Catherine M. Giroux, Aliki Thomas, André Bussières
et al.
Abstract Objective Learning health systems (LHS) may improve healthcare access, innovation, coordination, continuity and quality. To ensure implementation success, healthcare organizations must be able to assess their current readiness to adopt an LHS approach; however, there is a paucity of LHS-specific readiness tools in the extant literature. Thus, the overarching aim of this study was to map the depth and breadth of LHS literature to identify the domains and items, alongside barriers, facilitators, implementation strategies and competencies relevant to include in an LHS readiness tool. Methods A scoping review informed by Arksey and O’Malley’s framework and updates proposed by Levac et al. was employed. Scopus, MEDLINE, Embase, CINAHL, PsychINFO, Education Source and Business Source Complete were searched from inception to May 2024. English or French publications that addressed the definitions, frameworks, competencies, barriers and facilitators of an LHS were eligible. Results The bibliographic database search and screening process yielded 90 articles, published between 2007 and 2024. A total of 72 articles defined LHS, with most emphasizing continuous learning cycles, evidence integration, infrastructure and stakeholder engagement. In addition, 56 articles presented 21 frameworks (educational, logic, maturity, organizational, equity and implementation), and 50 described key domains, including the D2K–K2P–P2D cycle, core values, and leadership, governance, and data infrastructure. Barriers to implementation included limited resources, unsupportive culture, poor interoperability and ethical challenges, while facilitators were strong leadership, shared purpose, robust partnerships and supportive policies. Identified competencies spanned research, informatics, quality improvement, systems science, engagement and ethics, with educational strategies ranging from collaboratives and training programs to graduate curricula and peer learning. Readiness and maturity assessments were discussed in 28 articles, but only a few operationalized these concepts. No specific LHS readiness assessments were identified. Conclusions Current readiness tools derived from quality-improvement contexts may be helpful but not sufficiently specific for assessing healthcare organizations’ readiness to implement an LHS approach. This review identified important barriers, facilitators, and strategies related to the collective behaviour change required to implement an LHS approach that should be considered in the future development of an LHS readiness assessment.
The purpose of the study is to evaluate the extent of corruption in the South African environment. The systematic organization of scholarly sources and methods for combating corruption shows that because it jeopardizes the integrity of a respectable government, corruption generally opposes accountability and the rule of law. Anti-corruption initiatives in the nation are still hampered by several issues, notwithstanding efforts to eradicate corruption. The article explores explicitly that there are various factors causing corruption to exist despite all measures. These factors are political interference, resource constraints, lack of accountability, complex bureaucracy, nepotism and patronage, inadequate legal framework, cultural factors, economic factors, and global factors. Investigation in the paper is conducted in the following logical sequence: contextual framework of corruption in the country is explained during various timeframes, and after that, a theoretical framework is discussed. The research methodology is stated that is applied to gather information for this article. The methodology used is qualitative and a comprehensive literature review was conducted to collect information. The study made use of various journal articles, books, legislative frameworks, and official records of the Auditor-General and Public Service Commission to obtain relevant information. The data was assessed through documents and conceptual analysis. The findings indicate that, despite anti-corruption laws, policies, and organizations, South Africa still confronts a variety of significant obstacles to corruption. Political leaders who use their connections to further their own interests may be the ones to foster an environment of unethical governance, which makes weak governance one of the most annoying obstacles of all. The article’s conclusion suggests that reducing corruption requires a strong emphasis on social accountability, public engagement, and citizen participation. These are excellent strategies, but sometimes they are not implemented or applied consistently. To reduce corruption, it is advised to inculcate moral principles at all governmental and governed levels to ensure reciprocal accountability.
Adriano Koshiyama, Emre Kazim, Philip Treleaven
et al.
Business reliance on algorithms is becoming ubiquitous, and companies are increasingly concerned about their algorithms causing major financial or reputational damage. High-profile cases include Google’s AI algorithm for photo classification mistakenly labelling a black couple as gorillas in 2015 (Gebru 2020 In The Oxford handbook of ethics of AI, pp. 251–269), Microsoft’s AI chatbot Tay that spread racist, sexist and antisemitic speech on Twitter (now X) (Wolf et al. 2017 ACM Sigcas Comput. Soc. 47, 54–64 (doi:10.1145/3144592.3144598)), and Amazon’s AI recruiting tool being scrapped after showing bias against women. In response, governments are legislating and imposing bans, regulators fining companies and the judiciary discussing potentially making algorithms artificial ‘persons’ in law. As with financial audits, governments, business and society will require algorithm audits; formal assurance that algorithms are legal, ethical and safe. A new industry is envisaged: Auditing and Assurance of Algorithms (cf. data privacy), with the remit to professionalize and industrialize AI, ML and associated algorithms. The stakeholders range from those working on policy/regulation to industry practitioners and developers. We also anticipate the nature and scope of the auditing levels and framework presented will inform those interested in systems of governance and compliance with regulation/standards. Our goal in this article is to survey the key areas necessary to perform auditing and assurance and instigate the debate in this novel area of research and practice.
George-Dumitru Constantin, Crisanta-Alina Mazilescu, Teodora Hoinoiu
et al.
This study investigated the attitude of Romanian medical students and doctors toward business ethics by measuring the preference for a particular ethical philosophy, namely, the preference for Machiavellianism, moral objectivism, social Darwinism, ethical relativism, and legalism. At the same time, this study aimed to explore the influence of sex, age, and ethics education on the attitude toward business ethics. The data collection was performed using a voluntary self-administered online survey including the Attitudes Toward Business Ethics Questionnaire (ATBEQ) instrument. Our findings show that the values based on which Romanian medical students and doctors make business decisions belong predominantly to the moral objectivism philosophy, which is grounded on rational actions based on a set of objective moral standards.
The aim of this paper is to show that business entities that apply ethical principles in their business, gain a good reputation on the market and trust in the quality of their product. Thus, it is known that the business entity is responsible, which enables it to fulfill the basic goal of business, which is to make a profit. The subject of research in this paper is the impact of socially responsible business on the market position of business entities. The authors specifically investigated the application and impact of socially responsible business rules on the position of agricultural farms in the territory of the municipality of Ruma. The instruments used in this research are a survey of farm owners and other stakeholders, an extensive literate review and a method of comparative analysis. The results of the research show that compliance with the rules of business ethics, in the long term, brings more profit to the business entity, so compliance with those standards is becoming more and more universal. That is why agricultural producers follow the rules of socially responsible business. The authors concluded that the social responsibility of business entities is an ethical demand that society places on them, a correlation with two demands that they are already faced with: economic - gaining profit and legal.
Photo by Adhy Savala on Unsplash
ABSTRACT
During a crisis, when healthcare capacity becomes overwhelmed and cannot meet regular standards of patient care, crisis standards of care are invoked to distribute scarce hospital space, staff, and supplies. When transitioning between conventional standards of care and crisis standards, hospitals may have to manage resources under scarcity constraints in an intermediate phase defined as the contingency phase. While much attention has been paid to the ethics of crisis standard of care protocols, contingency measures were more widely implemented, though little exists within the literature on the ethics of contingency measures or a clearly explicated contingency standard of care. This paper addresses three ethical issues with the current contingency response to COVID-19: the lack of formalization, the risks of using short-term solutions for prolonged contingency shortages, and the danger of exacerbating health disparities through hospital-level resource allocation. To mitigate these ethical issues, I offer recommendations for reimagining resource allocation during contingency standards of care.
