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Truth that Matters: A Role for Family Caregivers in the Care of People with Dementia
No full textPhoto by Danie Franco on Unsplash
ABSTRACT
This research paper explores the family caregivers' role in resolving the ethical dilemma of deception in dementia care. Family members possess the unique capability to engage in "white lies" in a manner that both respects and upholds an individual with dementia's identity.
INTRODUCTION
It was our usual family Shabbat dinner: golden flames flickered in crystal candleholders, and the smell of warm challah permeated the air. “Where is Elena?” my great-grandmother anxiously asked, scanning the doorway. “I am here, sitting right next to you, babushka!’’ my mother affectionately reassured her. Having raised my mother in Russia, my great-grandmother Tsilya, then in her early nineties, had resided in our Riverdale home for several years. “No, I know you are here, but where is the little Elena?” Any attempt to explain that “little Elena” had grown into an adult only agitated my great-grandmother. She eventually calmed down, distracted by the promise of a scrumptious meal. As Tsilya’s mind wandered back into the reality of her past, where my mother Elena was a young girl living in Tsilya’s modest flat in Leningrad, what we then believed was a temporary moment of confusion turned out to be the first glimpse into Tsilya’s future.
Over the next few years, as Alzheimer’s disease brought on Tsilya’s cognitive decline, erasing her memories and taking her identity with them, Tsilya’s concerns about the “little Elena” transformed into attempts at leaving the house to attend parties hosted by television celebrities. She would also cry and ask for her own mother at night. In the beginning, my mother always tried to uphold the truth and reorient my great-grandmother to the reality of her situation. However, as Tsilya’s cognitive decline advanced, my mother often had to redirect her attention to family photo albums or, in moments of extreme distress, resort to occasional “white lies” to validate some of her inaccurate beliefs. My mother’s actions provided such solace and felt so instinctive that I never questioned the legitimacy of her strategies to mitigate my great-grandmother’s distress. Nevertheless, over the last two decades, the issue of truthfulness in dementia care has become the object of study and contemplation by both medical professionals and ethicists alike.
I. Person-Centered Care for People with Dementia
Most current discussions about the care of people with dementia begin with the principles of person-centered care, a revolutionary new philosophy of care introduced in the 1990s by Tom Kitwood, an English social psychologist and gerontologist. Rather than treating a person with dementia in a medical, protocol, and task-based fashion, Kitwood advocates approaching the care of such patients through a more holistic method that considers social and environmental factors, rather than only the patients’ biochemical brain changes.[1] The main tenets of person-centered care include the awareness of the uniqueness and individuality of each person, the recognition of the subjective nature of experiences of people with dementia, and the maintenance of close relationships with people with dementia, allowing them to uphold bonds and lasting attachments to their loved ones.[2]
This philosophy of care highlights the importance of social interactions and interpersonal relationships in dementia care. “[T]o care for others,” Kitwood writes, “means to value who they are; to honor what they do; to respect their unique qualities and needs; to help protect them from harm and danger; and – above all – to take thoughtful and committed action that will help to nourish their personal being.”[3] Kitwood also emphasizes the need for people with dementia to have “a standing or status that is accorded by others.”[4] However, the emphasis on conferring personhood onto individuals through their relationships with others introduces a challenge in implementing person-centered care. If a caretaker acknowledges and respects the subjective reality of a person with dementia, who may perceive a reality disconnected from their present, the caretaker may have to compromise their commitment to absolute truth-telling. On the other hand, if a caretaker solely adheres to the objective truth, they implicitly delegitimize the subjective reality and experiences of people with dementia.
II. Truthfulness versus Therapeutic Lying in Dementia Care
Scholars contemplating truthfulness versus therapeutic lying in dementia care hold different views. Some believe that maintaining the selfhood of people with dementia justifies occasional deception, while others claim that only uncompromised truth-telling can offer people with dementia the respect they deserve from others. This dichotomy of opinion presents a moral dilemma for individuals and institutions involved in the care of people with dementia. However, family members caring for individuals with dementia possess a unique capability to navigate this dilemma.[5] They have a profound understanding of their loved ones' identities and personal stories, allowing them to preserve the selfhood of people with dementia through occasional therapeutic lying without compromising the integrity of their relationships. As a result, the inclusion of family caregivers in the conversation about the permissibility of therapeutic lying in dementia care can facilitate the implementation of true person-centered care for people with dementia.[6]
While a central argument for the necessity of uncompromised truth-telling to people with dementia rests on the importance of truth in maintaining human bonds, family members can uphold this value despite occasional deception. In her article “Truthfulness and Deceit in Dementia Care: An Argument for Truthful Regard as a Morally Significant Human Bond,” Dr. Philippa Byers, an ethics researcher, rejects the validity of lying for therapeutic purposes in dementia care. Byers argues that truth-telling is a moral value that establishes trustful relationships and therefore should not be denied to people with dementia. She grounds her argument in the notion of “truthful regard,” which she defines as the “regard for another person as one for whom truth matters, just as it does for oneself.” As a result, Byers contends that lying must be avoided to maintain truthful regard, rather than paternalism or condescension, in the caretaker’s relationship with a person with dementia. Despite her seemingly uncompromising stance, Byers does approve of refraining from truth-telling in interactions with a friend sharing the same story over and over again. [7] Byers claims that if one cares for their friend, one can forgo the truth-telling of informing the friend that one has heard the story before by making decisions “involving the judgment, discretion, and tact that is characteristic of (most) respectful communication with one another…without suspending our truthful regard” for the other person. In communicating with people with dementia, family caregivers embody the role of such friends. As a result, due to close social relationships with a person with dementia, family caregivers can eschew blunt truth-telling without compromising the truthful regard they hold for the person. When my great-grandmother would get upset and agitated in her desire to attend a party hosted by a television celebrity and when all efforts at redirecting her attention failed, my mother occasionally had to offer “white lies” in telling her that the host cancelled the party due to inclement weather. While not truthful, such statements did not undermine my mother’s truthful regard for my great-grandmother but served as a measure of last resort to ensure my great-grandmother’s safety by preventing her from leaving the house alone at night. Byers states that truthful regard for other people “does not require close affiliative bonds.” [8] Yet, it is precisely the existence of such close bonds that imparts special privileges on family members in their relationships with people with dementia, similarly to the way Byers affords such privileges to close friends. Family caregivers, therefore, may introduce the necessary “white lies” if their respectful judgment demands them.
