ICF course introduction
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ICF course introduction
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ICF course introduction
- 1. Sentrum vir Gesondheidsberoepe Onderwys Centre for Health Professions Education Fakulteit Gesondheidswetenskappe Faculty of Health Sciences International Classification of Functioning, Disability & Health --- Interprofessional Care Framework for the biopsychosocialspiritual approach to patients, communities and systems --- Stefanus Snyman DAY 1: The ICF? What?
- 2. What on earth are you doing here? • Name • Your role in College • What is your role in health professions education? • Expectations of the ICF course?
- 3. Outcomes of ICF series of workshops • Apply the World Health Organisation’s International Classification of Functioning, Disability and Heath (ICF) as a framework for interprofessional team work to improve patient outcomes and strengthen health systems. • Argue why the ICF framework may be a catalyst to improve patient-centred and community-centred care, as well as the morale and motivation of staff.
- 4. Overview of ICF series (1) • Day 1: • Introduction to Health Professions Education for 21st century: • Overview of the ICF framework in the context of ethics and human • Interprofessional teams work out and present a case study • After Day 1 • Structured reflection (1h) (within 1 week) • Each interprofessional team prepare 1 case study to present at next workshop (3h)
- 5. Overview of ICF series (2) • Day 2 • Presentation by interprofessional teams on their real case study (Summative and formative assessment by peers (including ethics / human rights) • After Day 2 • Structured reflection on interprofessional case study that your team presented (1hour) • Interprofessional team prepare a draft document to submit to the Department of Health motivating the ICF framework as an approach to encourage patient-centred and community-centred care (4 hours)
- 6. Overview of ICF series (3) • Day 3: • Interprofessional teams conduct a ward round in hospital (1 patient for a group) based on the ICF framework, including team discussion, management plan and feedback to patient • Feedback by interprofessional teams regarding their proposed approach to present to the Department of Health a motivation to promote the use of the ICF framework to improve patient- and community- centred care • Summative and formative assessment of presentation • After Day 3: • Structured reflection & evaluation of course
- 7. Learning Resources • Taking notes during this contact session • ICF eLearning tooI: http://icf.ideaday.de/en/page26086.html • ICF Beginners Guide • ICF Checklist (email) • ICF Draft User Guide (email) • ICF Book (email) • ICF online: http://www.who.int/classifications/icf/en/ Your common sense !!!
- 8. The future of HPE in 1910 • Introduction of basic sciences in medical curricula • Doubling of human lifespan1910
- 10. Lancet December 2010 Health professionals have made huge contributions to health and socio-ecomonic development over the past century, but we cannot carry out 21st century health reforms with outdated or inadequate competencies…. That is why we call for a new round of more agile and rapid adaption of core competencies based on transnational, multi-professional, and long-term perspectives to serve the needs of individuals and populations What we need, more than just disciplinary knowledge and skills, is a well-rounded health professional acting as change agent to address the health needs of the 21st century
- 11. Transformative Learning Interdependence in Education Health Equity Patient-centred Population- based Locally responsive Globally connected Open educational resources Competency-based Responsive to rapidly changing needs Creative use of IT VISION Adapted from: J Frenk, L Chen, ZA Bhutta et al: Health Professionals for a new century: transforming education to strengthen health systems in an inderdependent world. www.thelancet.com, 2010;376:1923-1958 The Lancet et al. challenge
- 13. Adapted with the permission of CanMEDS © 2005
- 15. In search of an Interprofessional Care/Collaboration Framework: a common language and approach A statistical, research, clinical, social policy and educational tool to: • Provide scientific basis • Interprofessional teamwork • Common language • Permit comparison • Systematic coding scheme
- 17. Interdependence • Appreciate community workers role • Commit to teamwork Transformative learning • Ownership for holistic patient care • Question biomedical model used in tertiary hospitals • Integrate ethics and human rights in patient care • Initiate IPE community projects in response to gaps indentified using ICF Health system strengthening • Preceptors apply ICF in teaching and practice • Adopt ICF as approach to patient care in PHC and district hospital settings • Service providers request capacity building in ICF • Influence patient outcomes Results from study
- 18. International importance • Play important role to write WHO’s ICF User Guide • 1 of 4 projects worldwide selected by Institute of Medicine’s Global Forum of Innovation in Health professions Education
- 19. ICF @ the individual level • For the assessment of individuals: What is the person's level of functioning within their particular context? • For individual treatment planning: What treatments or interventions can maximize functioning? • For the evaluation of treatment and other interventions: What are the outcomes of the treatment? How useful were the interventions? • For communication among physicians, nurses, physiotherapists, occupational therapists and other health works, social service works and community agencies • For self-evaluation by patients: How would I rate my capacity in mobility or communication?
