In recent years, scholars have begun to lay the groundwork to justify a distinct application of ethics to the field of public health. They have highlighted important features that differentiate public health ethics from bioethics, especially public health’s emphasis on population health rather than issues of individual health. Articulations of public health ethics also tend to emphasize the role of social justice compared to the predominance of autonomy in the bioethical literature. Now that the field of public (...) health ethics is developing a unique focus and a language of its own, including a code of ethics disseminated by the American Public Health Association, the future of public health ethics may well be global health ethics, focusing on issues of global justice. As public health ethics evolves from its nascent stage of reflection to a place of action and application in the national and global arenas, two interrelated developments will need to occur: public health professionals, including practitioners, policymakers, and scholars, will need a richer understanding of the ethical challenges practitioners face on a daily basis and scholars will need to develop useful tools that practitioners may employ for identifying and tackling these ethical challenges. (shrink)

This review considers ethical challenges to research design and informed consent in biomedical and behavioral studies conducted in resource-poor settings. A review of the literature explores relevant social, cultural, and ethical issues in the conduct of biomedical and social health research in developing countries. Ten case vignettes illustrate ethical challenges that arise in international research with culturally diverse populations. Recommendations for researchers and policy-makers concerned about ethical practices in multinational studies conducted in resource-poor settings are also listed.

Population axiology concerns how to evaluate populations in terms of their moral goodness, that is, how to order populations by the relations “is better than” and “is as good as”. The task has been to find an adequate theory about the moral value of states of affairs where the number of people, the quality of their lives, and their identities may vary. So far, this field has largely ignored issues about uncertainty and the conditions that have been discussed (...) mostly pertain to the ranking of risk-free outcomes. Most public policy choices, however, are decisions under uncertainty, including policy choices that affect the size of a population. Here, we shall address the question of how to rank population prospects—that is, alternatives that contain uncertainty as to which population they will bring about—by the relations “is better than” and “is as good as”. We start by illustrating how well-known population axiologies can be extended to population prospect axiologies. And we show that new problems arise when extending population axiologies to prospects. In particular, traditional population axiologies lead to prospect-versions of the problems that they praised for avoiding in the risk-free settings. Finally, we identify an intuitive adequacy condition that, we contend, should be satisfied by any population prospect axiology, and show how given this condition, the impossibility theorems in population axiology can be extended to (non-trivial) impossibility theorems for population prospect axiology. (shrink)

Background: To better understand the kinds of ethical challenges that emerge when using coercion in mental healthcare, and the importance of these ethical challenges, this article presents a systematic review of scientific literature. Methods: A systematic search in the databases MEDLINE, PsychInfo, Cinahl, Sociological Abstracts and Web of Knowledge was carried out. The search terms derived from the population, intervention, comparison/setting and outcome. A total of 22 studies were included. Ethical considerations: The review is conducted according to the Vancouver (...) Protocol. Results: There are few studies that study ethical challenges when using coercion in an explicit way. However, promoting the patient’s best interest is the most important justification for coercion. Patient autonomy is a fundamental challenge facing any use of coercion, and some kind of autonomy infringement is a key aspect of the concept of coercion. The concepts of coercion and autonomy and the relations between them are very complex. When coercion is used, a primary ethical challenge is to assess the balance between promoting good (beneficence) and inflicting harm (maleficence). In the included studies, findings explicitly related to justice are few. Some studies focus on moral distress experienced by the healthcare professionals using coercion. Conclusion: There is a lack of literature explicitly addressing ethical challenges related to the use of coercion in mental healthcare. It is essential for healthcare personnel to develop a strong awareness of which ethical challenges they face in connection with the use of coercion, as well as challenges related to justice. How to address ethical challenges in ways that prevent illegitimate paternalism and strengthen beneficent treatment and care and trust in connection with the use of coercion is a ‘clinical must’. By developing a more refined and rich language describing ethical challenges, clinicians may be better equipped to prevent coercion and the accompanying moral distress. (shrink)

