Tailored tools to protect vulnerable patients We all expect high quality treatment from healthcare systems, but providing adequate protection for vulnerable people remains a major challenge. We spoke to Professor Samia Hurst of the University of Geneva about her work to develop a unified definition of vulnerability for use by healthcare professionals It is generally
agreed that vulnerable people deserve special protection or attention from our healthcare systems, but applying these protections remains a major theoretical and practical challenge. Based at the University of Geneva’s Institute for Biomedical Ethics, Professor Samia Hurst is coordinator of the Protecting Vulnerable Persons in Healthcare project, which aims to develop decision-making processes which will help protect vulnerable people in healthcare systems. “We started with two puzzles. First: there is broad consensus that vulnerable persons deserve greater attention or protection, but little consensus or even clarity on who the vulnerable are and what protections may be adequate. Second: we generally agree that fairness is important in healthcare, but agreeing on what fairness demands in this context is notoriously difficult,” she says. Vulnerability is part of the human condition to some extent, but some people are comparatively more likely to incur unjustified manifestations of vulnerability. “They are more likely to have their claims disregarded and thus to encounter wrongs,” continues Professor Hurst. “Applied to health care, this means that we can consider particularly vulnerable those who encounter an increased likelihood not to have their claims taken into just consideration.”
Vulnerability The first step in the project is to develop a clear definition of vulnerability that can be used by healthcare professionals and decision-makers, as well as patients and patient advocacy groups. The scope of this work is broad, bringing together researchers from different branches of medicine and philosophy to develop a unified definition that integrates all the
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various forms of vulnerability. “We are doing conceptual work to provide a definition of vulnerability that works. Once you have done that you can identify vulnerable populations, in part through existing data in the literature on, for example, the psychology of decisionmaking,” outlines Professor Hurst. Researchers are drawing from the sciences to understand why the claims of vulnerable people might not be considered as fairly as the claims of the less vulnerable. This difference in the evaluation of claims may often not be intentional on the part of healthcare professionals, but this fact does
everyone else,” says Professor Hurst. The project aims to help doctors assess each individual patient and tailor their interventions accordingly; Professor Hurst points to efforts to encourage patients to stop smoking as an example of how successful a tailored approach can be. “If you try and convince your patient to stop smoking there are conversations that are more or less scripted to help you do that, and also to adapt to where that person is with cigarettes, whether they have already contemplated stopping smoking, whether they’ve already tried, how willing they are and so on,” she
We are doing conceptual work to provide a definition of vulnerability that works. Once you have done that you can identify vulnerable populations, in part through existing data in the literature on, for example, the psychology of decision-making not make it less damaging to those who are vulnerable. “One hypothesis is that things like in-group bias – the fact that we tend to be more favourably inclined to people who are more like us – might have an impact on clinical decision-making,” says Professor Hurst. “This might actually explain part of what has been described in emergency situations, where there are disparities in the way in which people from different ethnic groups are treated.” Protecting these patients means ensuring their interests are taken into account in the same way as less vulnerable parts of the population. This does not necessarily mean treating everybody in exactly the same way, but rather moving towards tailored interventions that take the patient’s personal situation into account. “In some cases it means you will have to expend more effort for vulnerable patients simply to give them the same as
explains. “These conversations have been tested experimentally and they work. So if you take five minutes to try and convince your patient to stop smoking as a GP, a proportion of your patients will stop smoking.” Effective communication is crucial to the success of such interventions, and they need to be tailored further for some populations: this tends to be easier for doctors with patients of a similar educational background, as they are more likely to use similar language and be able to establish a personal rapport. Where that isn’t the case, these interventions work less well. Sometimes there are even bigger hurdles to overcome; migrant workers for example might be unfamiliar with how the health system works, not know the language, and have a precarious work situation, an accumulation of vulnerabilities that is greater than the
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