III. The Inclusion of Family Caregivers’ Perspectives in Navigating Truth-Telling
Despite the demonstrated significance of family caregivers in navigating truth-telling in the care of people with dementia, current discourse on justifying deception in dementia care often overlooks the perspectives of family caregivers. Dr. Matilda Carter, a lecturer in philosophy at King’s College London, claims that an insistence on truth delegitimizes the subjective experiences and undermines the current identities of people with dementia.[9] Carter contends that the norm of truth-telling to dementia patients, whose cognitive decline and memory loss lead them to exist in their own version of reality, is an ableist construction that disrespects the perceived realities of people with dementia. Therefore, Carter argues that “withholding the truth from and, in limited circumstances, lying to people living with dementia is not only morally permissible, but morally required.” “Ethical deception” is morally justified as an act of respect in seeing people with dementia through the lens of “the type of person that they are.” However, Carter’s justification of ethical deception overlooks the significance of careful judgment in the use of deception in dementia care, violating the personhood of people with dementia.
An example illustrating Carter’s perspective on ethical deception and the negative consequences of neglecting the voices of family members of individuals with dementia can be found in the medical case study “How Much a Dementia Patient Needs to Know” by Dr. Oliver Sacks.[10] In this short work, Sacks, a neurologist and a best-selling author, describes Mr. Q., a nursing home resident with dementia. Having been employed as a janitor in his earlier years, Mr. Q. continued performing his “duties” in the nursing home. While the nursing home staff realized that his adherence to his former identity was a delusion, they “respected and even reinforced” Mr. Q.’s identity by encouraging his actions and providing him with instruments and supplies for his janitorial duties. Initially questioning whether Mr. Q. should have been told the truth about the reality of his condition, Sacks ultimately concludes that the objective reality holds little meaning for Mr. Q and that truth-telling would be “pointless” and “cruel.” The story of Mr. Q. aligns with Carter’s concept of ethical deception, as the residential care facility staff knowingly upheld Mr. Q.’s erroneous identity.
However, Carter’s philosophical framework overlooks the attitudes of family caregivers towards such ethical deception, considering the caregivers’ deep understanding of the wishes and identities of their relatives. Mr. Q.’s facility caregivers could have encouraged his janitorial activities for their own convenience, such as to minimize the time needed to attend to his care. Additionally, Mr. Q. could have believed in holding onto the truth until the very end. If not for the nursing home staff’s deception, Mr. Q.’s family could have had the opportunity to reorient him to reality. This highlights the importance of caregivers’ meticulous deliberation on the use of deception in their interactions with individuals with dementia. Without such consideration, deception may be driven by ulterior motives or may disregard the wishes of people with dementia and their family caregivers.
A 2020 study demonstrated that telling a “white lie” was found acceptable if intended solely to minimize harm to a person with dementia and particularly if introduced by a caregiver who really “‘kn[e]w the person.’”[11] This acceptance was rooted in the belief that “the deep knowledge [caregivers] had about the person, their past, and their current experience allowed them to use lying in a genuinely caring and respectful manner.”[12] Even more significantly, people with dementia emphasized the importance of consulting family members in decision-making during later stages of disease because these family members “knew what mattered to them the most.”[13] Since there are no clear references to Mr. Q.’s personal beliefs or his family’s wishes, one cannot fully confirm the moral validity of the nursing staff’s approach. Conversely, my mother’s extensive years of caring for my great-grandmother, coupled with her understanding of her beliefs, provides moral justification for her use of ethical deception to ensure my great-grandmother’s safety. Therefore, family caregivers’ profound understanding of the identities and circumstances of individuals with dementia allows them to utilize deception in a manner that upholds the selfhood of people with dementia without diminishing the importance of truth.