INTRODUCTION
When transitioning between conventional standards of care and crisis standards, or in situations where shortages do not immediately threaten care delivery, hospitals may have to manage scarce resources in an intermediate phase, known as the “contingency” phase.[1] While much attention has been paid to the ethics of crisis standards, less literature covers the ethics of contingency measures or a clearly explicated contingency standard of care. Many states and hospital systems do not have contingency standards of care to dictate allocation absent an event triggering crisis standards. Crisis standards of care, used when healthcare capacity becomes overwhelmed and cannot meet regular standards of patient care, reflect ethical priorities relevant in times of shortage or other emergencies. These priorities include saving the most lives, the stewardship of scarce resources, and justice relating to equitable resource distribution.[2] Crisis standards of care delineate specialized allocation protocols and triage decision-making bodies at the institutional or state levels. Crisis standards of care require formal activation at the state level, and in the absence of clear triggers or governmental willingness to use them, hospitals may adopt informal strategies to manage allocation in the form of contingency measures.
The contingency phase is defined by two simultaneous goals: prevent or stall crisis-level scarcity by managing limited resources and providing patient care that is functionally equivalent to usual care.[3] In other words, allocate scarce resources with no significant health consequences to patients. However, this is an unrealistic expectation: meeting a patient’s medical needs and allocating resources on the basis of scarcity instead of medical indications can be at odds, creating ethical tension. This paper addresses three ethical issues with the current contingency response stemming from this tension: the lack of formalization, the risk of using short-term solutions for prolonged contingency shortages, and the danger of exacerbating health disparities through hospital-level resource allocation. To mitigate these ethical issues, I offer recommendations for reimagining resource allocation during contingency standards of care.
l. Lack of Formalization
One shortcoming of current contingency measures is that they fail to meet the same level of procedural detail and clarity as crisis standards. The early COVID-19 surges in Italy and France demonstrated the pitfalls of bedside allocation in the absence of procedural guidance. The acute scarcity of critical care resources forced doctors in these countries to make allocation decisions at the bedside, which often resulted in de facto age-based allocation as well as experiences of moral distress and shame among providers.[4] In France, medical allocation guidelines and statistics were never released to the public, raising concerns over the role of transparency in implementing crisis standards and triage guidelines and causing the public to question the trustworthiness of provider triage.[5] Though many states in the US have crisis standards of care that can be implemented in the case of a large-scale triage event, these measures vary widely. A 2020 review of 31 crisis standards of care in the US found that only 18 contained strong “ethical grounding,” 28 used “evidence-based clinical processes and operations,” 21 included “ongoing community and provider engagement, education, and communication,” and 16 had “clear indicators, triggers, and lines of responsibility.”[6]
The need for standardization, public transparency, and guidelines for crisis standards of care to prevent bedside allocation has been widely recognized. However, these issues remain unresolved by public policy or legislative efforts during the contingency period before (or after) crisis standards apply. A recent public health study that observed triage team members in a high-fidelity triage simulation highlighted the challenges of making equitable frontline allocation decisions.[7] In the simulation, participants nudged patient priority status up or down depending on what they subjectively identified as morally relevant factors. Through the simulation, participants reported difficulty separating implicit biases about patient characteristics from their clinical judgment. In the absence of formal institutional or regional guidelines for allocation during contingency-level shortages, there are few to no procedural safeguards against biased, ad hoc, and non-transparent rationing. Without formalized or standardized contingency allocation guidance, providers are left to make bedside allocation decisions that are susceptible to individual biases and patterns of unintended discrimination.
An example of this susceptibility is seen when hospitals allow patients who no longer benefit from ICU resources to continue occupying ICU beds. This is based on a first-come-first-served (FCFS) approach to bed allocation. FCFS is often a default for patient intake, which led to disparities in care access during the early COVID-19 pandemic. Media reports of hospitals with “plenty of space” being unwilling to accept patients from overwhelmed, lower-income hospitals illustrate that the FCFS default advantages those who could show up first to a particular hospital: often privileged, well-funded healthcare systems that were inaccessible to low-income communities.[8] FCFS is blind to several morally relevant factors, including the likelihood of survival to discharge, reciprocity (i.e. prioritizing healthcare workers), and varying degrees of access to healthcare. Therefore, it inappropriately privileges those in proximity to healthcare systems or with social connections enabling greater initial access to care.[9]
During crisis standards of care, excessive mortality that would result from FCFS is mitigated through formalized system-wide triage protocols based on current patient health status and potential benefit from resources. Crisis and contingency standards may provide liability coverage for providers who reallocate critical care beds away from those who no longer benefit during periods of scarcity. This liability coverage shifts bed allocation away from an FCFS model, but only if the policy is well-defined, clearly established, and known to providers. Without a formal system to guide the process or transition from the usual method of allocation to the contingency period, contingency decisions about who gets a scarce resource may continue to operate on an implicit FCFS basis, even when approaching crisis levels of scarcity. Additionally, these decisions will fall unsustainably on individual providers or transfer center workers, leading to moral distress on the frontlines when hospitals are already strained.
Lessons from the crisis and contingency responses during COVID-19 can improve future contingency responses. There are multiple ways of achieving equity during contingency allocation, ranging from hospital-level to state-level policy changes. State-wide policies and interventions to facilitate resource-sharing can relieve some of the scarcity burdens that hospitals may face during the contingency period. For example, moving ICU patients to lower levels of care once they have sufficiently recovered is a challenge for doctors, who often call other hospitals to find open beds. In these situations, providers who do not move patients who no longer benefit from ICU beds unknowingly reinforce the FCFS system in which those who arrive first keep the scarce beds, while those who arrive later or wait for one are disadvantaged by having limited access to them. State-wide patient transfer centers, often facilitated by state public health departments, present an alternative by balancing patient needs and bed distribution more equitably and efficiently than individual physicians do, as demonstrated following COVID-19 surges in hospitalization.[10] These centers aid not only in allocating open tertiary care beds, but also in identifying open beds at lower levels of care and assisting physicians with transferring out patients who can be safely downgraded and no longer benefit from tertiary care resources. However, the simplest solution is to encourage the creation of ethics guidance or protocols for contingency allocation at the hospital level. In hospitals, institutional ethics guidance can help providers navigate difficult decisions and conversations with patients. When providers face time-sensitive allocation decisions, like the allocation of open ICU beds, the guidance would be a useful tool for making transparent, principled, and ethically justified allocation decisions in real-time to mitigate the risk of ad hoc or implicit rationing.
ll. Unsuited for Prolonged Resource Shortages
Secondly, neither contingency nor crisis standards are currently designed to respond to prolonged strains on the healthcare system. Since the start of the pandemic, a prolonged period of staffing shortages began and is projected to persist.[11] However, both crisis and contingency standards assume that the system will eventually return to conventional standards of care. For example, as a contingency or crisis standard, many hospitals deferred elective surgeries to preserve limited resources for emergency and life-saving procedures. Massachusetts, for instance, issued a public health emergency order that required hospitals to defer 50 percent of all non-essential and non-urgent (elective) surgeries. This order demonstrates the use of this contingency measure in response to prolonged staffing and bed shortages.[12] However, the deferral of elective procedures can result in adverse long-term community health consequences. Medical conditions typically addressed through elective surgery, such as joint replacement surgeries for osteoarthritis patients, may worsen if delayed. This can result in greater numbers of acute emergencies, the need for more complex surgical procedures later, increased reliance on pain medications, and longer recovery times.[13] Without a greater understanding of long-term complications in community health, existing contingency strategies, such as the deferral of elective surgeries, may be unsuitable for prolonged shortages.
