of evaluations examining crowdsourcing. The most common clinical areas evaluated were dermatology and general diagnostic and triage advice for a range of conditions. Evaluations were highly variable in methodology and conclusions, with about half describing app characteristics and half examining actual performance. Apps were found to vary widely in functionality, accuracy, safety and effectiveness, although the usefulness of this evidence was limited by a frequent failure to provide results by named individual app. Overall, the current evidence base on DTC, interactive diagnostic apps is sparse in scope, uneven in the information provided and inconclusive with respect to safety and effectiveness, with no studies of clinical risks and benefits involving real-world consumer use. Given that DTC diagnostic apps are rapidly evolving, rigorous and standardized evaluations are essential to inform decisions by clinicians, patients, policymakers and other stakeholders.

The Pink Underside: The Commercialization of Medical Risk Assessment and Decision-Making Tools for Hereditary Breast Cancer Risk

The growth of the Internet since the millennium has opened up a myriad of opportunities for education, particularly in medicine. Although those looking for health care information used to have to turn to a face-to-face doctor's visit, an immense library of medical advice is now available at their fingertips. The BRCA genetic predispositions (mutations of the BRCA1 and BRCA2 breast cancer genes) which expose men and women to greater risk of breast, ovarian, and other cancers can be researched extensively online. Several nonprofit organizations now offer online risk assessment and decision-making tools meant to supplement conversation with medical professionals, which in actuality are quickly replacing it. We argue here through a critical qualitative template analysis of several such tools that the discursive frameworks utilized are prone to fearmongering, commercialization, and questionable validity. Left unchecked, these assessment tools could do more harm than good in driving young women especially to take unnecessary extreme surgical action.

Shopping on the Public and Private Health Insurance Marketplaces: Consumer Decision Aids and Plan Presentation

BACKGROUND

The design of the Affordable Care Act's (ACA) health insurance marketplaces influences complex health plan choices.

OBJECTIVE

To compare the choice environments of the public health insurance exchanges in the fourth (OEP4) versus third (OEP3) open enrollment period and to examine online marketplace run by private companies, including a total cost estimate comparison.

DESIGN

In November-December 2016, we examined the public and private online health insurance exchanges. We navigated each site for "real-shopping" (personal information required) and "window-shopping" (no required personal information).

PARTICIPANTS

Public (n = 13; 12 state-based marketplaces and HealthCare.gov ) and private (n = 23) online health insurance exchanges.

MAIN MEASURES

Features included consumer decision aids (e.g., total cost estimators, provider lookups) and plan display (e.g., order of plans). We examined private health insurance exchanges for notable features (i.e., those not found on public exchanges) and compared the total cost estimates on public versus private exchanges for a standardized consumer.

RESULTS

Nearly all studied consumer decision aids saw increased deployment in the public marketplaces in OEP4 compared to OEP3. Over half of the public exchanges (n = 7 of 13) had total cost estimators (versus 5 of 14 in OEP3) in window-shopping and integrated provider lookups (window-shopping: 7; real-shopping: 8). The most common default plan orders were by premium or total cost estimate. Notable features on private health insurance exchanges were unique data presentation (e.g., infographics) and further personalized shopping (e.g., recommended plan flags). Health plan total cost estimates varied substantially between the public and private exchanges (average difference $1526).

CONCLUSIONS

The ACA's public health insurance exchanges offered more tools in OEP4 to help consumers select a plan. While private health insurance exchanges presented notable features, the total cost estimates for a standardized consumer varied widely on public versus private exchanges.

Alternative Medicine in North America: A Christian Pastoral Response

Complementary and Alternative Medicine is popular among North Americans. However, there are many areas of concern, both scientific and spiritual, about its appropriate use. Those involved in pastoral care may be consulted for advice and therefore should be knowledgeable about Complementary and Alternative Medicine. This paper reviews and evaluates it from a Christian perspective, and offers suggestions for a pastoral response.