IV. Artificially Constructed Realities for People with Dementia
Regardless of the caregiver's type or intentions, some critics reject deception on the grounds that it leads to the construction of artificial realities for people with dementia.[14] Such critics claim that deception inherently contradicts the innate human desire for experiences grounded in true reality, a philosophical idea developed by American political philosopher Robert Nozick.[15] Nozick introduces the concept of an “experience machine,” a device that would provide desired experiences through targeted brain stimulation. Nozick claims that while the machine can allow people to feel good “‘from the inside,’” people would reject it because they want to “do certain things, and not just have the experience of doing them… to be a certain way, to be a certain sort of person.”[16]
Proponents of Nozick’s ideas might draw a parallel between Mr. Q.’s existence and a person hooked up to the experience machine since the nursing home staff’s treatment of Mr. Q. is not grounded in objective reality. However, people with dementia already live in their own subjective realities due to cognitive decline and frequent reversion to past identities. Therefore, upholding these realities differs from constructing them de novo. Furthermore, while the experience machine offers a passive existence, Mr. Q. can physically attend to the expected responsibilities of his believed identity. As a result, when artificially constructed realities are introduced with the well-being of individuals with dementia in mind, and by those who understand what that well-being entails, they offer genuine experiences that enable people with dementia to realize their individuality within the bounds of their cognitive abilities.
Artificially constructed realities and the importance of family caregivers in upholding the personhood of individuals with dementia living within such realities come into focus in De Hogeweyk, the first dementia village for people with advanced dementia.[17] De Hogeweyk, which opened its doors in Weesp, Netherlands in 2009, is a gated community with a single entrance and exit where its residents receive twenty-four-seven care.[18] The village aims to maintain continuity with the residents’ past lives by grouping them into themed homes based on their previous lifestyles and by offering familiar social events and physical activities.[19] Through thoughtful planning and design, the founders of De Hogeweyk have integrated all the “deceptive” aspects of their institutional reality into the village’s infrastructure, including residences that look like real homes, a supermarket that does not use money, and a restaurant and hair salon staffed by trained caregivers who do not require payment for their services.[20] Although it is a closed facility, De Hogeweyk welcomes both family members and outside volunteers of all ages to interact with its residents.[21]
While critics of De Hogeweyk have likened it to The Truman Show, multiple family members report their satisfaction with De Hogeweyk’s model of care.[22] Ada Picavet, whose husband Ben is a resident at De Hogeweyk, shares her experience of visiting him daily, playing the piano, and singing songs together. These activities serve as an attempt to preserve a sense of normalcy and continuity with their life before his dementia diagnosis.[23] While some might claim that their relationship is deceptive due to Ben’s limited cognitive abilities, Ada’s visits demonstrate a profound respect for her husband's subjective reality. She recognizes that his dementia shapes his perception of the world and maintains the continuity of his identity by allowing him to engage in activities they enjoyed together in the past, such as singing. By portraying Ada and other family members visiting their loved ones at De Hogeweyk as true partners in care, Dr. Sanjay Gupta, in his CNN report on De Hogeweyk, underscores the importance of family caregivers in addressing the moral dilemmas in dementia care through their understanding of the personal preferences and experiences of their loved ones with dementia.
De Hogeweyk aligns with Kitwood’s person-centered care model that emphasizes the recognition of individuality, dignity, and well-being of individuals with dementia. The infrastructure and social environment provided at De Hogeweyk contribute to an immersive world that resonates with the residents’ personal histories and identities. Despite the constructed nature of the residents’ world, its depth and significance come from the interpersonal connections between residents and their family members outside the dementia village. As a result, family caregivers can occasionally employ carefully considered acts of beneficent deception without undermining the importance of truth-telling in dementia care. They can also transcend the limitations of cognitive decline by providing love and dedication as the fundamental truths that matter.
CONCLUSION
At the end of her life, my great-grandmother Tsilya could no longer recognize or communicate with family members. She would sit quietly, staring at the wall. Yet, my family members and I continued to spend time with her every day, simply holding her hand or stroking her hair. While it may be true that these visits might not have mattered to my great-grandmother, who no longer had an awareness of the outside world, they upheld her selfhood in the eyes of our family and to everyone else around her. Family caregivers, like my mother, have the knowledge and experience to navigate moral dilemmas surrounding truth and deception in dementia care. As the number of people suffering from dementia continues to rise, future studies should examine new ways to engage family caregivers in helping to establish the true meaning of person-centered care.
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[1] Matthew Tieu, “Truth and Diversion: Self and Other-Regarding Lies in Dementia Care,” Bioethics 35, no. 9 (2021): 858, https://doi.org/10.1111/bioe.12951.
[2] Tom Kitwood, “The Concept of Personhood and Its Relevance for a New Culture of Dementia Care.,” in Care-Giving in Dementia: Research and Applications, ed. Bere M.L. Miesen and Gemma M.M. Jones, vol. 2 (Routledge, 1997), 10-11.
[3] Kitwood, 3.