This becomes a greater threat to patient safety when contingency measures inappropriately take the place of crisis standards, risking the long-term implementation of emergency measures designed for temporary use. Although some state emergency planning documents identify indicators and triggers for activating contingency and crisis operations,[14] this transition is not always clear in action. For example, New York did not implement crisis standards of care during the early COVID-19 pandemic despite being one of the hardest-hit cities in the US.[15] Other states, including California, Texas, and Florida, did not activate crisis standards of care, leaving hospitals to implement informal contingency measures that ultimately required allocation strategies very similar or identical to many crisis standards of care protocols.[16] Due to the hesitance to activate crisis standards, ad hoc contingency measures and bedside decision-making prevailed over formal triage protocols. If contingency measures are not set forth in objective documents and are inappropriately used in the place of crisis standards, these short-term measures may result in an unfair or non-transparent distribution of scarce resources. When shortages in space, staff, or supplies jeopardize the ability to provide necessary care for critically ill patients under a conventional standard of care, failures to activate crisis standards risk the inappropriate use of ad hoc contingency measures in their place.
With clear contingency standards of care, the duration of an ad hoc approach could be limited. Crisis standards are defined and activated at the regional or state-wide level, but outside of hospital-specific resource limitations, there are generally no standardized indications or triggers for transitioning into and out of contingency measures. Leaving contingency needs to individual hospitals may seem beneficial but defining the contingency period at the hospital level and the crisis period at the state or regional level blurs the line about when it is appropriate for decision makers to activate crisis standards, risking delayed activation or failure to activate them at all. Therefore, it is important that state policies implement automatic triggers for activation that clearly delineate between contingency and crisis responses.[17] Automatic triggers based on validated metrics like remaining available resources can inform the appropriate decision makers about when they must activate crisis standards. These triggers should be transparent to the public, validated, and updated over time with evolving data. These automatic triggers would prevent confusion, inconsistent guidelines, and inequitable contingency allocation at the hands of distressed providers when crisis standards are needed. Defining when to begin crisis standards could help limit the length of the contingency period. This would protect against the inappropriate application of contingency measures to crisis-level scarcity and prolonged shortages that they could not sustainably ameliorate.
lll. Potential to Exacerbate Health Disparities
Inconsistencies in contingency allocation open the door to disparities in care and unequal distribution of scarcity burdens among different communities based on their location or health needs. This is a concern because it is unclear whether contingency measures can meet their goal of achieving functionally equivalent patient outcomes when resource allocation must be balanced with patient-centered care.[18] The care under contingency standards is meant to be functionally equivalent to regular care. The definition assumes (or may wrongly suggest) that any contingency strategy in place to avoid critical scarcity has no significant impact on patient outcomes. While functional equivalence is attainable, there is currently little research into which contingency measures achieve functionally equivalent outcomes and which patient groups may be disproportionately affected by harmful resource allocation strategies. Although the transition from contingency standards to crisis standards is defined by the inability to provide functionally equivalent care, the difference in practice may merely be a distinction between visible, immediate sacrifices to patient well-being during crises and less-obvious, long-term decrements in community health due to protracted contingency care alterations.
Two common contingency measures are cause for concern over disparate patient outcomes and the attainability of functional equivalence. First, restricting emergency room visits by the patient’s degree of need has worrying consequences. In late 2021 and early 2022, hospitals in Massachusetts faced widespread staffing shortages, leading to an emergency order that restricted emergency visits to emergency needs.[19] While this order is a reasonable method of allocating limited staff in the emergency department during severe shortages, it is doubtful that the outcomes of this restriction were equivalent to usual care. Health issues that are soon-to-be emergencies are filtered out until they worsen, resulting in patients overflowing to urgent care clinics or presenting to ERs with more severe forms of sicknesses later on. Given the empirical evidence demonstrating ER treatment and admission disparities that disadvantage Black and Hispanic patients, such a measure would only exacerbate these disparities by further limiting access to needed care.[20]
Second, altered staffing ratios, which stretch a limited number of providers to meet patient needs during a staffing shortage, are another concerning yet common contingency measure. Staffing allocation is often viewed similarly to the allocation of space and medical equipment, such that contingency alterations to staffing operations may not seem like they significantly jeopardize patient care quality and outwardly appear functionally equivalent.[21] However, lower ratios of qualified nurses are associated with poor outcomes such as higher inpatient mortality[22] and lower survival rates of in-hospital cardiac arrest for Black patients.[23] These examples highlight the strong potential for contingency measures to amplify social health disparities, particularly when adopted over a prolonged time frame.
Lowered standards of care in crisis allocation disproportionately impact racial and ethnic minorities.[24] For example, crisis standards of care used clinical scoring systems that were not developed or validated for crisis triage to prioritize access to life-saving treatments during the COVID-19 pandemic. This practice actively gives rise to racial health disparities and discrimination against disabled patients.[25] Not only were the standards inequitable in practice, but they varied widely from state to state and sometimes even from hospital to hospital, creating disparities across and within geographic regions.[26] If contingency measures are similarly implemented across hospitals or hospital departments without standardization or advance planning to ensure equitable outcomes, it is likely that the burden of a lower standard of care will fall primarily on disadvantaged patient groups and racial minorities. However, standardization alone may be insufficient. Other factors like varying levels of details on patients’ charts between hospitals could produce unfair outcomes if used to determine patient admission or transfer priority, even if the criteria for admissions and transfers are consistent. Thus, ongoing monitoring for unintended patterns of disparity must accompany standardization to ensure that blind spots in the allocation process are identified and corrected.
Bioethics has long been preoccupied with the micro-allocation of limited resources within hospitals instead of confronting the structural inequities that underlie broader scarcity and patient needs. The traditional dilemma of allocating limited hospital resources among a certain number of patients overlooks questions about how other resources have already been allocated, which patients were present at the hospital in the first place, where hospitals have (and have not) been built, and whether previous allocation strategies created bias in the broader distribution of resources. Therefore, to achieve fairness, bioethicists must pay attention to aspects of the broader distribution of resources, such as social determinants of health and the allocation of preventative resources at the public health level. One strategy for measuring and addressing these disparities is the Area Deprivation Index (ADI). The ADI quantifies the effects of race, class, and socioeconomic background by geographic region for use in public health research and the prioritization of resources.[27] It has shown promise in identifying geographic regions in need of targeted community health efforts for diabetes management based on electronic patient health records.[28] The ADI and similar tools would be useful in proactively deciding how to allocate public health resources when hospitals are strained. Moreover, through using population health and resource data, public health organizations may forecast contingency shortages allowing for the adoption of early measures to mitigate health disparities that might otherwise be amplified from hospital-level contingency allocation decisions.