Patients and consumers

Successive governments of the UK have strongly supported two policies: an NHS free at the point of delivery, and the encouragement of consumer choice. It was natural for governments to think that amalgamating the policies would increase patient satisfaction, improve efficiency and save money. There are many reasons why this has not been well-received by patients and doctors and has not saved money, but the underlying problem is that there is a conceptual misfit between healthcare as public policy and as individual responsibility. Patients in the NHS cannot become consumers and doctors cannot become suppliers of goods and services.

Thinking with care infrastructures: people, devices and the home in home blood pressure monitoring

The growing consumer market in health monitoring devices means that technologies that were once the preserve of the clinic are moving into spaces such as homes and workplaces. We consider how one such device, blood pressure monitors, comes to be integrated into everyday life. We pursue the concept of 'care infrastructure', drawing on recent scholarship in STS and medical sociology, to illuminate the work and range of people, things and spaces involved in self-monitoring. Drawing on a UK study involving observations and interviews with 31 people who have used a consumer blood pressure monitor, we apply the concept beyond chronic illness, to practices involving consumer devices - and develop a critical account of its value. We conclude that the care infrastructure concept is useful to highlight the socio-material arrangements involved in self-monitoring, showing that even for ostensibly personal devices, monitoring may be a shared practice that expresses care for self and for others. The concept also helps draw attention to links between different objects and spaces that are integral to the practice, beyond the device alone. Care infrastructure draws attention to the material, but ensures that analytic attention engages with both material and social elements of practice and their connections.

Ideology and resistance in young people's experiences of health under the 'imperative of enjoyment'

This article explores upper secondary school students' understandings and experiences of health in Denmark, where public health promotions appeal to pleasure. Health promotion thereby taps into capitalist society's 'imperative of enjoyment', which reproduces ideological fantasies about the fulfilment of desires through the consumption of health. Based on qualitative empirical material produced through participatory and visual methods during fieldwork conducted in 2012, the analysis shows that relations between healthiness and pleasure are conflated and paradoxical: the students try to fit into society not only by being healthy, but also by enjoying healthiness; but if they fail pleasure, they fail healthiness and experience a loss of individual social value. Although the 'enjoyment society' has the potential to produce individualisation and marginalisation, the students in this study actively attempt to subvert its double bind by insisting that collective experiences with peers constitutes the foundation of enjoyable healthiness. Nevertheless, public health promotions that reproduce enjoyment as an imperative, even in the pursuit of health, risk reinforcing young people's resistance towards health.

Who Uses a Price Transparency Tool? Implications for Increasing Consumer Engagement

Despite the recent proliferation of price transparency tools, consumer use and awareness of these tools is low. Better strategies to increase the use of price transparency tools are needed. To inform such efforts, we studied who is most likely to use a price transparency tool. We conducted a cross-sectional study of use of the Truven Treatment Cost Calculator among employees at 2 large companies for the 12 months following the introduction of the tool in 2011-2012. We examined frequency of sign-ons and used multivariate logistic regression to identify which demographic and health care factors were associated with greater use of the tool. Among the 70 408 families offered the tool, 7885 (11%) used it at least once and 854 (1%) used it at least 3 times in the study period. Greater use of the tool was associated with younger age, living in a higher income community, and having a higher deductible. Families with moderate annual out-of-pocket medical spending ($1000-$2779) were also more likely to use the tool. Consistent with prior work, we find use of this price transparency tool is low and not sustained over time. Employers and payers need to pursue strategies to increase interest in and engagement with health care price information, particularly among consumers with higher medical spending.

The Roles of Cost and Quality Information in Medicare Advantage Plan Enrollment Decisions: an Observational Study

BACKGROUND

To facilitate informed decision-making in the Medicare Advantage marketplace, the Centers for Medicare & Medicaid Services publishes plan information on the Medicare Plan Finder website, including costs, benefits, and star ratings reflecting quality. Little is known about how beneficiaries weigh costs versus quality in enrollment decisions.