- 20. ICF @ the institutional level… • For educational and training purposes • For resource planning and development: What health care and other services will be needed? • For quality improvement: How well do we serve our clients? What basic indicators for quality assurance are valid and reliable? • For management and outcome evaluation: How useful are the services we are providing? • For managed care models of health care delivery: How cost-effective are the services we provide? How can the service be improved for better outcomes at a lower cost?
- 21. ICF @ social level • For eligibility criteria for state entitlements such as social security benefits, disability pensions, workers’ compensation and insurance: Are the criteria for eligibility for disability benefits evidence based, appropriate to social goals and justifiable? • For social policy development, including legislative reviews, model legislation, regulations and guidelines, and definitions for anti-discrimination legislation: Will guaranteeing rights improve functioning at the societal level? Can we measure this improvement and adjust our policy and law accordingly? • For needs assessments: What are the needs of persons with various levels of disability -impairments, activity limitations and participation restrictions? • For environmental assessment for universal design, implementation of mandated accessibility, identification of environmental facilitators and barriers, and changes to social policy: How can we make the social and built environment more accessible for all person, those with and those without disabilities? Can we assess and measure improvement?
- 22. The qualifiers Individual / Community Functioning & Disability Body function & structure Change in body function Change in body structure Activities & Participation Capacity Performance Contextual factors Environmental factors Barriers / Facilitators Personal Factors
- 23. Defining concepts (1): Body function and structure Health condition / service (individual / community) Body function & structure (Impairment) Activities (Limitations) Participation (Restriction) Personal factors Environmenta l factors Contextual factors
- 24. Defining concepts (1): Body function and structure • Body functions Physiological functions of body systems • Body structures Anatomical parts of the body
- 25. Body function and structure: Impairment (2) • Mental status • Sensory functions (vision, hearing, vestibular, pain) • Voice and speech • Vascular and circulatory system • Respiratory system • Endocrine, digestive and metabolic • Genito-urinary and reproductive systems • Skin and related structures
- 26. Defining concepts (3): Activity and participation Health condition / service (individual / community) Body function & structure (Impairment) Activities (Limitations) Participation (Restriction) Personal factors Environmenta l factors Contextual factors
- 27. Defining concepts (3): Activity and participation • Activity Tasks or actions • Activity limitation Inability / difficulty to perform an activity in the manner or range considered normal for all individuals of a similar group • Participation Life roles • Participation restriction Problems related to social roles
- 28. Defining concepts (4): Participation • Life roles • 9 domains of participation • Participation restriction: Problems related to social roles
- 29. Participation domains (1) • Learning and applying knowledge • General tasks and demands • Organising and planning tasks • Multiple tasks • Using money and finance • Communication • Verbal (understanding and producing) • Nonverbal (understanding and producing)
- 30. Participation domains (2) • Mobility • Indoors (home) • Outdoors • Transportation
- 32. Participation domains (3) • Self care • Personal care • Health care • Domestic life • Domestic management and tasks
- 33. Participation domains (4) • Interpersonal interactions • Family • Intimate • Informal • Major life • Education • Employment
- 34. Participation domains (5) • Community, social and civic life • Community • Recreation and leisure • Religion and spirituality
- 35. Defining concepts (3): Activities • Tasks and actions related to fulfilling your social and life roles • Examples Moving in bed, transfers, walking, driving, dressing, washing, grooming, cooking, cleaning, doing laundry, ironing, taking out the garbage, performing working tasks, using the computer etc. • Activity limitation Inability / difficulty to perform an activity in the manner or within the range considered normal for all individuals or a similar group
- 36. International Classification of Functioning (ICF) Health condition / service (individual / community) Body function & structure (Impairment) Activities (Limitations) Participation (Restriction) Personal factors Environmenta l factors Contextual factors
- 37. Defining concepts (4): Contextual factors • Environmental • Personal Represent the specific context and background of an individuals life
- 38. Environmental factors • Products and technology • Natural environment and man made changes • Support & relationships • Attitudes • Services, systems & policies
- 40. Personal factors • Positive / negative • Age • Gender • Race • Education • Experiences • Personality • Aptitude • Coping styles • Lifestyle • Fitness, etc.