Recently, in his Rolf Schock Prize Lecture, Derek Parfit has suggested a novel way of avoiding the Repugnant Conclusion by introducing what he calls “imprecision” in value comparisons. He suggests that in a range of important cases, populations of different sizes are only imprecisely comparable. Parfit suggests that this feature of value comparisons opens up a way of avoiding the Repugnant Conclusion without implying other counterintuitive conclusions, and thus solves one of the major challenges in ethics. In this article, I (...) try to clarify Parfit's proposal and evaluate whether it will help us with the paradoxes in population ethics. (shrink)

The Alzheimer field is in desperate need for an effective treatment. After decades of research, the available drugs treat only symptoms, and even their effectiveness is disputed. Because brain changes precede the clinical symptoms by years to decades, disease-modifying treatments should probably be started early, when the first symptoms occur—or even before. But how to determine who to treat? In this issue, Erik Gustavsson c.s. approach this question by addressing the benefits, harms and ethical issues encountered when using different (...) modes of screening for ‘preclinical’ or early symptomatic Alzheimer disease.1 Their overall conclusion is clear—screening for high risk of developing AD dementia to select those who are eligible for treatment is ethically problematic, unless extremely effective treatment becomes available. An additional major challenge is that diagnostic test accuracy is generally poor, with a particularly high risk of false-positive results, that is, biological evidence of Alzheimer pathology in persons who will never develop dementia. The risk of overmedicalisation is serious, and the potential harms of screening for AD should not be ignored, as Le Couteur c.s. previously argued.2 In short, there is no evidence base for any form of screening for AD whether in a preclinical stage (an …. (shrink)

Because of the transfer of responsibility from hospitals to community-based settings, providers in home-based care have more responsibilities and a wider range of tasks and responsibilities than before, often with limited resources. The increased responsibilities and the complexity of tasks and patient groups may lead to several ethical challenges. A systematic search in the databases MEDLINE, CINAHL, and SveMed+ was carried out in February 2019 and August 2020. The research question was translated into a modified PICO (Population, Intervention, Comparison, (...) and Outcome) worksheet. A total of 40 articles were included. The review is conducted according to the Vancouver Protocol. The main findings from the systematic literature review show that ethical challenges experienced by healthcare and social care providers in home-based care are related to autonomy and balancing ethical principles, decisions regarding intensity of care, challenges related to priority settings, truth-telling, and balancing the professional role. Findings regarding ethical challenges within home-based care are in line with findings from institutional healthcare and social care settings. However, some significant differences from the institutional context are also highlighted. (shrink)

The article by Gustavsson et al 1 addresses the important question how to handle new medications with focus on drug candidates that reduce Aβ or tau in the brain, for individuals with Alzheimer’s disease, where the need for a disease-modifying drug is enormous. There are several ethical issues to deal with. The challenges and ethical implications associated with whom should be eligible for treatment are thoroughly discussed in the article. Should treatment only be available to those with mild symptoms and/or (...) to those with no symptoms but with risk for AD? Where do we draw the line between who will be eligible for treatment and who will not? Who will be responsible for the prioritisation? There are many ethical problems with both population screening and screening of those with high risk well discussed in the article. Indeed, the first immunotherapy drug Aducanumab was approved by the US Food and Drug Administration in …. (shrink)

Intensive research is carried out to develop a disease-modifying drug for Alzheimer’s disease. The development of drug candidates that reduce Aß or tau in the brain seems particularly promising. However, these drugs target people at risk for AD, who must be identified before they have any, or only moderate, symptoms associated with the disease. There are different strategies that may be used to identify these individuals. Each of these strategies raises different ethical challenges. In this paper, we analyse these challenges (...) in relation to the risk stratification for AD necessary for using these drugs. We conclude that the new drugs must generate large health benefits for people at risk of developing AD to justify the ethical costs associated with current risk stratification methods, benefits much larger than current drug candidates have. This conclusion raises a new set of ethical questions that should be further discussed. No data are available. (shrink)