CONCLUSION
Meeting community health needs during periods of contingency scarcity, both before and after crisis standards of care apply, will require contingency standards of care rather than a bedside ad hoc distribution of scarce resources. While it is not inherently ethically unjustifiable for hospitals to adopt measures that may lower the standard of care during contingency standards, the necessity of these measures requires that bioethicists consider how equity, transparency, and the overall aim of functional equivalence can best be achieved under conditions of scarcity. The long-term health consequences of existing contingency measures, the potential for ad hoc and inconsistent allocation of scarce resources, and the need for consensus about when it becomes appropriate to make the formal transition to crisis standards of care demand further consideration. Because contingency measures will likely amplify existing disparities as crisis standards have, hospital-level management of scarcity is inadequate. Public health measures should be adopted in parallel to anticipate and manage health needs at the community or state level when resources are strained.
-
[1] Altevogt, B. M., Stroud, C., Hanson, S. L., Hanfling, D., & Gostin, L. O. (2009). Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. The National Academies Press. https://doi.org/10.17226/12749
[2] Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A., Zhang, C., Boyle, C., Smith, M., & Phillips, J. P. (2020). Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine, 382(21), 2049–2055. https://doi.org/10.1056/NEJMsb2005114
[3] Alfandre, D., Sharpe, V. A., Geppert, C., Foglia, M. B., Berkowitz, K., Chanko, B., & Schonfeld, T. (2021). Between Usual and Crisis Phases of a Public Health Emergency: The Mediating Role of Contingency Measures. The American Journal of Bioethics, 21(8), 4–16. https://doi.org/10.1080/15265161.2021.1925778
[4] Rosenbaum, L. (2020). Facing Covid-19 in Italy—Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line. New England Journal of Medicine, 382(20), 1873–1875. https://doi.org/10.1056/NEJMp2005492
[5] Orfali, K. (2020). What Triage Issues Reveal: Ethics in the COVID-19 Pandemic in Italy and France. Journal of Bioethical Inquiry, 17(4), 675–679. https://doi.org/10.1007/s11673-020-10059-y
[6] Romney, D., Fox, H., Carlson, S., Bachmann, D., O’Mathuna, D., & Kman, N. (2020). Allocation of Scarce Resources in a Pandemic: A Systematic Review of US State Crisis Standards of Care Documents. Disaster Medicine and Public Health Preparedness, 14(5), 677–683. https://doi.org/10.1017/dmp.2020.101
[7] Butler, C. R., Webster, L. B., Diekema, D. S., Gray, M. M., Sakata, V. L., Tonelli, M. R., & Vranas, K. C. (2022). Perspectives of Triage Team Members Participating in Statewide Triage Simulations for Scarce Resource Allocation During the COVID-19 Pandemic in Washington State. JAMA Network Open, 5(4), e227639. https://doi.org/10.1001/jamanetworkopen.2022.7639
[8] Dwyer, J. (2020, May 14). One Hospital Was Besieged by the Virus. Nearby Was ‘Plenty of Space.’—The New York Times. The New York Times. https://www.nytimes.com/2020/05/14/nyregion/coronavirus-ny-hospitals.html
[9] Persad, G., Wertheimer, A., & Emanuel, E. J. (2009). Principles for allocation of scarce medical interventions. Lancet (London, England), 373(9661), 423–431. https://doi.org/10.1016/S0140-6736(09)60137-9
[10] Mitchell, S. H., Rigler, J., & Baum, K. (2022). Regional Transfer Coordination and Hospital Load Balancing During COVID-19 Surges. JAMA Health Forum, 3(2), e215048. https://doi.org/10.1001/jamahealthforum.2021.5048
[11] ASPE. (2022, May 3). Impact of the COVID-19 Pandemic on the Hospital and Outpatient Clinician Workforce: Challenges and Policy Responses. ASPE. https://aspe.hhs.gov/reports/covid-19-health-care-workforce
[12] Executive Office of Health and Human Services. (2021). Baker-Polito Administration Provides COVID-19 Update on Mask Advisory, Hospital Support | Mass.gov. https://www.mass.gov/news/baker-polito-administration-provides-covid-19-update-on-mask-advisory-hospital-support
[13] The Lancet Rheumatology. (2021). Too long to wait: The impact of COVID-19 on elective surgery. The Lancet Rheumatology, 3(2), e83. https://doi.org/10.1016/S2665-9913(21)00001-1
[14] For an example of transition planning between crisis and contingency standards, see Minnesota Department of Health. (2021). Ethical Framework for Transitions Between Conventional, Contingency, and Crisis Conditions in Pervasive or Catastrophic Public Health Events with Medical Surge Implications (Minnesota Crisis Standards of Care). https://www.health.state.mn.us/communities/ep/surge/crisis/framework_transitions.pdf
[15] Powell, T., & Chuang, E. (2020). COVID in NYC: What We Could Do Better. The American Journal of Bioethics, 20(7), 62–66. https://doi.org/10.1080/15265161.2020.1764146
[16] Persoff, J., & Wynia, M. K. (2021). Ethically Navigating the Murky Waters of “Contingency Standards of Care.” The American Journal of Bioethics, 21(8), 20–21. https://doi.org/10.1080/15265161.2021.1939810
[17] Board on Health Sciences Policy & Institute of Medicine. (2013). Indicators and Triggers. In Crisis Standards of Care: A Toolkit for Indicators and Triggers. National Academies Press (US). http://www.ncbi.nlm.nih.gov/books/NBK202381/
[18] Frith, L., Draper, H., Fovargue, S., Baines, P., Redhead, C., & Chiumento, A. (2021). Neither ‘Crisis Light’ nor ‘Business as Usual’: Considering the Distinctive Ethical Issues Raised by the Contingency and Reset Phases of a Pandemic. The American Journal of Bioethics, 21(8), 34–37. https://doi.org/10.1080/15265161.2021.1940363
[19] Rosseau, M. (2022, January 14). New emergency orders issued to help understaffed Mass. Hospitals. Boston.Com. https://www.boston.com/news/coronavirus/2022/01/14/new-emergency-orders-issued-to-help-understaffed-mass-hospitals/
[20] Zhang, X., Carabello, M., Hill, T., Bell, S. A., Stephenson, R., & Mahajan, P. (2020). Trends of Racial/Ethnic Differences in Emergency Department Care Outcomes Among Adults in the United States From 2005 to 2016. Frontiers in Medicine, 7. https://www.frontiersin.org/articles/10.3389/fmed.2020.00300
[21] Hick, J. L., Hanfling, D., & Wynia, M. (2022). Hospital Planning for Contingency and Crisis Conditions: Crisis Standards of Care Lessons from COVID-19. The Joint Commission Journal on Quality and Patient Safety. https://doi.org/10.1016/j.jcjq.2022.02.003
[22] Musy, S. N., Endrich, O., Leichtle, A. B., Griffiths, P., Nakas, C. T., & Simon, M. (2021). The association between nurse staffing and inpatient mortality: A shift-level retrospective longitudinal study. International Journal of Nursing Studies, 120, 103950. https://doi.org/10.1016/j.ijnurstu.2021.103950
[23] Brooks Carthon, M., Brom, H., McHugh, M., Sloane, D. M., Berg, R., Merchant, R., Girotra, S., & Aiken, L. H. (2021). Better Nurse Staffing Is Associated With Survival for Black Patients and Diminishes Racial Disparities in Survival After In-Hospital Cardiac Arrests. Medical Care, 59(2), 169–176. https://doi.org/10.1097/MLR.0000000000001464
[24] Annas, G. J., & Crosby, S. S. (2021). Standard Racism: Trying to Use “Crisis Standards of Care” in the COVID-19 Pandemic. The American Journal of Bioethics, 21(8), 1–3. https://doi.org/10.1080/15265161.2021.1941424
[25] Wynia, M. K., & Sottile, P. D. (2020). Ethical Triage Demands a Better Triage Survivability Score. The American Journal of Bioethics, 20(7), 75–77. https://doi.org/10.1080/15265161.2020.1779412