- 41. The ICF • Function & Disability is… Result of a complex relationship between health condition, participation and contextual factors • Contextual factors • May hinder / cause barriers • May facilitate • No linear relationship between impairment / activity / contextual factors
- 42. Examples: Disabilities that may be associated with the 3 levels of functioning linked to a health condition.
- 43. Different levels of disability are linked to three different levels of intervention.
- 45. Example of patient presentation
- 46. Rumours • Time • Complex • Impossible
- 47. Barriers • Professional tribalism • Biomedical model • Tradition • Individual stars • Against transformative learning – a threat
- 48. ICF within ethical, human rights and legal framework Health condition / disorder / disease Body function & structure (Impairment) Activities (Limitations) Participation (Restriction) Personal factors Environmenta l factors Contextual factors In context of ethics, human rights and legal framework Bio-psycho-social-spiritual approach
- 49. BATHO PELE Access Openness and Transparency Consultation Redress Courtesy Service standards Information Value for Money PATIENT CHARTER Healthy and Safe environment Participation in Decision-Making Access to Health Care Knowledge of one’s health insurance/medical aid scheme Choices in health services Treated by a named health care provider Confidentiality and privacy Informed consent Refusal of treatment A second opinion Continuity of care Complaints about health services Better patient outcomes and Improvement of health system
- 50. Questions
- 51. (1) Assess (2) Compile interprofessional management plan Health condition / disorder / disease Body function & structure (Impairment) Activities (Limitations) Participation (Restriction) Personal factors Environmenta l factors Contextual factors In context of ethics, human rights and legal framework Bio-psycho-social-spiritual approach
- 52. Case study example • Mr X, 45-year old male • with below-knee amp R side, three days ago. Eager for prosthesis. • Medical history: Type I diabetes • Social history: weekend alcohol abuse and smokes 15 cigarettes per day. • Permanently employed as skilled labourer (bricklayer) by builing contractor for RDP housing. • Lives in Parow. Own home, accessible.Uses public transport. Plays darts recreationally. • Married. Supporting family. Wife does not work. Three dependent school-going children.