[4] Kitwood, “The Concept of Personhood and Its Relevance for a New Culture of Dementia Care,” 4, 11.
[5] See “Holding One Another (Well, Wrongly, Clumsily) in a Time of Dementia,” an essay where Hilde Lindemann, a philosopher and a bioethicist, examines the role of family caregivers in upholding their loved ones with dementia’s identities.
[6] This essay is specifically concerned with informal family caregivers, such as children, close relatives, or romantic partners, as opposed to formal paid caregivers in the medical establishment. For people with dementia who have no informal caregivers and end up in institutional care early on, the lessons learned from family caregivers can contribute to creating guidelines for institutional person-centered care. See the United Kingdom’s Mental Health Foundation 2016 report “What is Truth: an Inquiry about Truth and Lying in Dementia Care” for a further discussion regarding the necessity for non-family caregivers to understand the life stories and values of people with dementia.
[7] Byers, “Truthfulness and Deceit in Dementia Care: An Argument for Truthful Regard as a Morally Significant Human Bond,” 231-232.
[8] Byers, 234.
[9] Matilda Carter, “Ethical Deception? Responding to Parallel Subjectivities in People Living with Dementia,” Disability Studies Quarterly 40, no. 3 (2020), .
[10] Oliver Sacks, “How Much a Dementia Patient Needs to Know,” The New Yorker, February 25, 2019, www.newyorker.com/magazine/2019/03/04/how-much-a-dementia-patient-needs-to-know.
[11] Dympna Casey et al., “Telling a ‘Good or White Lie’: The Views of People Living with Dementia and Their Carers,” Dementia 19, no. 8 (2020): 2583.
[12] Casey et al., 2593-1594.
[13] Casey et al., 2595.
[14] Robert Sparrow and Linda Sparrow, “In the Hands of Machines? The Future of Aged Care,” Minds and Machines 16 (2006): 155, https://doi.org/10.1007/s11023-006-9030-6.
[15] Sparrow and Sparrow, 155.
[16] Richard Nozick, Anarchy, State, and Utopia (Basic Books, 1974), 42-43.CNN’s World’s Untold Stories: Dementia Village (CNN, 2013), www.youtube.com/watch?v=LwiOBlyWpko.
[17] CNN’s World’s Untold Stories: Dementia Village (CNN, 2013), 02:00-02:13, www.youtube.com/watch?v=LwiOBlyWpko.
[18] CNN’s World’s Untold Stories: Dementia Village, 03:45-03:53.
[19]CNN, 05:10-06:00.
[20] CNN, 14:45-15:30.
[21] CNN, 20:20-20:40
[22] CNN, 06:50-07:55.
[23] CNN, 10:20-12:2
Colombia and Medical Tourism: Tourists or International Patients?
No full textPhoto ID 131102170 © Geckophotos | Dreamstime.com
INTRODUCTION
Medical tourism should contribute to developing a more robust healthcare system that acts in the best interests of patients and ensures equal access to healthcare. This paper examines medical tourism in Colombia and argues that developing a system that aligns with bioethical principles is necessary. People traveling for care should have access to the Ministry of Health rather than only the Ministry of Industry and Tourism, emphasizing their purpose as patients seeking medical procedures or treatments rather than tourists engaging in leisure activities. Additionally, in the interest of justice, Colombian patients should benefit from the revenue derived from medical tourism. It is crucial to recognize that both patients traveling for care and people in the destination country can derive benefits from medical tourism. The Colombian government can protect the rights and well-being of patients seeking care and ensure that any benefits are distributed fairly among Colombian citizens.
I. Background
Medical tourism refers to people traveling to foreign countries to obtain health care.[1] Many individuals from high-income countries seek health care in less developed countries to take advantage of the lower costs. Destination countries are increasingly showing interest in becoming medical tourism hubs due to the significant financial potential of this multi-billion dollar industry. The global medical tourism market is projected to reach 6.3 billion by 2032.[6]
Colombia intends to have medical tourism play a significant role in its economy. However, ethical issues exist. The Colombia Ministry of Industry and Tourism is more involved in medical tourism than the Ministry of Health is. Additionally, the government has not been held accountable for the shortcomings in the medical tourism industry. There should be an organization advocating for the rights and well-being of medical tourists. Furthermore, using public funds to attract international patients may divert funds from local communities. Last, the negative impacts of medical tourism on Colombian patients deserve attention. This paper aims to explore these ethical issues from two perspectives: that of medical tourists and that of Colombian citizens. I argue that the benefits of medical tourism outweigh the harms but that those traveling for health care deserve protection.
II. Patients: Are They International Patients or Tourists?
When medical tourists seek hospitals and physicians in a destination country, facilitators may direct them to non-licensed practitioners and questionable facilities. These facilitators, who receive commissions, may not act in the patient’s best interest. Rather, like travel agents, they base their referrals on the referral fees that hospitals or physicians pay.[7] International patients risk getting lower-quality health care from unregulated hospitals or providers. This can interfere with informed consent and increase the risk of infections. There may be an absence of medical malpractice coverage from physicians. Unregulated or unlicensed medical care may even lead to patient fatalities. Therefore, it is crucial for international patients to carefully evaluate the risks associated with “booking” their healthcare options.