OBJECTIVE

We aimed to assess associations between publicly reported Medicare Advantage plan attributes (i.e., costs, quality, and benefits) and brand market share and beneficiaries' enrollment decisions.

DESIGN, SETTING, PARTICIPANTS

We performed a nationwide, beneficiary-level cross-sectional analysis of 847,069 beneficiaries enrolling in Medicare Advantage for the first time in 2011.

MAIN MEASURES

Matching beneficiaries with their plan choice sets, we used conditional logistic regression to estimate associations between plan attributes and enrollment to assess the proportion of enrollment variation explained by plan attributes and willingness to pay for quality.

KEY RESULTS

Relative to the total variation explained by the model, the variation in plan choice explained by premiums (25.7 %) and out-of-pocket costs (11.6 %) together explained nearly three times as much as quality ratings (13.6 %), but brand market share explained the most variation (35.3 %). Further, while beneficiaries were willing to pay more in total annual combined premiums and out-of-pocket costs for higher-rated plans (from $4,154.93 for 2.5-star plans to $5,698.66 for 5-star plans), increases in willingness to pay diminished at higher ratings, from $549.27 (95 %CI: $541.10, $557.44) for a rating increase from 2.5 to 3 stars to $68.22 (95 %CI: $61.44, $75.01) for an increase from 4.5 to 5 stars. Willingness to pay varied among subgroups: beneficiaries aged 64-65 years were more willing to pay for higher-rated plans, while black and rural beneficiaries were less willing to pay for higher-rated plans.

CONCLUSIONS

While beneficiaries prefer higher-quality and lower-cost Medicare Advantage plans, marginal utility for quality diminishes at higher star ratings, and their decisions are strongly associated with plans' brand market share.

Patient Use of Cost and Quality Data When Choosing a Joint Replacement Provider in the Context of Reference Pricing

Health plans are encouraging consumerism among joint replacement patients by reporting information on hospital costs and quality. Little is known about how the proliferation of such initiatives impacts patients’ selection of a surgeon and hospital. We performed a qualitative analysis of semistructured interviews with 13 patients who recently received a hip or knee replacement surgery. Patients focused on the choice of a surgeon as opposed to a hospital, and the surgeon choice was primarily made based on reputation. Most patients had long-standing relationships with an orthopedic surgeon and tended to stay with that surgeon for their replacement. Despite growing availability of cost and quality information, patients almost never used such information to make a decision.

The role of material deprivation and consumerism in the decisions to engage in transactional sex among young people in the urban slums of Blantyre, Malawi

Transactional sex has been associated with a high risk of HIV acquisition and unintended pregnancy among young women in urban slums in sub-Saharan Africa. However, few studies have explored the structural drivers of transactional sex from the perspective of both genders in these settings. This paper explores how young men and women understand the factors that lead to transactional sex among their peers, and how deprivation of material resources (housing, food and health care access) and consumerism (a desire for fashionable goods) may instigate transactional sex in the urban slums of Blantyre, Malawi. Data from 5 focus group discussions and 12 in-depth interviews undertaken with a total of 60 young men and women aged 18-23 years old, conducted between December 2012 and May 2013, were analysed using anticipated and grounded codes. Housing and food deprivation influenced decisions to engage in transactional sex for both young men and women. Poor health care access and a desire for fashionable goods (such as the latest hair or clothing styles and cellular phones) influenced the decisions of young women that led to transactional sex. Interventions that engage with deprivations and consumerism are essential to reducing sexual and reproductive health risks in urban slums.

"Nutritional Wastelands": Vending Machines, Fast Food Outlets, and the Fight over Junk Food in Canadian Schools

In light of a growing obesity crisis among children and concern about junk food in schools, this article investigates the attempt by food and beverage companies to gain entry into Canadian schools. Focusing in particular on the introduction of fast-food franchises in cafeterias and on school boards' secret exclusivity deals with soft drink manufacturers in the 1990s, it examines how and why this process occurred, public reactions to it, and government responses. Placing this phenomenon within a larger pattern of commercialization in North American schools, it argues that long-lasting reforms require government intervention and enforcement.