[26] Fink, S. (2020). Ethical Dilemmas in Covid-19 Medical Care: Is a Problematic Triage Protocol Better or Worse than No Protocol at All? The American Journal of Bioethics, 20(7), 1–5. https://doi.org/10.1080/15265161.2020.1788663
[27] Knighton, A. J., Savitz, L., Belnap, T., Stephenson, B., & VanDerslice, J. (2016). Introduction of an Area Deprivation Index Measuring Patient Socioeconomic Status in an Integrated Health System: Implications for Population Health. EGEMS (Washington, DC), 4(3), 1238. https://doi.org/10.13063/2327-9214.1238
[28] Kurani, S. S., Lampman, M. A., Funni, S. A., Giblon, R. E., Inselman, J. W., Shah, N. D., Allen, S., Rushlow, D., & McCoy, R. G. (2021). Association Between Area-Level Socioeconomic Deprivation and Diabetes Care Quality in US Primary Care Practices. JAMA Network Open, 4(12), e2138438. https://doi.org/10.1001/jamanetworkopen.2021.38438
Global trade is world-wide. This book focuses on East. The main countries examine China, Japan, Korea and Southeast Asia. The diasporas of some Eats Asian counties are examined in this book. Many different authors are considered in this book. A scholar East Asia and commerce may find this book to be helpful.
Photo by Waranont (Joe) on Unsplash
INTRODUCTION
The age-adjusted COVID-19 mortality rate among Black Americans is twice as high as White Americans.[1] This shocking evidence of health disparities, coincident to a public reckoning with the history of racism in the US, highlights the inverse relationship between race and health. Public sentiment may now favor addressing these pressing public health issues, but the sprawling healthcare system largely focuses on clinical care; it lacks tools to influence the social determinants of health at the point of the healthcare institution. Reinvigorating organizational ethics, sometimes called institutional ethics, may provide such a tool.
BACKGROUND
Organizational ethics became part of the healthcare system during the upheavals in financing and organization of health care in the 1990s. Yet organizational ethics in a medical setting must be more than simple business ethics.[2] Just as health care professionals are granted special privileges in society in exchange for adherence to a code of medical ethics and duties, healthcare organizations and systems also must now adhere to ethical requirements in exchange for their privileged position that includes the right to provide, and be reimbursed for, health care.[3]
In the 1990s, ethicists began to discuss how clinical ethics committees might develop an understanding of business ethics in order to provide comprehensive organizational ethics reviews.[4] Some bioethicists even believed that the challenges of integrating business and medical care would compel ethics committees to look outward, engaging in public advocacy around ethical issues in health care.[5] To fulfill the mission of maintaining organizational ethics standards within the healthcare system, ethics committees would need to advocate for patients in the public sphere. Ethics committees might even take positions at odds with those of the healthcare institutions in which they work.
Organizational ethics committees might have served as watchdogs, ensuring that healthcare organizations fulfill their fiduciary duties to their patients and communities. Bioethicists soon realized that the vision of a robust ethics committee involving administrators, bioethicists, and medical staff advising multiple divisions of large organizations and policy makers would fall short.[6] The two ethical systems remained separate: most organizations developed a combination of a clinical ethics committee adjunct to the medical staff with a compliance department to oversee organizational ethics. However, organizational ethics really goes beyond compliance; it “cannot be addressed by focusing narrowly on business matters or by quasi-legal mechanisms to assure that behavior conforms to pre-established codes or rules.”[7] As a result, there is no centralized entity with power in each healthcare institution that can treat healthcare inequities as an institutional ethical failure that must be addressed.
Current research on specific inequitable outcomes due to bias in clinical care includes specialties such as maternal care,[8]cardiac care,[9] pain management, and technology.[10] Implicit bias and racist clinical interactions, once identified, may be addressed through staff training and other interventions. Yet the ethics of clinical care requires little attention to the social determinants of health such as high levels of police surveillance in the community which may cause increased rates of hypertension,[11] pre-term birth,[12] and may affect mental health. Leaving these problems to the public health realm disconnects health practitioners and institutions from the ability to remedy some of the causes of health problems in their patients. Simply treating the effects of racism in the practice of medicine is not curative – it is really palliative care.[13]
ANALYSIS
The term “organizational ethics” is too limited to encompass the scope of change needed to address structural racism and the social determinants of health in today’s healthcare institutions. Structural Justice Ethics[14] better describes a plan and a process that requires the healthcare system and professionals to look both inward and outward to take on the structural causes of racism and health disparities. Building on organizational and clinical ethics, Structural Justice Ethics could amplify the research on systemic issues such as the effects of social determinants of health, racism in clinical care, and necessary advocacy with the local community. To be effective and complete, organizations should recognize duties to patients that arrive at their doorstep, damaged by generations of subordination and racism. To ethically treat patients who have experienced racism, the system and health practitioners must acknowledge and work to reduce the inequities in society that cause harm to their health in the clinical setting. Accreditation companies such as The Joint Commission could amend their standards to require top-rated healthcare organizations to form new Structural Justice Ethics committees in their organizations, taking affirmative steps to acknowledge the ethical implications of racism and the social determinants of health.
Many bioethicists have already called for the field of bioethics to address racism as an ethical issue in healthcare, some even calling for a new Black Bioethics.[15] This frustration with the profession of bioethics has developed in other areas, such as disability ethics and feminist ethics, and reflects a belief that mainstream bioethics is a rigidly principlist endeavor. The education of new bioethicists is grounded in practical philosophy graduate programs, entwined with academia’s history of exclusivity. As a relatively young academic subject, bioethics has the potential to expand and grow into a more practical and justice-oriented tool, learning how to counter the overly individualistic bioethics that has roots in our racist and Protestant-dominant history.[16] Expanding organizational ethics into Structural Justice Ethics in health care could bring Black bioethicists into the center of healthcare ethics and provide the tools to implement changes needed to address racism in health care.