To mitigate these risks, it is important for international patients to thoroughly assess the accreditation status of the hospital or clinic they plan to visit. The Joint Commission International (JCI) accreditation can provide patients with an external quality assessment and assist them in making an informed decision.[8] International patients should proactively seek out certified and reputable healthcare providers and institutions to ensure both their safety and a high quality of care. Colombia has five hospitals and clinics with JCI accreditation.[9]
Colombia is the third most-used destination for plastic surgery in the world; the first is Brazil, and the second is Turkey. In Colombia, one out of every three plastic surgery patients is an international patient.[10] The Colombian Association for Plastic Surgery advises all patients to check the hospital's accreditation. Patients should check the website of the local Secretary of Health in each city and see if the physician conducting the plastic surgery is listed.[11] Institutions and doctors must fully comply with requirements, including describing the procedure and obtaining informed consent from patients. It is very common to read in the media plastic surgeries conducted in what is known in Latin America as “clinicas de garage” (garage clinics) with negative results and deaths.[12] Official data covers plastic surgeries conducted at accredited institutions with registered doctors. There is a lack of data on garage clinics.
There are a few things the government can do to make medical tourism safer. First, the Ministry of Health’s website should maintain a list of healthcare providers with JCI accreditation. In each city, the local Secretary of Health is responsible for providing patients with information about the quality of care of the hospitals in its region. Second, the government should take responsibility for providing accurate and comprehensive information to international patients, enabling them to make fully informed decisions regarding their medical procedures. In the context of informed consent, patients may have trouble understanding due to language barriers, terminology, and the complexity of the risks involved in medical procedures. Lastly, Congress should enact a legal framework that determines the responsibility of all parties involved in medical tourism.[13]
In the unfortunate event that a medical tourist requires intensive care, it becomes imperative to determine who will bear the responsibility for their well-being and any potential financial implications. Medical tourists are not protected from errors and failures of medical procedures because the Colombia Constitution specifies that the healthcare system exclusively caters to its citizens, while coverage for foreigners is limited to emergencies only. The US State Department recommends that those traveling to Colombia have international health insurance.[14] International patients can sue doctors in Colombia for medical malpractice, referred to as medical liability.[15]
The government should take responsibility for certifying medical institutions and issuing medical visas with specific requirements and regulations specific to medical tourism.[16] A new medical visa system is in place. Changing the terminology may help the government see those traveling for care as medical patients rather than medical tourists. That may lead to a different mindset and spur the government to protect them and ensure high-quality care. It may also help those traveling avoid tourism industry facilitators and find reputable surgeons and hospitals.
III. Are Colombian Patients and the Local Healthcare System Benefiting from Medical Tourism?
The main reason for the growth of medical tourism from developed countries to developing countries like Colombia is the excessive cost of treatment in wealthier nations.[17] Other reasons include the long queues for certain types of medical services in the home country, the availability of better technologies abroad, inadequate (or absence of) health insurance, and the unavailability[18] (or prohibition) of certain medical services in the home country.[19]
The Colombian Constitution recognizes health as a fundamental right for all citizens.[20] Pursuant to the Constitution’s health mandate, Colombia designed a mandatory universal social health insurance system in 1993. It aims to achieve a fair distribution of resources, opportunities, and services while holding the government accountable.[21] Before 1993, less than 25 percent of the population had coverage; now, between 94 and 99 percent have it, regardless of income level or employment.[22] However, universal care does not entitle Colombian citizens to many of the modern surgical centers, technology, and doctors that tourists access. Local wealthy Colombian citizens tend to purchase private insurance that allows them many more healthcare options.[23] The OECD reports that only 41 percent of Colombian citizens were satisfied with the availability of the quality of care, while the OECD average is 67 percent. According to the OECD, the out-of-pocket health expenditure in Colombia is 14 percent, which is lower than the OECD average of 18 percent. Despite its recognized right to health care, the current system is not providing the quality of care that the people would prefer.
Those traveling to Colombia for care are not covered by universal social health insurance and must pay for their health care[24] out of pocket or through their private insurers using international coverage.[25] Like local supplemental private insurance, medical tourists and their insurance plans tend to pay more for their care than the rate that the universal system would pay the providers for care provided to the general Colombian population. This situation often leads to higher revenue from medical tourists than local patients unless the local patients have supplemental private insurance. The mismatched payment schemes leave the local population with unequal access to healthcare resources[26] since healthcare providers prefer to cater to patients paying more than the government-subsidized insurance pays. Medical tourism “threatens to result in a dual market structure”[27] characterized by a higher-quality, expensive segment that serves wealthy nationals and foreigners alongside a lower-quality segment that caters to the poor, most of whom are covered by universal healthcare coverage.[28]
Medical tourists should pay taxes or a special premium to improve the local healthcare system. While the medical tourism industry arguably generates tax revenue,[29] some additional money should flow from the medical tourists to the healthcare outlets that the local people use. Then, the country can benefit even more from promoting medical tourism while ensuring that the government and the healthcare system follow the principles of justice, beneficence, and public welfare.[30]
In Colombia, Fundación Cardioinfantil, a private non-profit hospital known as “La Cardio,” is a good example of a regional leader committed to providing clinical excellence to both national and international patients.[31] About 20 years ago, La Cardio, well known for its cardiovascular health care, aimed to become the top hospital in the region (Latin America and the Caribbean) to obtain financial resources for improving its facilities. It became the first hospital in Colombia to achieve the JCI accreditation, attracting patients from countries with inadequate cardiovascular healthcare systems.[32] Foreign governments covered their citizens’ medical expenses, allowing La Cardio to fund system improvement. Currently ranked as the fifth-best clinic in Latin America and having won the Gold Award for Corporate Social Responsibility, La Cardio has received recognition for its dedication to serving economically disadvantaged Colombian patients.[33] This example demonstrates how introducing a high-paying market has not led to neglecting local patients, as resources from medical tourists are used to enhance the healthcare system for the local population.