Mixing metaphors in pharmacy education is a bad solution for students

Scholarly discussion has recently been directed toward the negative effects of consumerism in pharmacy education. Frequently in these discussions, the metaphor of student-as-customer is cited as an indicator of such consumer mentality. However, the customer metaphor is more deeply entangled in the thinking on this matter than has been acknowledged, even for those who roundly criticize its use. A richer understanding of the power of metaphor and of the fiducial obligations that underlie professionalism can help to create educational paradigms more likely to meet the best interests of students, faculty members, and the general public.

Academic entitlement and academic performance in graduating pharmacy students

OBJECTIVES

To determine a measurable definition of academic entitlement, measure academic entitlement in graduating doctor of pharmacy (PharmD) students, and compare the academic performance between students identified as more or less academically entitled.

METHODS

Graduating students at a private health sciences institution were asked to complete an electronic survey instrument that included demographic data, academic performance, and 2 validated academic entitlement instruments.

RESULTS

One hundred forty-one of 243 students completed the survey instrument. Fourteen (10%) students scored greater than the median total points possible on 1 or both of the academic entitlement instruments and were categorized as more academically entitled. Less academically entitled students required fewer reassessments and less remediation than more academically entitled students. The highest scoring academic entitlement items related to student perception of what professors should do for them.

CONCLUSION

Graduating pharmacy students with lower levels of academic entitlement were more academically successful than more academically entitled students. Moving from an expert opinion approach to evidence-based decision-making in the area of academic entitlement will allow pharmacy educators to identify interventions that will decrease academic entitlement and increase academic success in pharmacy students.

Narcissism and consumer behaviour: a review and preliminary findings

We review the literature on the relation between narcissism and consumer behavior. Consumer behavior is sometimes guided by self-related motives (e.g., self-enhancement) rather than by rational economic considerations. Narcissism is a case in point. This personality trait reflects a self-centered, self-aggrandizing, dominant, and manipulative orientation. Narcissists are characterized by exhibitionism and vanity, and they see themselves as superior and entitled. To validate their grandiose self-image, narcissists purchase high-prestige products (i.e., luxurious, exclusive, flashy), show greater interest in the symbolic than utilitarian value of products, and distinguish themselves positively from others via their materialistic possessions. Our review lays the foundation for a novel methodological approach in which we explore how narcissism influences eye movement behavior during consumer decision-making. We conclude with a description of our experimental paradigm and report preliminary results. Our findings will provide insight into the mechanisms underlying narcissists’ conspicuous purchases. They will also likely have implications for theories of personality, consumer behavior, marketing, advertising, and visual cognition.

Complexity, public reporting, and choice of doctors: a look inside the blackest box of consumer behavior

Health care consumers often make choices that are imperfectly informed and inconsistent with their expressed preferences. Past research suggests that these shortcomings become more pronounced as choices become more complex, through either additional options or more performance metrics. But it is unclear why this is true: Consumer choice remains a "black box" that research has scarcely illuminated. In this article, we identify four pathways through which complexity may impair consumer choice. We examine these pathways using data from an experiment in which consumers (hypothetically) selected a primary care physician. Some of the loss of decision quality accompanying more complex choice sets can be explained by consumers' skills and decision-making style, but even after accounting for these factors, complexity undermines the quality of decision making in ways that cannot be fully explained. We conclude by discussing implications for report designers, sponsors, and policy makers aspiring to promote consumer empowerment and health care quality.