Healthcare organizations should not expect Black healthcare practitioners to take on these Structural Justice Ethics roles as “extra” work. Too often, people of color are expected to bear the burden of explaining racism and working to eradicate it.[17]The Structural Justice Ethics committee should be a new model, centered in ethics and policy, with professional-level staffing that reflects the racial and ethnic makeup of the community it serves. Calling on bioethicists as moral agents in the world, and particularly within the medical system, to act as social justice advocates against systemic injustice in a system where they have privilege and power seems logical and surprisingly necessary. “Going forward, bioethics needs to engage with the nuances of race with the same vigor that it has approached discussions of moral theories and biotechnologies.”[18] Graduate-level bioethics programs have expanded significantly in recent years, with 45 current master’s level programs,[19] and there should be a wealth of professionals ready to oversee the role of encouraging and monitoring justice in the system. These programs focus primarily if not exclusively on the dominant paradigm of bioethics, yet as ethics programs, they should be able to course-correct and embrace greater diversity in people and thought. Structural Justice Ethicists can guide healthcare organizations to become learning institutions open to the idea that bias and inequity are ethical harms that they can and should address.
Some may question whether such close attention to Black health care needs amounts to reparations or “reverse” discrimination, a controversial topic in our political discussions. However, when posed as an ethical duty of health care, there is no option to continue to treat Black people unethically. Of course, healthcare systems will have to balance competing budgetary interests; even with unlimited funding, disparities in health care would not disappear overnight.[20] In a fair process where decisionmakers must weigh the demands of stakeholders, the ethical obligation to address the social determinants of health must have an advocate. Moreover, setting high ethical standards is not the same as government spending to make reparations for past harms. In fact, Structural Justice Ethics does not look to the past at all but looks to the needs of subordinated communities of patients as they exist today. Any community that is harmed by structural injustice in health care can be the focus of a Structural Justice Ethics review.
The Joint Commission and other accrediting organizations can require healthcare organizations to meet the challenges of health inequities by adopting new Structural Justice Ethics committees, just as The Joint Commission added organizational ethics to its requirements in 1995. Admittedly, Structural Justice Ethics is an amorphous concept and its role within healthcare institutions needs to be refined and assigned specific tasks. However, there is substantial research on the social determinants of health; the challenge for the Structural Justice Ethics is to recommend systemic changes from within, rather than beginning this research anew. The Joint Commission’s Center for Transforming Healthcare, as a data-driven and process-oriented patient safety organization, is well-primed to take on this task. The Center can collaborate with existing academic and governmental health equity researchers to set short- and long-term goals for Structural Justice Ethics committees. To begin with, a Structural Justice Ethics committee can pose the question of “how is racism operating here” and:
a. connect with current research on specific inequitable outcomes due to bias in medicine and bring best practices to the attention of medical staff.
b. work with human resources and medical staff to support and increase diverse populations in the workforce.
c. ensure that implicit bias and other trainings are properly provided to all staff, as well as expanding the scope of such trainings to address developing areas such as epistemic harm, or the harm of one’s own physical experience being discounted by medical professionals.[21] The health care workforce should also be trained in Title VI law.[22]
d. evaluate research data on the organization’s own potential disparate outcomes due to race, to determine areas for improvement both within and outside of the organization.
e. invite the local community to come in for listening and learning sessions, to better understand the community’s concerns and perspective on health equity.
f. improve advocacy on behalf of community members to state and local authorities, effectively taking a stand for health care equity for local stakeholders. Dr. Camara P. Jones describes a collaborative endeavor like this as critical to anti-racist work and likens it to adopting a community health center model where the health facility takes responsibility for the health and well-being of the local community.[23] AMA policy already encourages this type of effort in opinion 8.11 of the AMA Code, which states that, alongside diagnosis and treatment, “physicians also have a professional commitment to prevent disease and promote health and well-being for their patients and the community.”[24]
A theoretical framework and concrete plan for radical improvement in the ethics of the healthcare system will help all healthcare professionals. Some healthcare practitioners may not recognize their own biases and need training to meet best practices standards in light of health inequities. Other healthcare practitioners may feel disillusioned because they know they face individual patients suffering the effects of structural racism, yet they can treat only the illness.[25] The scope of the problem may overwhelm practitioners, and without a belief that the system is committed to improvement, practitioners may become numb to the suffering, a trauma reaction that affects both the practitioners and their patients. Unfortunately, when current medical students ask the question, “what can I do to fight systemic racism?” the answer is usually “call it out.” But putting the onus on newly minted individual practitioners to call out racism in an established structure is unrealistic, unfair, and destined to be unsuccessful. Just as we should not expect subordinated individuals to “overcome” their social determinants of health, we should not expect health professionals to make this change individually. Addressing injustices in the institution and adjusting medical ethics accordingly can alleviate the burden of these ethical dilemmas.
CONCLUSION
Structural Justice Ethics must be woven into the ethics committees at the institutional level. Organizational ethics committees can evaluate healthcare organizations by their integrity, i.e., how well their actions fulfill the moral obligations they have undertaken.[26] Our healthcare system has avoided the moral obligation to address racism and the social determinants of health by focusing on clinical ethics, leaving public health to academics and the government. Expanding organizational ethics to take on the issues of structural injustice within each healthcare institution will help organizations better measure, change, and ultimately fulfill their moral obligations to their patients and communities.
[1] “Color of Coronavirus: COVID-19 Deaths Analyzed by Race and Ethnicity,” APM Research Lab, accessed June 1, 2021, https://www.apmresearchlab.org/covid/deaths-by-race.
[2] M. Constantinescu, “Seeing the Forest beyond the Trees: A Holistic Approach to Health-Care Organizational Ethics,” in Contemporary Debates in Bioethics: European Perspectives, 2018, 86–96, https://doi.org/10.2478/9783110571219-009.
[3] See Norman Daniels, Just Health: Meeting Health Needs Fairly (Cambridge: Cambridge University Press, 2008) at 219.
[4] Elizabeth Heitman and Ruth Ellen Bulger, “The Healthcare Ethics Committee in the Structural Transformation of Health Care: Administrative and Organizational Ethics in Changing Times,” HEC Forum 10, no. 2 (June 1, 1998): 152–76, 162, https://doi.org/10.1023/A:1008865603499.
[5] Cohen, Cynthia B. "Ethics Committees as Corporate and Public Policy Advocates." The Hastings Center Report 20, no. 5 (1990): 36+. Gale Academic OneFile (accessed May 6, 2021). https://link.gale.com/apps/doc/A8998890/AONE?u=nysl_oweb&sid=AONE&xid=84a1cade.
[6] Linda L. Emanuel, “Ethics and the Structures of Healthcare Special Section: Issues in Organization Ethics and Healthcare,” Cambridge Quarterly of Healthcare Ethics 9, no. 2 (2000): 151–68, 166.