This study argues the thesis that a set of guidelines ‐ firmly rooted in a particular interpretation of African moral theory, specifically, Ubuntu – will do a better job than current medical ethics frameworks, in addressing ethical challenges around misattributed parentage within the clinical context. Incidental information such as information with significant personal/health implications raises unique challenges for medical professionals. For example, withholding information of misattributed paternity accidentally discovered in clinical interactions may be seen by a patient as a violation (...) of his/her right‐to‐know. Contrarily, disclosure where a patient has not requested information – or where establishing paternity is not the purpose of clinical visit/interaction – may be taken by the patient as a violation of his/her right ‘not‐to‐know’. Resolving these challenges remain a herculean task. African moral theory contains an under‐emphasized value for addressing such ethical challenges around misattributed parentage in the field of transplant. I seek to contribute this knowledge; and enhance clinician‐patient relationship. This study builds off three completed systematic reviews, which aimed to answer the following questions: “what are the ethical challenges regarding information health professionals face within the clinical contest?” and “what core aspects (or common themes) of Ubuntu can be identified in existing literature describing the same?” In this present study, I applied the definition of Ubuntu which captures the core aspects of the theory in ethical literature on the same, to address ethical issues around unsought information of misattributed parentage in the field of transplant. (shrink)

Background The COVID-19 pandemic continues to disrupt every society as SARs-CoV-2 variants surge among the populations. Health care providers are exhausted, becoming ill themselves, and in some instances have died. Indeed, hospitals are struggling to find staff to care for critically ill patients most in need. Previous work has reported on the unending work-related conditions that hospital staff are laboring under and their subsequent mental and physical health strains. Health care providers need support, but it is not clear where that (...) support is to come from. While much research has reported on the COVID-19-related fears of nurses and physicians, fewer studies have focused on supportive features of the hospital work environment and how it may provide relief to front-line health care providers.Purpose This purpose of this study was to explore an often-overlooked resource within hospital systems across the United States—clinical ethicists—and examine their many roles during COVID-19 and the types of ethical issues they addressed with nurses, physicians, administrators, and others.Methods This was a primary analysis of semi-structured, qualitative interviews with 23 clinical ethicists across the United States. The interviews were conducted from November 2020–April 2021 and were audiotaped, transcribed verbatim, and de-identified; both inductive and deductive analyses were used to identify qualitative themes.Results Five major themes were identified: ethical issues that were increasingly more complex, moral distress that was “endemic,” shifting ethical paradigms from the focus on the individual to the population, fostering a supportive environment, and organizational ethics: variation in the value, roles, and policy input of clinical ethicists.Conclusions Our findings report on the integral and expanded role of clinical ethicists at an unprecedented time in our nation, and how they stepped forward to support front-line clinicians in hospitals across the country. (shrink)

Background: Neonatal nurses report a great deal of ethical challenges in their everyday work. Seemingly trivial everyday choices nurses make are no more value-neutral than life-and-death choices. Everyday ethical challenges should also be recognized as ethical dilemmas in clinical practice. Research objective: The purpose of this study is to investigate which types of ethical challenges neonatal nurses experience in their day-to-day care for critically ill newborns. Research design: Data were collected through semi-structured qualitative in-depth interviews. Phenomenological-hermeneutic analysis was applied to (...) interpret the data. Participants and research context: Six nurses from neonatal intensive care units at two Norwegian hospitals were interviewed on-site. Ethical considerations: The study is designed to comply with Ethical Guidelines for Nursing Research in the Nordic Countries and the Helsinki declaration. Findings: Findings suggest that nurses experience a diverse range of everyday ethical challenges related to challenging interactions with parents and colleagues, emotional strain, protecting the vulnerable infant, finding the balance between sensitivity and authority, ensuring continuity of treatment, and miscommunication and professional disagreement. Discussion: A major finding in this study is how different agents involved in caring for the newborn experience their realities differently. When these realities collide, ethical challenges arise. Findings suggest that acting in the best interests of the child becomes more difficult in situations involving many agents with different perceptions of reality. Conclusion: The study presents new aspects which increases knowledge and understanding of the reality of nursing in a neonatal intensive care unit, while also demanding increased research in this field of care. (shrink)