- 53. Let’s apply it… Health condition / disorder / disease Body function & structure (Impairment) Activities (Limitations) Participation (Restriction) Personal factors Environmenta l factors Contextual factors In context of ethics, human rights and legal framework
- 54. What’s the patient’s condition? Patient (Health condition disorder / disease) Body function & structure (Impairment) Activities (Limitations) Participation (Restriction) Personal factors Environmental factors • R below knee amputation – wound present • DM pathology (eyes, kidneys, CVS, sensation) • ? Lungs • ? Liver • ? Mental health •Limited walking ability (affects walking to taxi/station/work environment) •Unsafe when bathing and using the toilet •Cannot use train •Work •Family (economic & social support) •Domestic tasks •Leisure time •Health care access Negative •Alcohol •Smoking •Life style - nutrition •Self worth •? Stress / Coping skills •Grade 8 education Positive •Economically active age •Physically fit and strong •Positive about receiving prosthesis Barriers •Social •Employer attitude •Inaccessible public transport •Delayed prosthetic rehabilitation Individual •Nil Facilitators Social •EEA •Employment benefits Individual •Access to home, etc. •Supporting family Diabetis Type 1
- 55. Management (1): Short-term & Medium to Longterm Patient (Health condition disorder / disease) Body function & structure (Impairment) Activities (Limitations) Participation (Restriction) Personal factors Environmental factors Diabetes • Work: • Sick leave benefits (Dr, Co) • Temp dis / UIF during rehab period (OT, Co, Dr) • Social support between sick leave & temp dis (Co, OT, SW, Ds) • Family support / counseling (SW, Ds) • If delayed rehab results in loss of employment: Alternative placement / retraining, re- employability [OT, PT, SW, Dr] • Revise temp dis 6/12 [AT, PT, Dr, Co] • Revise any social family support [SW, Ds] • Pain mgt, wound & skin care, Anti- sepsis (Sr) • Stump maturation & oedema management (PT, OT, Sr) • Control DM & target organs (Dr, Sr) • ?Angina (Dr) • Secondary prevention management & training (Dr, Sr, OT, PT) • Medication (Pharmacist) • Counselling (Ps, SW, Sr, Dr, Rev) • DM diet education (Sr, Dr, Dietician) • DM, Rook, -OH (All) • Early rehabilitation intervention – e.g. balance retraining (OT, PT) • Rehabilitation management planning with client (All) • Prosthesis [Pr Sr, PR, PT] • DM control & manage [Dr, Sr] • Smoke, Alcohol [All] • Improve standing & walking balance for gait & self-care activities (PT, OT) • Improve gait endurance & dynamic balance (PT, OT) • Assess need for temp wheelchair (PT/OT) • Optimise self care by improving safety, e.g. provision of assistive device (e.g. bath board, grab rails) [PT/OT] • Prosthetic rehab with focus on gait, domestic tasks, work activities [PT, OT] Due to inaccessible transport & potential loss in income in early phase: • Arrange for transport for medical care and rehab access • Consider need for inpatient rehab
- 56. Management (2): Short-term & Medium- to Long-term Patient (Health condition disorder / disease) Body function & structure (Impairment) Activities (Limitations) Participation (Restriction) Personal factors Environmental factors Diabetes • Work: • Sick leave benefits (Dr, Co) • Temp dis / UIF during rehab period (OT, Co, Dr) • Social support between sick leave & temp dis (Co, OT, SW, Ds) • Family support / counseling (SW, Ds) • If delayed rehab results in loss of employment: Alternative placement / retraining, re- employability [OT, PT, SW, Dr] • Revise temp dis 6/12 [AT, PT, Dr, Co] • Revise any social family support [SW, Ds] • Wound & skin care, Anti-sepsis (Sr) • Stump maturation & oedema management (PT, OT, Sr) • Control DM & target organs (Dr, Sr) • Secondary prevention management & training (Dr, Sr, OT, PT) • Medication (Pharmacist) • Counselling (Ps, SW, Sr, Dr, Rev) • DM diet education (Sr, Dr, Dietician) • DM, Rook, -OH (All) • Early rehabilitation intervention – e.g. balance retraining (OT, PT) • Rehabilitation management planning with client (All) • Prosthesis [Pr Sr, PR, PT] • DM control & manage [Dr, Sr] • Smoke, Alcohol [All] • Improve standing & walking balance for gait & self-care activities (PT, OT) • Improve gait endurance & dynamic balance (PT, OT) • Assess need for temp wheelchair (PT/OT) • Optimise self care by improving safety, e.g. provision of assistive device (e.g. bath board, grab rails) [PT/OT] • Prosthetic rehab with focus on gait, domestic tasks, work activities [PT, OT] Due to inaccessible transport & potential loss in income in early phase: • Arrange for transport for medical care and rehab access • Consider need for inpatient rehab
- 57. What now? • Structured reflection • Max 500 words (1-1½ pages). • Prepare your real case study to present on ….. • Each interprofessional team prepare 1 case study to present at next workshop on ??? • Compile your teams now! Give names to Maryke • Pitch on ….: The ICF - it works! • Diarise the last workshop: … The ICF - what are we waiting for?