CONCLUSION
The Colombian government needs to recognize that international patients are seeking medical services, not tourism or vacation experiences. Therefore, a new policy should categorize international patients separately from the tourism sector and treat them purely as patients. The introduction of medical visas may help this. Once establishing international patients are patients and not tourists, the Colombian government could impose taxes on them and allocate the funds generated to reinvest in the healthcare needs of its citizens, ensuring justice and promoting awareness of the ethical rights of international patients. At the same time, home country governments directing patients to a destination country should conduct thorough due diligence of the ethical principles applied to international patients as well as the accreditation of the destination country’s hospitals. Colombia may be aware of the implications of the difference in terms but unwilling to modify the language due to the associated costs, liabilities, and risks involved.
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[1] Gaines, J., Lee, C. V. (2019). Medical tourism. Travel Medicine, 371–375. https://doi.org/10.1016/b978-0-323-54696-6.00039-2 https://www.sciencedirect.com/science/article/pii/B9780323546966000392
[2] Forecasted Evolution of Medical Travels, 2023-2027: A Segmental View. ReportLinker. (2023, December). https://www.reportlinker.com/p06473784/Medical-Tourism-Market-Size-Share-Trends-and-Analysis-by-Region-Service-Provider-and-Segment-Forecast.html
[3] Forecasted Evolution of Medical Travels, 2023-2027: A Segmental View. ReportLinker. (2023, December).
[4] Arias-Aragonés, F.J.A., Payares, A.M.C., & Jiménez, O.J. (2020). Characterization of the healthcare tourism in the city of Bogotá and the District of Cartagena. Clío América, 14 (28), 486-492. https://doi.org/10.21676/23897848.3941
[5] Arias-Aragonés, et al. (2020).
[6] Arias- Aragones, et al. (2020). https://www.colombiaproductiva.com/ptp-sectores/historico/turismo-salud (citing the Colombian Production Transformation Program (PTP))
[7] Glenn Cohen, Patients with Passports Medical Tourism, Law, and Ethics. New York Oxford University Press, 2015, p. 25
[8] Glenn, Cohen. (2015), p. 23-24.
[9] A Global Leader for Health Care Quality and Patient Safety. Joint Commission International. https://www.jointcommissioninternational.org/ (The five Colombian hospitals and clinics with JCI accreditation are two hospitals in the capital city Bogota (la Cardio and Fundación Hospital Universitario Santa Fé de Bogotá), one hospital in Cali (Clinica Inbanaco), one hospital in Medellín (Hospital Pablo Tobón), and one clinic in Florida Blanca (Fundación Cardiovascular de Colombia). Nearby countries such as Venezuela and Trinidad Tobago do not have any accredited hospitals or clinics. Ecuador and Panamá have one each, Perú has eleven, and Brazil has seventy-one.)
[10] International Society of Aesthetic Plastic Surgery ISAPS (2023), ISAPS International Survey on Aesthetic/Cosmetic Procedures performed in 2022, p. 52. https://www.isaps.org/discover/about-isaps/global-statistics/reports-and-press-releases/global-survey-2022-full-report-and-press-releases/ (most frequently cited countries of foreign patients in Colombia are the US, Spain, and Panama.)
[11] Why choose a member of the SCCP. (2023). Colombia Plastic Surgery Association (SCCP). https://cirugiaplastica.org.co/porque-elegir-un-miembro-de-la-sccp/ See also: To Find a Surgeon. (2023). Colombia Plastic Surgery Association (SCCP). https://cirugiaplastica.org.co (This website is helpful for checking the list of members of the SCCP.)
[12] Cosmetic Surgeries Performed in Garage Offices can Become a Public Health Problem. Concejo de Bogotá D.C. (2022). https://concejodebogota.gov.co/cirugias-esteticas-practicadas-en-consultorios-de-garaje-se-pueden/cbogota/2015-07-17/100100.php (There are many cases of deaths resulting from illegal plastic surgeries. The local government in Bogota is aware of the deaths, as reported in the Bogota Counsel (2015)). See also Travel.State.Gov, US Department of State, Bureau of Consular Affairs. (August 17, 2023). https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html (There is a warning that says: “Although Colombia has many elective/cosmetic surgery facilities that are on par with those found in the United States, the quality of care varies widely. If you plan to undergo surgery in Colombia, carefully research the doctor and recovery facility you plan to use. Make sure that emergency medical facilities are available, and that professionals are accredited and qualified. Share all health information (e.g., medical conditions, medications, allergies) with your doctor before surgery.")