The Complexities of 'Consumerism': Choice, Collectivism and Participation within Britain's National Health Service, c.1961-c.1979

This article explores the overlapping and conflicting points of contact between 'consumerism', collectivism and participation in Britain's National Health Service during a period of relatively well-funded expansion during the economic 'golden age' of the 1960s and 1970s. Despite recent neo-liberal attempts to define 'consumerism' around the wishes and choices of the individual, and to conceptualise areas such as individual hospital referrals as particularly 'consumerist', this article demonstrates that collective provision, the protection of disadvantaged groups and the concept of 'participatory' citizen involvement were all alternative meanings of the concept during this period, co-existing uneasily with the competitive concepts that have become more familiar since the late 1980s. This insight is then utilised to show how health care debates today might become better informed, ignoring extreme claims for all three concepts and focusing instead on a theoretically informed but ultimately empirical grasp of constant flux in any health care system.

Repositioning the patient: patient organizations, consumerism, and autonomy in Britain during the 1960s and 1970s

This article explores how and why the patient came to be repositioned as a political actor within British health care during the 1960s and 1970s. Focusing on the role played by patient organizations, it is suggested that the repositioning of the patient needs to be seen in the light of growing demands for greater patient autonomy and the application of consumerist principles to health. Examining the activities of two patient groups-the National Association for the Welfare of Children in Hospital (NAWCH) and the Patients Association (PA)-indicates that while such groups undoubtedly placed more emphasis on individual autonomy, collective concerns did not entirely fall away. The voices of patients, as well as the patient, continued to matter within British health care.

Can Consumers Control Health-Care Costs?

The ultimate aim of health care policy is good care at good prices. Managed care failed to achieve this goal through influencing providers, so health policy has turned to the only market-based option left: treating patients like consumers. Health insurance and tax policy now pressure patients to spend their own money when they select health plans, providers, and treatments. Expecting patients to choose what they need at the price they want, consumerists believe that market competition will constrain costs while optimizing quality. This classic form of consumerism is today's health policy watchword. This article evaluates consumerism and the regulatory mechanism of which it is essentially an example - legally mandated disclosure of information. We do so by assessing the crucial assumptions about human nature on which consumerism and mandated disclosure depend. Consumerism operates in a variety of contexts in a variety of ways with a variety of aims. To assess so protean a thing, we ask what a patient's life would really be like in a consumerist world. The literature abounds in theories about how medical consumers should behave. We look for empirical evidence about how real people actually buy health plans, choose providers, and select treatments. We conclude that consumerism is unlikely to accomplish its goals. Consumerism's prerequisites are too many and too demanding. First, consumers must have choices that include the coverage, care-takers, and care they want. Second, reliable information about those choices must be available. Third, information must be put before consumers in helpful ways, especially by doctors. Fourth, the information must be complete and comprehensible enough for consumers to use it. Fifth, consumers must understand what they are told. Sixth, consumers must actually analyze the information and do so well enough to make good choices. Our review of the empirical evidence concludes that these pre-requisites cannot be met reliably most of the time. At every stage people encounter daunting hurdles. Like so many other dreams of controlling costs and giving patients control, consumerism is doomed to disappoint. This does not mean that consumerist tools should never be used. If all that consumerism accomplished is to raise general cost-consciousness among patients, still, it could make a substantial contribution to the larger cost-control efforts by insurers and the government. Once patients bear responsibility for much day-to-day spending on their health needs, they should be increasingly sensitized to the difficult trade-offs that abound in medical care and might even begin to understand that public and private health insurers have a legitimate interest in controlling medical spending.

Can we consume our way out of climate change? A call for analysis

The problem of climate change is analyzed as a manifestation of economic growth, and the steady-state economy of ecological economics is proposed as a system-wide solution. Four classes of more specific solutions are described. In the absence of analysis, cultural inertia will bias solutions in favor of green consumption as a generalized solution strategy. By itself, green consumption is a flawed solution to climate change because it perpetuates or even accelerates economic growth that is incompatible with a sustainable culture. Addressing climate change requires an integration of regulatory, energy efficiency, skill-based, and dissemination solutions. Behavioral scientists are encouraged to work with others in ecological economics and other social sciences who recognize cultural reinvention as a means of achieving sustainability.