- 58. Instructions for structured reflection • Introduce yourself (name, family, occupation, position) [2 paragraphs] • What was your understanding of the ICF before today? (Refer to the notes you made during the introductions) [1 paragraph] • What on earth were you doing here today? What was your expectations of this series of workshops? (Refer to the notes you made during the introductions) [1 paragraph] • Identify and critically analyse your positive and negative feeling about the ICF after the first session in the context of (1) health professions education and (2) patient-centred care. [½ -1 page]
- 59. Thank you
Editor's Notes
- Students took greater ownership for holistic patient-centred care Students committed to IP biopsychosocialspiritual model of care, questioning the outdated, traditional biomedical approach still modelled in most medical schools. Students were able to integrate ethical and human rights issues in patient care. Students appreciated and took an interest to work in a rural and community-based setting after graduation. Students started IP community projects in response to gaps identified by applying the ICF framework while caring interprofessionally for patients.
- Use this example to show how there is no linear relationship between impairment activity and part Restr. Also emphasise the extent to which contextual barriers may result in part restr, irrespective of the severity or presence of impairments.
- Emphasize the intervention and prevention strategies linked to each element. Link to SA health care approach of primary prevention. Emphasise secondary prevention in chronic conditions. Note the need for management / containment of contextual factors to successfully integrate a patient back into society and his social roles. Service providers to be aware of the impact of these factors on pt’s ability to attend appointments, or rehab or be able to follow health care protocol.
- Explain perceptions. If time allows, explain impact of contextual factors if this is 1st world setting vs 3rd world setting where patient has to walk to clinic, work, stand in train etc. vs. driving to work, etc.
- Discuss and explain the different concepts in 10-15 minutes. Assess if students can apply it in case study to follow. Notes from Willie Pienaar in “Textbook of Psychiatry” on principle-based ethics, p.38-41. Principle-based ethics represents a number of principles, which support the shared moral values of society. These principles are always prima facie (not absolute, but always valid at face value), place a duty on the individual to respect them, and are not contrary to any other moral theory. The four principles that today form the foundation of bio-ethics arguments are (i) respect for the autonomy of every person, (ii) beneficence, (iii) non-malevolence and, (iv) justice. Every person agrees about the intrinsic value of these four principles and they are therefore often called the common-morality. Autonomy. Everyone has a right to self-determination. This means, allowing an autonomous agent (person) the right to voice his or her own opinions, make decisions and to act according to his or her own values or belief systems. What is an autonomous agent (person)? This is someone who is free from the ‘control’ of another individual and someone who is free from limitations in his or her own decision-making. For the psychiatrist, it is often extremely difficult to judge whether a person with a mental illness is ‘free’ from the limitations to free choice. Sometimes it is easy, as when a patient is suffering from a severe psychotic disorder and is without contact with reality and is a danger to himself and possibly to others. This patient is temporarily not an autonomous person, and should the therapist be in a position to restore autonomy, it would be beneficent to intervene and treat him. In other borderline cases it might be extremely difficult to determine when one should temporarily limit autonomy and when not. Consider patients with severe depression with suicidal thoughts or patients with life-threatening anorexia nervosa. These difficult scenarios underline the essence of principle-based ethics. The principles give us good and valuable points of departure, but difficult decisions will still have to be made daily. The four principles can be opposed to one another, and that is why it is essential to weigh and balance these principles. Nevertheless, it is vital for the therapeutic team to respect the patient’s autonomy. Very good reasons should exist for the temporary suspension of the principle of respect for autonomy. (More will be said on this topic in the section Informed Consent, Competence and Therapeutic Actions). It is the duty of the therapist to empower the patient (person) or, otherwise stated, to inform the patient in such a manner that he or she is able to make informed decisions. In order to do this, the doctor must do five things: Speak the truth Respect the patients’ privacy Respect confidentiality Obtain informed consent Aid the patient in making decisions by imparting helpful information and discussing treatment options, but only if such help is requested. However, it is very easy for the therapist to be paternalistic. His or her knowledge, experience, skills and even good intentions contribute to this attitude. In addition, the patient’s faith in our profession and the fact that help is being requested make a paternalistic approach such a common state of affairs. We must be careful when we use the word ‘paternalism’. Paternalism may mean ‘loving father’. An example of this would be if the therapist makes a sincere decision to go against a patient’s wishes in order to ensure a better outcome for the patient or to avoid harm. In certain therapeutic situations this type of paternalism is good. Another form of paternalism can never be good. In this form, paternalism means ‘meddling’ or interfering, such as when denying the patient’s right to exert free choice, placing unnecessary pressure on a person, twisting the truth, concealing information, or performing any action that prevents autonomous decisions by the patient. The therapist must first empower the patient to make his or her own decisions. Thereafter, the therapist should accept and respect the competent patient’s decision, even a ‘wrong’ decision. Isaiah Berlin summed up the principle of autonomy eloquently in the following: Isaiah Berlin (Latvian-born British historian and liberalist, 1969)3: “I wish my life and decisions to depend on myself, not on external forces of whatever kind. I wish to be the instrument of my own, not of other men’s acts or will. I wish to be a subject, not an object: to be moved by reasons, by conscious purposes, which are my own, not causes which affect me, as it were from outside. I wish to be somebody, not nobody, a doer, deciding, not being decided for, self directed and not acted upon by external nature or by other men as if I were a thing, or an animal, or a slave… I wish, above all, to be conscious of myself as a thinking, willing, active being, bearing responsibility for my choices and able to explain them by references to my own ideas and purposes”. Privacy means that the therapist does not intrude on the privacy of the patient. This includes unnecessary and inappropriate intimate physical contact, eliciting personal facts and attitudes, and performing inappropriate actions in the one-on-one situation. Violation of the privacy of the patient can take place at any time during the therapist-patient interaction, but it is especially a risk in a psychotherapeutic relationship. The clinical skill of the therapist in being comfortable, respectable, empathic and friendly has strong boundaries that must always be regarded. Confidentiality refers to something that belongs to the patient that the therapist cannot give away without being given explicit consent. In psychiatric practice and in the context of the patient-therapist relationship, patients frequently share very ‘private’ personal information, sometimes spontaneously, sometimes of necessity. If this information is appropriate within the therapeutic process, the patient should be able to trust us with this information. If the patient can no longer trust confidentiality in the practice of psychiatry, we have lost the most important reason for our existence. In exceptional circumstances it would be desirable to breach the confidentially rule without the patient’s permission: In an emergency situation in which the patient cannot provide consent and the breach of confidentiality is clearly essential for a good result. (Weigh and balance confidentiality against beneficence). When compelled to do so by the presiding officer of a court of Law, then under protest. When demanded by the Law, for example when reporting child abuse. Rarely, when another person’s rights stand to be violated (justice) the right to confidentiality might be waived (weigh and balance). Beneficence. Beneficence means to do good to your patient. In most cases this will mean respecting the wishes, choices or preferences of the patient. In general, respect for autonomy carries a great deal of weight in current moral debates and in society. The principles of beneficence and autonomy are frequently in conflict with one another. An example would be if my patient’s requests are not in his or her best interests, or are harmful, or do not constitute good clinical practice or do not represent good professional conduct. In these cases it is sometimes just or reasonable not to comply with the patient’s request but to act in the best interests of the patient. All four principles, autonomy, beneficence, non-malevolence and justice are good, but in practice often need to be weighed against one another. If a competent person makes a wrong decision, the consequences of which are not serious and which still falls within the bounds of good clinical practice, the autonomy