[13] Arias-Aragonés, F.J.A., Payares, A.M.C., & Jiménez, O.J. (2020), p. 490. (report “the absence of regulation and a legal framework that determines the responsibilities of each link in the production chain” as a difficulty that affects competitivity to become a leader in medical tourism in the Latin American region.) See also: Trujillo, M. A. (2023, November 24). Colombia’s New Bill on Regulating Cosmetic Surgeries. BNN Breaking. https://bnn.network/breaking-news/health/colombia-to-regulate-cosmetic-surgeries-a-step-towards-patient-safety/ (On November 22, 2023, as a response to rising cases of death and injuries associated with plastic surgeries, a bill was introduced in the Colombian House of Representatives to regulate the practice of cosmetic surgeries and protect the integrity of patients)
[14] U.S. Department of State, Travel.State.Gov, Colombia. (August 17, 2023). Traveler’s Checklist, https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html
[15] U.S. Department of State, Travel.State.Gov, Colombia. (August 17, 2023). Traveler’s Checklist. See also: Medical Tourism and Elective Surgery. The Department of State informs that “U.S. citizens have suffered serious complications or died during or after having cosmetic surgery or other elective surgery“ and “the legal options in cases of malpractice are very limited in Colombia,” https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html See also: The law firm Alvarez Gonzalez Tolosa Attorneys. (August 8, 2023). Medical Malpractice in Colombia, includes medical malpractice as one of the areas of expertise of the firm. https://www.agtattorneys.com/blog/medical-malpractice-in-colombia/
[16] Colombia recently enacted a new visa regulation (Resolution 5477 from July 22, 2022, issued by the Ministry of Foreign Affairs) effective as of October 22, 2022. No data currently exists about a "medical treatment" visa because it is a new legislation. Even though the regulation refers to the visitor as a patient and includes requirements such as (1) a letter from the medical institution explaining the treatment and approximate duration, (2) a letter explaining costs and who will pay for the treatment, (3) insurance policy, and (4) the general requirements for tourists, the regulation specifically explains that this kind of visa is considered as a TOURISM visa (art 37).
[17] Glenn, Cohen. 2015
[18] Frequently Asked Questions. Bioxcellerator. https://www.bioxcellerator.com/faqs (For example, Bioxellerator stem cell therapies conducted in Medellin, Colombia, are not FDA-approved.)
[19] Vovk, Viktoriia, Lyudmila Beztelesna, and Olha Pliashko. (2021). "Identification of Factors for the Development of Medical Tourism in the World" International Journal of Environmental Research and Public Health 18, no. 21: 11205. https://doi.org/10.3390/ijerph182111205
[20] Colombian Constitution. (1991). art. 49
[21] Ministry of Health and Protection. Columbia Ministry of Health. (2023). https://www.minsalud.gov.co/English/Paginas/Ministry.aspx
[22] “Does Colombia’s Health System Need an Overhaul?” (March 2, 2023). The Dialogue, Latin America Advisor. https://www.thedialogue.org/analysis/does-colombias-health-system-need-an-overhaul/
[23] Health at a Glance 2021 Colombia Country Note. OECD. (2023). https://search.oecd.org/colombia/health-at-a-glance-Colombia-EN.pdf
[24] Travel.State.Gov, US Department of State, Bureau of Consular Affairs.
https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html
[25] Glenn, Cohen. (2015). p. 2-9.
[26] Banco de la República. (2023). Regional Health Inequalities in Colombia. https://www.banrep.gov.co/en/regional-health-inequalities-colombia (The Central Bank of Colombia (“Banco de la República”) in reports that despite having relatively high health coverage compared with other countries, empirical results show persistent inequalities in the healthcare system. The aim is to reduce and eventually eliminate such inequalities.)
[27] Glenn, Cohen (2015), p. 158-160, citing Rupa Chanda, an Indian business professor, Trade in Health Services, 80 Bull. World Health Org. 158, 16
Closed Circuits
No full textLandline, Lifeline is a sculpture by Kamari Carter in which four telephones play cauterised halves of 911 emergency call conversations. The listener hears the callers and despatchers separately, together or in new configurations, implicating themselves in the process.