Demanding patient or demanding encounter?: A case study of a cancer clinic

This paper explores the sociological relevance of demanding encounters between doctors and patients. Borrowing from Potter and McKinlay's [(2005). From a relationship to encounter: an examination of longitudinal and lateral dimensions in the doctor-patient relationship. Social Science & Medicine, 61, 465-479] reconceptualization of the doctor-patient relationship, we suggest an analytic shift away from 'demanding patients' toward 'demanding encounters'. Such a shift places provider-patient conflict within a broader socio-cultural context, emphasizing constraints facing both doctor and patient as they interact in a clinical setting. Specifically, through an ethnographic study of doctor-patient interactions at the oncology clinic of a US University Hospital, we examine the respective influences of new information technologies and patient consumerism in the production of demanding encounters in oncology. Findings suggest that these interconnected socio-cultural realities, in tandem with patient tendencies to challenge physician judgment or expertise, play a role in demanding encounters. We conclude by considering the implications of demanding encounters for doctors, patients and healthcare organizations.

When there is no doctor: reasons for the disappearance of primary care physicians in the US during the early 21st century

Primary care doctoring in the USA today (2007) bears little resemblance to what existed just 25 years ago. We focus on what is likely to unfold in the U.S. over the next several decades and suggest that by about 2025, primary care doctoring in the U.S. could be rare, possibly unrecognizable and even nonexistent. Seven reasons for the probable disappearance of primary care doctoring are identified. The most important reason is medicine's loss of state sponsorship: the U.S. state has shifted from a pluralistic orientation to a New Right approach. With less state protection medicine has become even more attractive for private interests. Six additional reasons include: (1) the epidemiologic transition (chronic diseases reduce doctors to a palliative role and monitoring of incurable conditions); (2) the overcrowded health care playing field (non-physician clinicians are supplanting primary care doctors); (3) the unintended consequences of clinical guidelines (the art of doctoring is reduced to formulaic tasks, easily codified and performed by non-physician clinicians); (4) the demise of the in-person examination (in-person examination is being replaced by impersonal testing); (5) primary care doctoring is becoming unattractive (physicians are dissatisfied, alienated and experiencing income declines. Applications by U.S. graduates to primary care programs continue to decline); (6) patients are not what they used to be (Internet access and Direct to Consumer advertising are changing the doctor-patient relationship). By 2025, many everyday illnesses in the U.S. will be managed via the Internet or by non-physician clinicians working out of retail clinics. Some medical problems will still require a physician's attention, but this will be provided by specialists rather than by primary care doctors (general practitioners).

Choice and responsibility in the NHS

Patient choice is becoming the centre of health policy in the UK and other countries. But there is ambiguity about what choice means. As the term is used in everyday life, choice is the foundation of the doctrine of patient consent. The doctor is responsible for choosing appropriate treatment, and the patient is responsible for choosing (for consenting to or refusing) what is offered and accepts responsibility for that choice. That simple and ethically acceptable doctrine is being replaced politically by consumerist choice. But consumerism in healthcare is incompatible with a publicly funded service. Moreover, consumerism changes the locus of responsibility from the doctor to the consumer (the patient). The doctor will cease to have the values of a professional and will become simply an agent of the patient's demands.

Matching resources to treatment decisions for patients with acute coronary syndromes

Multiple dynamic forces are having an impact on the way cardiovascular disease is treated today and will be in the future. These forces include extended life expectancy, decreased disability, and accelerated improvement in the effectiveness of medical technology. All of these forces will lead to a predictable increase in health care costs. Cardiologists must also be cognizant of the rise in health care consumerism; patients are assuming a larger role in decisions about their medical care and treatment. All of these factors are driving the climate of evidence-based medicine, particularly in the cardiovascular field. Payers and the government are beginning to require the clinical community to define quality. In turn, these third parties are beginning to measure quality as defined by the profession and to hold providers accountable for the quality of what they do. Although the frontier of genetic prediction in therapeutics will serve as an intellectual focus for bringing these issues closer to the forefront in cardiovascular medicine, the fundamental provision of value in health care (high quality at reasonable cost) cannot wait on genomics. Because the amount of evidence in acute coronary syndromes (ACS) exceeds other areas of medicine, therapies for ACS will undergo increasingly intense scrutiny.