[7] George Khushf and Rosemarie Tong, “Setting Organizational Ethics within a Broader Social and Legal Context,” HEC Forum 14, no. 2 (June 2002): 77–85, 78.
[8] Olivia Pham, Usha Ranji Published: Nov 10, and 2020, “Racial Disparities in Maternal and Infant Health: An Overview - Issue Brief,” KFF (blog), November 10, 2020, https://www.kff.org/report-section/racial-disparities-in-maternal-and-infant-health-an-overview-issue-brief/.
[9] Eberly Lauren A. et al., “Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center,” Circulation: Heart Failure 12, no. 11 (November 1, 2019): e006214, https://doi.org/10.1161/CIRCHEARTFAILURE.119.006214.
[10] Michael W. Sjoding et al., “Racial Bias in Pulse Oximetry Measurement,” New England Journal of Medicine 383, no. 25 (December 17, 2020): 2477–78, https://doi.org/10.1056/NEJMc2029240.
[11] Alyasah Ali Sewell et al., “Illness Spillovers of Lethal Police Violence: The Significance of Gendered Marginalization,” Ethnic and Racial Studies 44, no. 7 (July 22, 2020): 1–26, https://doi.org/10.1080/01419870.2020.1781913.
[12] Brad N. Greenwood et al., “Physician–Patient Racial Concordance and Disparities in Birthing Mortality for Newborns,” Proceedings of the National Academy of Sciences 117, no. 35 (September 1, 2020): 21194–200, https://doi.org/10.1073/pnas.1913405117.
[13] The term “palliative care” as applied to patients suffering from the social determinants of health was used by Dr. Michelle Morse at a webinar entitled “Medical Stereotypes: Confronting Racism and Disparities in US Health Care: A Health Policy and Bioethics Consortium” presented by the Harvard Petrie-Flom Center on February 12, 2021.
[14] Linda L. Emanuel coined the term “Structural Ethics” in 2000. This term did not seem to generate much interest from the bioethics community at the time. Her explanation of this term is consistent with my thinking, although I expand it to address the health system as an entity, and focus on improving health equity.
[15] Keisha Shantel Ray, “Black Bioethics and How the Failures of the Profession Paved the Way for Its Existence | Bioethics.Net,” www.bioethics.net, August 6, 2020, http://www.bioethics.net/2020/08/black-bioethics-and-how-the-failures-of-the-profession-paved-the-way-for-its-existence/; Yolonda Y. Wilson, “Racial Injustice and Meaning Well: A Challenge for Bioethics,” The American Journal of Bioethics 21, no. 2 (February 1, 2021): 1–3, https://doi.org/10.1080/15265161.2020.1866875.
[16] See Catherine Myser, “Differences from Somewhere: The Normativity of Whiteness in Bioethics in the United States,” The American Journal of Bioethics 3, no. 2 (May 2003): 1–11, https://doi.org/10.1162/152651603766436072.
[17] Ushe Blackstock, “Why Black Doctors like Me Are Leaving Academic Medicine,” STAT (blog), January 16, 2020, https://www.statnews.com/2020/01/16/black-doctors-leaving-faculty-positions-academic-medical-centers/.
[18] Zamina Mithani, Jane Cooper, and Boyd J. Wesley, “Race, Power, and COVID-19: A Call for Advocacy within Bioethics,” The American Journal of Bioethics21, no. 2 (2021): 11–18, 13 https://doi.org/10.1080/15265161.2020.1851810.
[19] “Graduate Programs,” The Hastings Center, accessed 2 June, 2021, https://www.thehastingscenter.org/publications-resources/bioethics-careers-education/graduate-programs-2/.
[20] Norman Daniels, Just Health: Meeting Health Needs Fairly, at 299.
[21] Ian James Kidd and Havi Carel, “Epistemic Injustice and Illness,” Journal of Applied Philosophy 34, no. 2 (2017): 172–90, https://doi.org/10.1111/japp.12172.
[22] Ruqaiijah Yearby, “Sick and Tired of Being Sick and Tired: Putting an End to Separate and Unequal Health Care in the United States 50 Years after the Civil Rights Act of 1964,” Health Matrix 25, no. 1 (January 1, 2015): 1–33, at 11.
[23] Jones CP, Maybank A, Nolen L, Fields N, Ogunwole M, Onuoha C, Williams J, Tsai J, Paul D, Essien UR, Khazanchi, R. “Episode 5: Racism, Power, and Policy: Building the Antiracist Health Systems of the Future.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. January 19, 2021.
[24] Sienna Moriarty, “AMA Policies and Code of Medical Ethics’ Opinions Related to Health Promotion and Community Development,” AMA Journal of Ethics 21, no. 3 (March 1, 2019): 259–61, https://doi.org/10.1001/amajethics.2019.259.
[25] Constantinescu, “Seeing the Forest beyond the Trees,” at 92.
[26] Ana Smith Iltis, “Organizational Ethics: Moral Obligation and Integrity,” in Institutional Integrity in Health Care, ed. Ana Smith Iltis, Philosophy and Medicine (Dordrecht: Springer Netherlands, 2003), 175–82, https://doi.org/10.1007/978-94-017-0153-2_10.
The objective of this paper is to examine the practices of religious values and the enterprises’ performance in microcredit program. The primary data were collected from 756 micro enterprises under the microcredit program in which stratified sampling method was utilized for the data collection. The data were then analysed using the Factor analysis and multiple regression analysis. The findings reveal that the practices of religious values are significantly related to micro enterprises’ performance. The factors of religious values such as virtue, observance and persistence have a significant positive relationship with micro enterprises’ performance. However, religious values such as truth and kindness indicate an insignificant relationship with micro enterprises’ performance. From the viewpoint of policy and business strategy, a comprehensive guiding mechanism involving business ethics and religious values among entrepreneurs should be implemented to ensure that Muslim entrepreneurs do not deviate from the religious values set forth by their religion. Total business ethics and the practices of religious values do not only guarantee success in the economic activities but also the promise of victory in the hereafter. This paper proves that religious values are important to the successful performance of a business. However, generally entrepreneurs are greedier in pursuing their business values rather than the religious values and their decision making is usually based on socio-moral considerations in which these are sometimes quite insignificant in explaining their business performance. Stakeholders should take note that it is important to adhere to the religious values in order to determine business performance but the entrepreneurs’ attitude tends to make the values insignificant.
Renda Putri Hasanah, Kadenun Kadenun, Nafi'ah Nafi'ah
This research is motivated by buying and selling second hand cellphones with a cash on delivery system that is rife in the city of Ponorogo. In practice, sellers and sellers offer their wares through the Second Ponorogo HP Buy and Sell Forum group. In their activities, the buyer feels disadvantaged by the seller due to the seller's dishonest and fraudulent attitude regarding the quality and condition of the second hand cellphone being sold. The sale and purchase (COD) cash on delivery earlier has caused confusion and disputes for one of the parties, because of hidden defects. This study uses field research methods (field research) with a qualitative approach. The data used is the Second Ponorogo HP buying and selling forum contract and the khiyar practice of the Second Ponorogo HP buying and selling forum. The data sources for this research are informants who are involved and active in the Second HP Second HP Sale and Purchase Forum Ponorogo. This study resulted in; The sale and purchase contract at the Second Ponorogo HP Buying and Selling Forum was in accordance with Islamic law and Islamic ethics with the fulfillment of the pillars and conditions of sale and purchase. However, the contract was flawed due to the element of fraud on the quality of the cellphone. While in the practice of Khiyar in The Second Ponorogo HP Sale and Purchase Forum is included in the khiyar Majlis, meaning that the buyer and seller have the right to continue or cancel the transaction before leaving the place of transaction. Judging from the percentage, Islamic ethics in the practice of buying and selling above has not been fully implemented.