of the patient should have precedence. One should, however, do good only if it is truly good. Unreasonable requests coming from competent patients cannot be complied with. An example of this would be a young man who asks the doctor to complete a sick certificate or disability claim form without good reason, or requests a ‘double’ prescription to save money. Initially, it appears to be ‘good’ to concede to the person’s requests, but these actions do not ultimately promote the common good. In practice it can become very tempting, especially when persons are in dire straits, to try to be ‘good’ and help them by ‘beating the system’. The therapist should, however, seriously consider the end result and what is ultimately the ‘good’ thing to do. Non-malevolence. It is better to do nothing than to do harm. Therapists have a natural inclination to want to help. This tendency or attitude can sometimes be exaggerated. Since we see the therapist-patient relationship as a 50/50 one, the therapist also has the right to refuse certain actions that could be harmful. Especially in psychiatry, where we often have therapeutic dealings with patients with ‘difficult’ personality traits, we need to guard against actions that could ultimately be harmful. These difficult situations in therapy must be recognised and become part of the psychotherapeutic process. Good clinical practice, professional standards and peer group evaluation are our measurement instruments in the healing professions. Justice. Very few things in life are fair. The natural lottery of life may perhaps be indiscriminate, but for those who come last in it, it seems very unjust. Beauty, riches, poverty, health, love, talents, et cetera, are part of this natural lottery. The form of justice on which we shall now focus, is the justice that has been fashioned in the community by societal norms. Justice, fairness and equity are principles toward which society must strive. This can occur through the legal system, but occurs mainly by means of changed social norms and by consensus. The principle of justice advocates that each person deserves at least a minimum degree of equality, fairness and impartiality. Can some then be afforded a greater degree of ‘fairness’ than others? Aristotle expresses it so well when he says, ‘Equals must be treated equally, but unequals must be treated unequally’. What does this ‘outrageous’ declaration mean? It means that no person should, despite all the differences between individuals, be treated ‘unequally’, except when those differences are relevant to the way in which they should be treated. We can therefore make the following practical deduction. We should make special concessions (treatments) available to young children, the cognitively impaired elderly and patients with serious mental disorders, by treating them as ‘unequals’. One of the big dilemmas of our current health system is the affordability of health care. The science of health care is far more advanced than the level we can afford to deliver. How should we, with a small budget, perform the large masses of work that need to be done? Who do we treat and who should not be treated? We talk about distributive justice. The macro allocation of the health budget is done by the government. Here international rules hold, and differences exist between first and third world countries. The micro allocation of funds deals with how we should apply the frequently inadequate funds, the management thereof, and the channelling of funds to the man in the street. In the face of a small available budget, we must design and maintain a minimum, basic, effective health care system, affordable and available to all. This would constitute a reasonable and fair service. The application of private funding over and above the above-mentioned basic services is also admissible, but will not be discussed further here. As mentioned, the different principles and rights of persons clash with one other. In the therapist’s employment of the weighing and balancing process to ensue good moral action, justice and reasonableness must occupy an important place. If, for example, a person with HIV/AIDS, after thorough counselling, and without good reason, still refuses to practice safe sex and inform his or her sexual partner, and insists on the therapist’s confidentiality, what course of action would be reasonable or unreasonable? Build a moral argument by asking the following questions: 1. What carries greater weight, respect for confidentiality, or fairness? 2. What are all the facts of the case? 3. What course of action will produce the best results? 4. Must the therapist base his action on good intention alone? 5. What would a good or a virtuous person do? 6. Whose rights are being violated? 7. What will the community expect from the patient and therapist? 8. And, finally, what is the therapist’s duty of care? In this simple case we have used all the moral theories discussed to build moral arguments.