Physicians' opinions on patients' requests for specific treatments and examinations

OBJECTIVE

The number of technologies used in health care is growing, patients' educational level has risen, health and drug information is increasingly available and patients today are actively looking for information from different sources. The aim of the study was to investigate physicians' opinions on patients' requests for specific treatments and examinations.

DESIGN

The data were gathered as part of an annual physician's survey sent to all Finnish physicians (n=16,698) by the Finnish Medical Association in March 2002. The response rate was 85% (n=14,157). Physicians involved in clinical work were selected for this study (n=12,255).

RESULTS

Half (53%, n=6,521) of the clinicians reported either 'very often', or 'often' receiving requests from patients for specific treatments or examinations, and of them, 76% (n=4,972) reported an increase in such requests. The younger clinicians received more often patient requests. Women physicians, those working in health centres, and non-specialized clinicians reported more experience of, and an increase in patients making requests. Of those clinicians who received patient requests 'very often' or 'often', 24% (n=1,595) considered such requests as having a positive, and 43% (n=2,808) a negative, effect on patient care and interaction; clinicians who did not receive many patient requests had similar opinions. Older, men, those working in private practice and specialized clinicians had a more positive attitude towards such requests than other clinicians. The reasons given for the positive and negative opinions were varied.

CONCLUSIONS

Active patients (consumer patients) are a reality in the Finnish health care system. Physicians have varying opinions on this phenomenon.

Five cases, four actors and a moral: lessons from studies of contested treatment decisions

The case of Jaymee Bowen (child B) illustrated the conflict that may arise over treatment decisions in the National Health Service (NHS). This article reviews four further cases involving disagreement between patients and families on the one hand, and health authorities on the other, and a fifth case in which a health authority questioned the treatment decision of a medical specialist. The cases illustrate the rise of consumerism in health care and the challenge for health authorities in weighing the claims of individual patients against the needs of communities. They also demonstrate the increasing role of lawyers and the courts in resolving disputes over treatment decisions. Clinicians were closely involved in all cases, both in recommending treatment options and in serving as independent advisers when disputes arose. The findings presented here indicate that there is a need to strengthen the process of decision-making in cases of this kind and to make greater use of evidence in informing decisions. In future, decision-making needs to be characterized by openness, reason giving, an appeals procedure and regulation of the process to ensure that these conditions are met. The funders of health care also need to consider each individual in his or her own right while also using their resources for the benefit of the population as a whole.

The role of doctors, patients and managers in priority setting decisions: lessons from the 'Child B' case

The difficulties in treating patients with life threatening illnesses were highlighted by the case of Jaymee Bowen, a 10-year-old girl with leukaemia who was refused funding for a second bone marrow transplant in 1995. Jaymee's case was widely reported at the time and came to epitomize the dilemmas of rationing in the United Kingdom's National Health Service. In reality, the paediatricians who had cared for Jaymee based their decision on clinical rather than financial considerations, and the media reporting of the case failed to reflect the complexities of the issues involved. The case also demonstrated the difficulties of determining the best interests of children and of obtaining their consent to treatment. There were disagreements between Jaymee's father and the paediatricians who had treated her about how her best interests could be served and this led to a breakdown of trust and the search for further opinions. This highlighted the rise of consumerism in health care and the challenge to doctors and managers to justify their decisions and to give reasons for these decisions. The common theme in Jaymee's story is the need for greater openness in decisions on priority setting and stronger safeguards for patients.