This paper summarizes the arguments and counterarguments within the scientific discussion on the issue of social housing, existing ethical dilemmas, and business development. The main purpose of the research is to investigate the interest level and popularity dynamics of social and affordable housing in the world in general and in OECD countries. The systematization of literary sources and approaches for solving the problem of ethical and economical aspects of social and affordable housing indicates that there is no single point of view on this issue among scientists. That is why the essence of the concepts of social, affordable, and public housing needs to be clarified considering existing differences. Besides it, comparative analysis of the results of analytical analysis of the interest level and popularity dynamics of social and affordable housing based on Google Trends tools and the results of statistical analysis in this context has not been conducted yet. Investigation of the topic about popularity dynamics of social and affordable housing emphasizing ethical needs and expected business benefits in the paper is carried out in the following logical sequence: systematization and clarification theoretical approaches to determine the essence and the difference between social, public and affordable housing; description of dominant types of funding social and affordable housing; analytical analysis of popularity dynamics of social and affordable housing with the determination of key value picks; statistical analysis of certain social housing indicators; comparing the results and making conclusions. Methodological tools of the research methods were logical generalization and scientific abstraction, statistical and structural analysis, comparative, and graphical analysis using the Excel software. Analytical analysis was realized based on Google Trends tools. The objects of research were the search requests about social, public, and affordable housing in the world in 2004-2021, and the indicators of social housing from the sample of OECD countries and other EU countries (limit in 2018 due to the availability of information on open information portals of The Organization for Economic Co-operation and Development). The paper presents the results of analytical, statistical, and comparative analysis of the level of interest (popularity) and development of social and affordable housing. The recommendations according to the coexistence of ethical and entrepreneurial principles can be useful for public and private investors in social and affordable housing.
maryam pourjamshidi, akbar momeni rad, Afshin Afzali
The purpose of this study was to identify the dimensions of social life of citizens and their impact on cyberspace in Hamadan province. The method of the present study is a mixed-type consecutive exploration design. Qualitative participants included experts in Hamadan province in the field of social issues, among whom 10 were selected as well as theoretical research related literature among which 7 books, 131 articles, and 10 theses were selected purposefully. The study population in the quantitative section includes the citizens of Hamadan province, from which 400 people were selected by stratified random sampling. A researcher-made questionnaire and semi-structured interview were used for data collection. The validity of the questionnaire was confirmed by experts and its reliability was confirmed by Cronbach's alpha coefficient and its construct validity through confirmatory factor analysis. The results were obtained in the qualitative section of 6 categories including social security and health, citizenship awareness, contrasting tradition and modernity, social ethics, social participation, and social responsibility. In the quantitative part, the results also showed that the largest use of cyberspace is in terms of quantity for entertainment and the least is commercial and economic activities. In terms of usage, communication is first and then entertainment, learning, and business activities, respectively. Also, the impact of cyberspace was negative on three categories of social issues including social security and health; citizen awareness; and the contrast between tradition and modernity
Background: There is increasing pressure on business organisations to behave ethically, in addition to running their operations in the most economical, efficient and effective manner possible to increase performance. Customers have also become increasingly mindful of the reputation of the businesses they patronise. Small and medium-sized enterprises (SMEs) have become the worst affected since they lack the funds, strategic information and relevant alliances to implement ethical practices. Aim: This article aims at evaluating the aspects of business ethics, significance of business ethics to SMEs, ethical dilemmas and challenges of SMEs, particularly in developing countries, and suggests strategies to address ethical dilemmas and challenges. Methods: The background literature review on ethical practices in SMEs in the context of developing countries was conducted on several journal articles. Peer-reviewed articles in recent journals were analysed to identify the aspects of business ethics, significance of business ethics to SMEs, ethical dilemmas and challenges of SMEs and the proposed strategies to address ethical dilemmas and challenges thereof. Results and conclusion: It is clear that business enterprises can no longer afford to disregard business ethics. There are continuous business failures as a result of unethical practices, especially those associated with employees and top executives. This article has added to the body of existing literature on ethical practices of SMEs in developing countries. As such, SME owners and managers can use the findings of this article to design ethical policy frameworks and guidelines to improve their reputations and competitiveness.
Recognizing that truth is socially constructed or that knowledge and power are related is hardly a novelty in the social sciences. In the twenty-first century, however, there appears to be a renewed concern regarding people’s relationship with the truth and the propensity for certain actors to undermine it. Organizations are highly implicated in this, given their central roles in knowledge management and production and their attempts to learn, although the entanglement of these epistemological issues with business ethics has not been engaged as explicitly as it might be. Drawing on work from a virtue epistemology perspective, this paper outlines the idea of a set of epistemic vices permeating organizations, along with examples of unethical epistemic conduct by organizational actors. While existing organizational research has examined various epistemic virtues that make people and organizations effective and responsible epistemic agents, much less is known about the epistemic vices that make them ineffective and irresponsible ones. Accordingly, this paper introduces vice epistemology, a nascent but growing subfield of virtue epistemology which, to the best of our knowledge, has yet to be explicitly developed in terms of business ethics. The paper concludes by outlining a business ethics research agenda on epistemic vice, with implications for responding to epistemic vices and their illegitimacy in practice.
Activist groups which oppose so-called ‘genetically modified organisms’ (GMOs) frequently affirm that they want to fight corporations and capitalism. While I do not discuss whether this legitimate ideological-political attitude is good or bad, right or wrong, I try to show that such avowed anti-industrial struggle in the field of green biotechnologies not only fails to hit the supposed target, but benefits and supports a sector of the industry whose products have a greater environmental impact than recombinant DNA (rDNA) cultivars. Therefore, GMO opponents are exploited by a part of the capitalistic front they are combating. In the meantime, steadfast resistance to GMOs as an indiscriminate whole creates heavy collateral damage, impeding the development of public and philanthropic biotech outcomes; such crops would help those whom activists declaredly want to protect: the poor. This detrimental action is based on one counterproductive and enormous mistake: the indiscriminate rejection of GMOs takes away precious energies from productive environmental and social battles.
Ainoa Biurrun Garrido, Carme Perelló Íñiguez, Bárbara Vidal Tegedor
The four principles of bioethics proposed by Beauchamp and Childress are commonly used to solve ethical issues in health sciences. This article suggests its application in the field of humanized attention to childbirth. Specifically, an analysis from a critical and contextualized perspective of principialism is proposed, considering the limitations of the original theory.
Medical philosophy. Medical ethics, Business ethics