As the average age of the population increases, so too do the number of people living with chronic illnesses. With limited resources available, the development of dialogue-based e-health systems that provide justified general health advice offers a cost-effective solution to the management of chronic conditions. It is however imperative that such systems are responsible in their approach. We present in this paper two main challenges for the deployment of e-health systems, that have a particular relevance to dialogue and argumentation: (...) collecting and handling health data, and trust. For both challenges, we look at specific issues therein, outlining their importance in general, and describing their relevance to dialogue and argumentation. Finally, we go on to propose six recommendations for handling these issues, towards addressing the main challenges themselves, that act both as general advice for dialogue and argumentation research in the e-health domain, and as a foundation for future work on this topic. (shrink)

Türkiye hosts approximately 3.6 million Syrian refugees, which accounts for roughly 4.5% of Türkiye's population. This places undeniable pressure on public institutions, particularly on healthcare services. The objective of this study is to document the healthcare structure for Syrian refugees and various challenges faced by Syrians when seeking healthcare and to highlight the ethical concerns emerging from those challenges. To achieve this, we conducted a comprehensive review of several qualitative studies and reports conducted by various organizations and institutions, specifically (...) focusing on health or including a dedicated chapter on health issues, published between 2011 and 2023. Following an extensive analysis of the secondary literature, we classified the challenges into three categories: procedural, cultural, and psychosocial. We argue that each of these challenges is linked to overarching medical ethics concerns. Finally, we propose three possible means to mitigate the challenges Syrians experience in accessing and uptake of healthcare services in Türkiye. (shrink)

Background: Clinical investigation is a growing field employing increasing numbers of nurses. This has created a new specialty practice defined by aspects unique to nursing in a clinical research context: the objectives (to implement research protocols and advance science), setting (research facilities), and nature of the nurse–participant relationship. The clinical research nurse role may give rise to feelings of ethical conflict between aspects of protocol implementation and the duty of patient advocacy, a primary nursing responsibility. Little is known about (...) whether research nurses experience unique ethical challenges distinct from those experienced by nurses in traditional patient-care settings. Research objectives: The purpose of the study was to describe the nature of ethical challenges experienced by clinical research nurses within the context of their practice. Research design: The study utilized a qualitative descriptive design with individual interviews. Participants and research context: Participating nurses (N = 12) self-identified as having experienced ethical challenges during screening. The majority were Caucasian (90%), female (83%), and worked in outpatient settings (67%). Approximately 50% had > 10 years of research experience. Ethical considerations: The human subjects review board approved the study. Written informed consent was obtained. Findings: Predominant themes were revealed: (1) the inability to provide a probable good, or/do no harm, and (2) dual obligations (identity as a nurse vs a research nurse). The following patterns and subthemes emerged: conflicted allegiances between protocol implementation, needs of the participant, desire to advance science, and tension between the nurse–patient therapeutic relationship versus the research relationship. Discussion: Participants described ethical challenges specific to the research role. The issues are central to the nurse–participant relationship, patient advocacy, the nurse’s role in implementing protocols, and/or advancing science. Conclusion: Ethical challenges related to the specialized role of clinical research nurses were identified. More research is warranted to fully understand their nature and frequency and to identify support systems for resolution. (shrink)

Pediatric cancer is accompanied by many ethical challenges, particularly those related to respecting the child's opinion and parental responsibility and consent.Questionnaires were collected from 400 participants, from four equal groups: doctors, nurses, parents and medical students, from three cities in Saudi Arabia, about three problematic issues which revolve around the mandatory consent of one or both parents, the extent of a child’s assent, and the acceptable form of consent and assent.Despite the diversity of the participants' cultural backgrounds, most preferred both (...) parents to give consent, followed by either parent without differentiation between parents, which reinforced a trend towards more gender equality. The majority of participants preferred that parental consent forms be detailed enough to obtain the maximum information, while others chose medium‐size consent forms; a large majority preferred that the form seeking to obtain the assent of the child with cancer be short, reflecting their desire not to increase the burden on the child, in addition to the fact that the final decision belongs to the parents rather than the child. Most participants preferred to rely on a child's level of maturity rather than having reached a certain age so that they could give assent, while the rest considered the age of 13‐14 as a suitable age.These findings reflect an increasing ethical awareness regarding parental consent and child assent, and they can be formulated in a recommendation for a more ethical practice in the field of childhood cancer and pediatrics in general. (shrink)

