Both prevention and treatment of obesity are necessary means to reduce risk of severe disease Law, ethics and medicine

BackgroundThe use of involuntary admission in psychiatry may be necessary to enable treatment and prevent harm, yet remains controversial. Mental health laws in high-income countries typically permit coercive treatment of persons with mental disorders to restore health or prevent future harm. Criteria intended to regulate practice leave scope for discretion. The values and beliefs of staff may become a determinating factor for decisions. Previous research has only to a limited degree addressed how legal criteria for involuntary psychiatric admission are interpreted by clinical decision-makers. We examined clinicians’ interpretations of criteria for involuntary admission under the Norwegian Mental Health Care Act. This act applies a status approach, whereby involuntary admission can be used at the presence of mental disorder and need for treatment or perceived risk to the patient or others. Further, best interest assessments carry a large justificatory burden and open for a range of extra-legislative factors to be considered.MethodsDeductive thematic analysis was used. Three ideal types of attitudes-to-coercion were developed, denoted paternalistic, deliberative and interpretive. Semi-structured, in-depth interviews with 10 Norwegian clinicians with experience from admissions to psychiatric care were carried out. Data was fit into the preconceived analytical frame. We hypothesised that the data would mirror the recent shift from paternalism towards a more human rights focused approach in modern mental health care.ResultsThe paternalistic perspective was, however, clearly expressed in the data. Involuntary admission was considered to be in the patient’s best interest, and patients suffering from serious mental disorder were assumed to lack decision-making capacity. In addition to assessment of need, outcome effectiveness and risk of harm, extra-legislative factors such as patients’ functioning, experience, resistance, networks, and follow-up options were told to influence decisions. Variation in how these multiple factors were taken into consideration was found. Some of the participants’ statements could be attributed to the deliberative perspective, most of which concerned participants’ beliefs about an ideal decision-making situation.ConclusionsOur data suggest how a deliberative-oriented ideal of reasoning about legal criteria for involuntary admission lapses into paternalism in clinical decision-making. Supplementary professional guidelines should be developed.

The debate on responsibility for health takes place within political philosophy and in policy setting.

BackgroundNew approaches to control healthcare expenditures and increase access to quality care are required by decision-makers in high-income countries. One strategy is to reallocate tasks from doctors to nurses. Evidence suggests that quality, effectiveness and efficiency of task shifting are context sensitive and affected by implementation. However, little is known about implementability of task shifting in specialised healthcare. We aimed to identify factors perceived to influence implementation of doctor-to-nurse task shifting in a hospital setting and improve understanding of task shifting implementability by using theory-based frameworks for analysing behaviour. Nurse-led bone marrow examination exemplified task shifting from the medical to the nursing domain.MethodsDoctors and nurses (n = 17) in a haematology department at a Norwegian university hospital were asked about factors perceived to influence implementation of nurse-led bone marrow aspirations and biopsies. Methods included in-depth semi-structured interviews (n = 11) and focus-group discussion (n = 6). Data were analysed using the Capability, Opportunity, and Motivation behaviour model and the Theoretical Domains Framework.ResultsTen factors perceived to influence implementation were identified. Three factors were related to capability, including (1) knowledge and acceptability of task shifting rationale; (2) dynamic role boundaries; and (3) technical skills to perform biopsies and aspirations. Five factors were related to motivation, including (4) beliefs about task shifting consequences, such as efficiency, quality and patient satisfaction; (5) beliefs about capabilities, such as technical, communicative and emotional skills; (6) job satisfaction and esteem; (7) organisational culture, such as team optimism; and (8) emotions, such as fear of informal nurse hierarchy and envy. The last two factors were related to opportunity, including (9) project planning and leadership, and voluntariness; and (10) patient preferences.ConclusionTask shifting from doctors to nurses in specialised healthcare requires not only development of technical skills but also complex changes in organisation, clinical routines and role identity. Educational and organisational interventions to build a team-oriented culture could potentially increase the possibility of successful task shifting and stimulate nurses to take on untraditional responsibilities. Environmental restructuring to support doctors using their time in activities only doctors can perform may be needed to realise potential efficiency gains.

Lifestyle-induced diseases are becoming a burden on healthcare, actualizing the discussion on health responsibilities. Using data from the National Association for Heart and Lung Diseases (LHL)’s 2015 Health Survey (N = 2689), this study examined the public’s attitudes towards personal and social health responsibility in a Norwegian population. The questionnaires covered self-reported health and lifestyle, attitudes towards personal responsibility and the authorities’ responsibility for promoting health, resource-prioritisation and socio-demographic characteristics. Block-wise multiple linear regression assessed the association between attitudes towards health responsibilities and individual lifestyle, political orientation and health condition. We found a moderate support for social responsibility across political views. Respondents reporting unhealthier eating habits, smokers and physically inactive were less supportive of health promotion policies (including information, health incentives, prevention and regulations). The idea that individuals are responsible for taking care of their health was widely accepted as an abstract ideal. Yet, only a third of the respondents agreed with introducing higher co-payments for treatment of ‘self-inflicted’ conditions and levels of support were patterned by health-related behaviour and left-right political orientation. Our study suggests that a significant support for social responsibility does not exclude a strong support for personal health responsibility. However, conditional access to healthcare based on personal lifestyle is still controversial.