Lazare Benaroyo

Competence in Mental Health Care: A Hermeneutic Perspective

In this paper we develop a hermeneutic approach to the concept of competence. Patient competence, according to a hermeneutic approach, is not primarily a matter of being able to reason, but of being able to interpret the world and respond to it. Capacity should then not be seen as theoretical, but as practical. From the perspective of practical rationality, competence and capacity are two sides of the same coin. If a person has the capacity to understand the world and give meaning to the situation, he or she is able to make decisions, and is thus competent. People can fail in the area of practical rationality. They can feel ill at ease, uncomfortable or not at home in the situation. Under such conditions, they appear as incompetent, and urge caregivers to respond in such a way that their competence can be raised. The issue is not how to measure their incompetence, but how to help them to become more competent, that is to get a practical grip on their situation and to be able to live out their lives in such a way that they develop their identity in relations with others. From a hermeneutic point of view, assessing a patients capacity implies focusing on the patients way of meaning making and regarding her behavior from the perspective of practical rationality. The focus should not be on the assessment as a matter of fact, but on improving capacity. This requires allowing the patient to experience the world meaningfully and affording her, in the context of a supportive and trustful institutional environment, the possibility of developing a personal narrative where her choices are expressed verbally or non-verbally.

Ethics and adolescent care: an international perspective.

Purpose of review This update reviews the concepts underlying ethical issues in various contexts and countries, highlighting the evolution in the use of the core values underpinning the field and practice of bioethics as applied to healthcare. Recent findings It stresses the specific position of the adolescent as being a unique individual searching for autonomy and, most of the time, being competent to make decisions regarding the adolescents own health. It briefly outlines the principles of a ‘deliberative’ approach in which the practitioner, while keeping in mind the legal context of the country where the practitioner is working, assesses to what extent the adolescent can be considered as competent, and then discusses with the adolescent the medical and psychosocial aspects of the various actions to be taken in a situation, as well as the basic ethical values linked with each of the various options available. The deliberation can involve relevant stakeholders, provided the issues concerning confidentiality have been fully discussed with the adolescent. Summary This process forces the practitioner, the adolescent patient and those who care for the adolescent patient to look outside their usual frameworks and make a decision that is in the best interest of the young person, and is informed by various ethical values.

Evaluation of clinical ethics support services and its normativity

Evaluation of clinical ethics support services (CESS) has attracted considerable interest in recent decades. However, few evaluation studies are explicit about normative presuppositions which underlie the goals and the research design of CESS evaluation. In this paper, we provide an account of normative premises of different approaches to CESS evaluation and argue that normativity should be a focus of considerations when designing and conducting evaluation research of CESS. In a first step, we present three different approaches to CESS evaluation from published literature. Next to a brief sketch of the well-established approaches of ‘descriptive evaluation’ and ‘evaluation of outcomes’, we will give a more detailed description of a third approach to evaluation—‘reconstructing quality norms of CESS’—which is explicit about the normative presuppositions of its research (design). In the subsequent section, we will analyse the normative premises of each of the three approaches to CESS evaluation. We will conclude with a brief argument for more sensitivity towards the normativity of CESS and its evaluation research.

Ethical issues in nutrition support of severely disabled elderly persons: a guide for health professionals.

Providing or withholding nutrition in severely disabled elderly persons is a challenging dilemma for families, health professionals, and institutions. Despite limited evidence that nutrition support improves functional status in vulnerable older persons, especially those suffering from dementia, the issue of nutrition support in this population is strongly debated. Nutrition might be considered a basic need that not only sustains life but provides comfort as well by patients and their families. Consequently, the decision to provide or withhold nutrition support during medical care is often complex and involves clinical, legal, and ethical considerations. This article proposes a guide for health professionals to appraise ethical issues related to nutrition support in severely disabled older persons. This guide is based on an 8-step process to identify the components of a situation, analyze conflicting values that result in the ethical dilemma, and eventually reach a consensus for the most relevant plan of care to implement in a specific clinical situation. A vignette is presented to illustrate the use of this guide when analyzing a clinical situation.

Financial incentives to improve organ donation: what is the opinion of the Vaud French-speaking population?

BACKGROUND With the increase of the organ shortage, several authors assume that financial incentives would improve organ donation rates and fill the unbalance between the demand and the organs available for transplant medicine. This line of argument has been criticised with people arguing that an exchange of money for organs would violate the legal and the ethical principle of gratuity, decrease voluntarism and increase the body parts commodification phenomena. PURPOSE Switzerland is often highlighted as having under-average organ donation rates compared to other European countries. In this paper we investigate the opinions of the Vaud French-speaking population concerning direct, indirect and non financial incentives in order to assess their opinions and anticipate the further debate. METHODS As part of a broad survey about the organ donation decision-making process, questions about incentives for both living and deceased organ donation were addressed to Vaud inhabitants and physicians. RESULTS The data collected showed that respondents were opposed to rewarding both living and deceased organ donation. The analysis of positive answers showed that indirect and non financial incentives were the most likely choice to acknowledge the donors act. People in critical financial situations preferred direct financial incentives. CONCLUSIONS These results showed that altruism and gratuity were key-values in the organ donation and transplantation social perceptions of the respondents. Thus, we assume that introducing financial incentives could tarnish the image of transplant medicine. Nevertheless, further studies are needed to evaluate if their introduction would improve the organ donation rates or decrease voluntarism.

Rudolf Virchow and the scientific approach to medicine

Rudolf Virchow proceeded to rebuild pathology by stating a physiological definition of disease and by introducing the cell theory. To him, disease is a phenomenon of life and must be studied in relation to life processes. He therefore undertook researches in pathological physiology which he hoped might prove of therapeutic value. These researches were based on a scientific methodology combining critical observation and experiment with an equally cautious and critical employment of working hypotheses. This article presents methodological and epistemological dimensions pertaining to Virchows scientific approach to medicine, which formulate the standards of our present-day medical methodology.

L'Unité d'éthique du CHUV de Lausanne: Pour une éthique immergée dans la pratique clinique

Pour une prise en charge adequate, ce qui releve de l’humain est tout aussi important que ce qui est donne par la technique. Lazare Benaroyo presente l’approche du soin telle qu’elle est developpee par l’Unite d’ethique du Centre hospitalier universitaire Vaudois de Lausanne (CHUV) : une visee qui englobe l’agir technique et l’agir relationnel.

Genèse d'un paradoxe clinique : l'institution de l'assurance maladie en Allemagne

Resume Cet article etudie la reaction du corps medical a l’introduction du systeme d’assurance sociale en Allemagne. Les arguments avances par de nombreux medecins de l’epoque de Weimar cherchaient a montrer que l’institution de l’assurance maladie obligatoire, inextricablement liee des le debut a des enjeux economiques et sociaux, etait imperceptiblement devenue un facteur de normalisation sociale du traitement des malades, risquant de prendre le pas sur l’ideal de guerison hippocratique de soumettreles medecins praticiens a des injonctions paradoxales au cœur meme de leurs pratiques. En rappelant ces arguments, cette etude souhaite eclairer l’envergure ethico-politique d’importants enjeux cliniques lies a l’institutionnalisation de l’assurance maladie, qui semblent aujourd’hui sous-estimes lors des debats contemporains sur le systeme d’assurances sociales.

Suffering, Time, Narrative, and the Self

This paper explores how temporality, narrative and the self are linked in the experience of suffering. It aims at understanding the extent to which personal identity may be affected by illness and suffering.