Oral healthcare is attracting much attention after decades of neglect from policymakers. Recent studies have shown a strong association between oral and overall health, which can lead to serious health problems. Availability of oral healthcare services is an essential part of ensuring universal healthcare coverage. More importantly, current gaps in its accessibility by minority or marginalized population groups are crucial public health as well as ethical concerns. One notable effort to address this issue comes from Non-Governmental Organizations (NGOs), which (...) offer oral healthcare services for non-insured refugees. However, the challenge remains that these care services are not comprehensive, which has implications for the refugees’ oral and general health. In this article, we discuss this complex issue in the German healthcare context by including ethical reflections. Therefore, the purpose of this article is to discuss the ethical challenges related to oral healthcare services provided by NGOs for refugees in Germany. First, we will introduce the general oral healthcare context worldwide and in Germany. Second, we will provide a general description of the oral healthcare services provided by NGOs for refugees in Germany, as well as an overview of existing gaps. This will provide us with the context for our third and most important task—discussing the ethical implications of the gaps. In doing so, and since the ethical implications can be several, we demarcate the scope of our analysis by focusing on the specific ethical issues of justice, harm, and autonomy. Finally, we offer some recommendations for how to move forward. (shrink)

Background: Neonatal nurses report a great deal of ethical challenges in their everyday work. Seemingly trivial everyday choices nurses make are no more value-neutral than life-and-death choices. Everyday ethical challenges should also be recognized as ethical dilemmas in clinical practice. Research objective: The purpose of this study is to investigate which types of ethical challenges neonatal nurses experience in their day-to-day care for critically ill newborns. Research design: Data were collected through semi-structured qualitative in-depth interviews. Phenomenological-hermeneutic analysis was applied to (...) interpret the data. Participants and research context: Six nurses from neonatal intensive care units at two Norwegian hospitals were interviewed on-site. Ethical considerations: The study is designed to comply with Ethical Guidelines for Nursing Research in the Nordic Countries and the Helsinki declaration. Findings: Findings suggest that nurses experience a diverse range of everyday ethical challenges related to challenging interactions with parents and colleagues, emotional strain, protecting the vulnerable infant, finding the balance between sensitivity and authority, ensuring continuity of treatment, and miscommunication and professional disagreement. Discussion: A major finding in this study is how different agents involved in caring for the newborn experience their realities differently. When these realities collide, ethical challenges arise. Findings suggest that acting in the best interests of the child becomes more difficult in situations involving many agents with different perceptions of reality. Conclusion: The study presents new aspects which increases knowledge and understanding of the reality of nursing in a neonatal intensive care unit, while also demanding increased research in this field of care. (shrink)

As the average age of the population increases, so too do the number of people living with chronic illnesses. With limited resources available, the development of dialogue-based e-health systems that provide justified general health advice offers a cost-effective solution to the management of chronic conditions. It is however imperative that such systems are responsible in their approach. We present in this paper two main challenges for the deployment of e-health systems, that have a particular relevance to dialogue and argumentation: (...) collecting and handling health data, and trust. For both challenges, we look at specific issues therein, outlining their importance in general, and describing their relevance to dialogue and argumentation. Finally, we go on to propose six recommendations for handling these issues, towards addressing the main challenges themselves, that act both as general advice for dialogue and argumentation research in the e-health domain, and as a foundation for future work on this topic. (shrink)

This paper examines how people in West Africa are reacting to the Ebola virus disease, an epidemic presently prevalent in the region. Certain lifestyle changes are suggested. Additionally, the heart of the paper focuses on the request by governments to be allowed access to experimental drugs, such as Zmapp and TKM-Ebola, for their infected populations. The author argues that granting such a request would circumvent research ethics procedures, which could potentially constitute significant risk to users of the drugs. The Pfizer (...) Kano meningitis trial of 1996 is cited as an example to buttress how unapproved drugs could prove fatal. (shrink)