Carter is an artist living in New York City and Providence, Rhode Island. He speaks here to his colleague Julian Day about the piece and the ideas that drive his practice: critical eavesdropping, hidden systems and racialised discrepancies of power.Included here is a video of the original installation alongside an interactive web version of the work and the conversation between Carter and Day as both edited text and audio
Racializing the Climate Justice movement in education
No full textIn this essay, we argue for racializing approaches to teaching climate change to better understand and address climate injustices. We draw upon the example of the Buffalo Blizzard of 2022 which caused a disproportionate number of deaths in the Black community. Extreme weather events such as the blizzard highlight the ways in which climate catastrophes and racial injustices are inextricably linked. We urge educators across all content areas to incorporate a climate justice education approach and outline an approach to transformative climate justice learning
Educating College Students about Dating Violence Bystander Behaviors: Evaluating an Innovative Animated Intervention
Get PDFDue to the extensively social nature of college campuses, peer intervention is a valuable tool for the reduction of college dating violence. While bystander training programs are becoming a common tool for addressing student welfare concerns on college campuses, there is little research evaluating the efficacy of these interventions. The purposes of this study were to revise an online bystander intervention program (STOP Dating Violence; O’Brien et al., 2021) and conduct a randomized controlled trial to test the effectiveness of this revised intervention. Specifically, the intervention was modified and converted into an engaging animated video and then tested for its effectiveness. College students (N=335) were randomly assigned to one of three conditions: (1) the STOP intervention, (2) a website containing information about dating violence, and (3) a control condition. Students who viewed the STOP Dating Violence video intervention had the greatest knowledge of bystander interventions when compared to the website and control conditions. Thus, the STOP Dating Violence video has potential to successfully educate undergraduates about appropriate bystander interventions for dating violence in a cost effective manner
Prevalence, Comfort With, and Characteristics of Sex Toy Use in a US Convenience Sample using Reddit.com
Get PDFAlthough Döring and Poeschl (2020) have presented findings on the use of a broader range of sex toys from a German national sample, little is known about the prevalence and characteristics of users of a broad range of sex toys in the United States. The present study aims to examine the prevalence, characteristics of, and comfort with sex toys among a sample of American adults (n = 231). Within this study, the term “sex toy” refers to any object used directly on the body (e.g., vibrator, dildo, handheld masturbator), while “sexual aids” refers to items that may enhance sexual pleasure or libido (e.g., lubrication, aphrodisiacs). We used survey data that was previously collected in 2020 using Reddit.com/r/SampleSize and Ball State University’s Communications Center to solicit participation. Using data from Döring & Poeschl (2020) to assess sex toy use, we added questions regarding participant comfortability using sex toys in the past. If the participant had never previously used sex toys but would be willing to do so in the future, we asked about the perceived comfort of using a sex toy. We also asked about the perceived positive and negative effects of toy use, as well as a number of possible predictors of use including personality, sexuality, mental health, and trauma-related experiences (sexual assault, sex problems/dysfunctions, being diagnosed with PTSD). Our findings revealed that a significant portion of Americans have previously used sex toys. Among our participants who have never used a sex toy, a significant portion said they would be willing to try doing so in the future. Future research could examine prevalence, comfort with, and characteristics of sex toy use among a more sexually and racially diverse sample. Implications for sexual health will be discussed in terms of the Positive Sexuality and Positive Technology frameworks
Choosing a Frame: How Medusa Tells the Story of Trauma and Life After Trauma
No full textThis paper names the elements of the Medusa myth that make it an uncanny allegory for trauma and examines the role of choice—both having choice and offering choice—in the treatment of trauma. It considers two perspectives on the myth: (1) Medusa as a captive object to the hero in the myth and (2) Medusa as an autobiographer, the narrator of her own story, and a subject working to establish more control over her own experience. This myth translates to the social work space. When a clinical social worker acts as the listener/observer and a patient as narrator/autobiographer, the social worker is uniquely positioned to support the patient in reclaiming life after trauma
Attractor States in Second Language Development
Get PDFIdentifying changing patterns of stability and variability is crucial when examining second language development (SLD) from a complex dynamic systems theory (CDST) perspective (Larsen-Freeman, 2020). By studying attractor states, or recurrent patterns of stability, light can be shed on the underlying dynamics of a complex dynamic system (van Geert & Verspoor, 2015). In the context of SLD, attractor states can be observed in individuals’ linguistic behaviors, as well as learners’ interactions with others (Hiver, 2014; van Geert & Verspoor, 2015). As such, attractor states have been cited in recent SLD literature (e.g., Amerstorfer, 2020; Evans & Larsen-Freeman, 2020; Syed et al., 2021; Gillies & Roger, 2022). The conceptual unpacking of attractor states can therefore be invaluable for SLD scholars seeking to enter the realm of CDST. Accordingly, serving as a stepping stone for those looking to foray into the CDST paradigm, this forum piece offers a definition of attractor state, identifies and describes different types of attractor states, clarifies some possible misconceptions about attractor states, and provides a few examples of attractor states in SLD
On Validity
Get PDFThe way in which validity has been conceptualized has changed throughout the years. The focus in validation studies shifted from evaluating distinct components of validity to developing a comprehensive argument for the use and interpretations of test scores. The argument-based approach to validity incorporates the distinct types of the componential approach, underscores Messick’s attention to construct validity, highlights the need for evidence of the evidence-gathering approach, and combines it all into one logical argumentative structure. Such a comprehensive argument is now an indispensable part of validity studies (Dursun & Li, 2021)