The multiverse theodicy proposes to reconcile the existence of God and evil by supposing that God created all and only the creation-worthy universes and that some universes like ours are, despite their evils, creation-worthy. Drawing on work in population ethics, this paper develops a novel challenge to the multiverse theodicy. Roughly, the challenge contends that the axiological underpinnings of the multiverse theodicy harbor a ‘mere addition paradox’: the assumption that creating creation-worthy universes would always make the world better turns (...) out to have morally repugnant consequences akin to those of the assumption that adding worthwhile lives to a population would always make the overall welfare of the population better. Further, the challenge leverages this difficulty into an argument against God’s having created all and only the creation-worthy universes, and hence against the multiverse theodicy. Responses to this challenge are considered but found wanting, largely because of commitments of the multiverse theodicy that have no analogs in population ethics. (shrink)

This study explored Swedish school nurses' experiences of school health record documentation. Fifty per cent of a representative sample of Swedish school nurses (n = 129) reported difficulties with documenting mental and social health problems in family relationships, schoolchildren's behaviour, and school situations. Ethical considerations concerning fears of misinterpretation and practical barriers to documentation were expressed as reasons for their worries. Mental and social ill health is an increasing and often dominating problem among schoolchildren, thus proper documentation is a basic (...) issue, both for individuals and for the population as a whole. School nurses obviously need professional guidance regarding documentation and ethical challenges. Systematic effort should be directed towards recognition and support of these nurses' unique opportunities to consider, follow and promote all aspects of schoolchildren's health. (shrink)

In this paper, I discuss two different metaethical challenges based on population ethical impossibility results. According to the anti‐realist challenge, the results pose a serious threat to the existence of objective moral facts. According to the skeptical challenge, the results pose a serious threat to the reliability of our moral intuitions. My aim is to systematically explore and evaluate these challenges. In addition to clarifying the issues, I argue that population ethical impossibility results do not in fact support (...) any anti‐realist or skeptical conclusions. (shrink)

Ecological research and conservation practice frequently raise difficult and varied ethical questions for scientific investigators and managers, including duties to public welfare, nonhuman individuals (i.e., animals and plants), populations, and ecosystems. The field of environmental ethics has contributed much to the understanding of general duties and values to nature, but it has not developed the resources to address the diverse and often unique practical concerns of ecological researchers and managers in the field, lab, and conservation facility. The emerging (...) field of “ecological ethics” is a practical or scientific ethics that offers a superior approach to the ethical dilemmas of the ecologist and conservation manager. Even though ecological ethics necessarily draws from the principles and commitments of mainstream environmental ethics, it is normatively pluralistic, including as well the frameworks of animal, research, and professional ethics. It is also methodologically pragmatic, focused on the practical problems of researchers and managers and informed by these problems in turn. The ecological ethics model offers environmental scientists and practitioners a useful analytical tool for identifying, clarifying, and harmonizing values and positions in challenging ecological research and management situations. Just as bioethics provides a critical intellectual and problem-solving service to the biomedical community, ecological ethics can help inform and improve ethical decision making in the ecology and conservation communities. (shrink)

Population ethics is the subfield of philosophy that focuses on the moral aspects of how actions affect who exists in a particular population and what quality of life they have. The choices regarding what policies are adopted in response to climate change will affect the identities of those who exist in the future, the size of future populations, and the quality of life that future people will have. This chapter examines the nonidentity problem, various theoretical outlooks on (...) class='Hi'>population ethics, some recent policy proposals aimed at reducing fertility, and the relationship between population reduction and the impacts of climate change. After summarizing the relevant issues, the relevance of the discourse to climate policy is highlighted, and points of consensus and dissensus are noted. Disagreement on some of the key theoretical questions in population ethics is significant and poses a challenge for deriving meaningful conclusions about climate policy. Fortunately, emerging points of consensus on other aspects of climate policy and its relationship to population provide reasons to think moral decision-making about these matters is far from hopeless. (shrink)

Millions of people undergo displacement in the world. Internally displaced people (IDP) are especially vulnerable as they are not protected by special legislation in contrast to other migrants. Research conducted among IDPs must be correspondingly sensitive in dealing with ethical issues that may arise. Muslim IDPs in Puttalam district in the North-Western province of Sri Lanka were initially displaced from Northern Sri Lanka due to the conflict in 1991. In the backdrop of a study exploring the prevalence of common mental (...) disorders among the IDPs, researchers encountered various ethical challenges. These included inter-related issues of autonomy, non-maleficence, beneficence, confidentiality and informed consent, and how these were tailored in a culture-specific way to a population that has increased vulnerability. This paper analyses how these ethical issues were perceived, detected and managed by the researchers, and the role of ethics review committees in mental health research concerning IDPs. The relevance of guidelines and methodologies in the context of an atypical study population and the benefit versus risk potential of research for IDPs are also discussed. The limitations that were encountered while dealing with ethical challenges during the study are discussed. The concept of post-research ethical conduct audit is suggested to be considered as a potential step to minimize the exploitation of vulnerable populations such as IDPs in mental health research. (shrink)

Today’s panel is about the expanding boundary of population health policy, what that expanding boundary has to do with law, and what kinds of challenges and opportunities come out of it. What I want to do for the next few minutes is talk to you about the notion of population health as it exists where law and policy are made, rather than where it exists in a spectacular international theoretical literature. Then I want to introduce our panelists. In (...) the process, I will explain why the Honorable John Nilson, is not with us, which tells you a great deal about not only the real world of the politics of population health, but also about the kind of trouble you can get into if you are a first class lawyer involved in population health. (shrink)

In this paper, I discuss two different metaethical challenges based on population ethical impossibility results. According to the anti-realist challenge, the results pose a serious threat to the existence of objective moral facts. According to the skeptical challenge, the results pose a serious threat to the reliability of our moral intuitions. My aim is to systematically explore and evaluate these challenges. In addition to clarifying the issues, I argue that population ethical impossibility results do not in fact support (...) any anti-realist or skeptical conclusions. (shrink)

There is limited information on the ethical issues encountered in living donor organ transplants performed on refugees and asylum seekers. This study investigates the ethical challenges faced by Syrian refugees under temporary protection in Türkiye who engage in living donor organ transplants. From April to July 2022 in Istanbul, the research employed a qualitative design involving semi-structured, in-depth interviews with 27 participants, including organ donors and recipients. The analysis utilized a thematic analytic method. The findings elucidate two principal themes related (...) to ethical concerns: justice and autonomy. Under the justice theme, several sub-themes emerged, highlighting the multifaceted challenges Syrian refugees face in accessing healthcare services. These include migration and language barriers, significantly impeding their ability to understand medical procedures and rights. Financial difficulties and restricted movement within the country further complicate their access to necessary healthcare. Despite these hurdles, refugees benefit from free access to organ transplantation services and medications, a policy underscoring Türkiye’s commitment to healthcare equity for protected populations. The autonomy theme addresses the ethical handling of donor consent and motivation. The results indicate that Syrian refugees undergo a transplantation process free from coercion, with rigorous oversight by organ transplant ethics committees ensuring the prevention of donor abuse. However, despite these protective measures, challenges persist in the informed consent process, primarily due to language barriers that hinder effective communication between healthcare providers and patients. While the efforts of healthcare professionals to assist are recognized as alleviating some difficulties, the broader issues of access to comprehensive health services remain a significant concern. These barriers suggest a need for enhanced linguistic and financial support to improve healthcare accessibility for refugees. This study posits that the healthcare framework provided by Türkiye to Syrians under temporary protection can serve as a model for international human rights and social justice. However, it also emphasizes the importance of addressing the persistent obstacles that limit healthcare access for asylum seekers. Recommendations for policy enhancements focus on improving language services, increasing financial support, and expanding the accessibility of comprehensive health services to ensure equitable health outcomes for refugees. (shrink)

Background Home-based care workers mainly work alone in the patient’s home. They encounter a diverse patient population with complex health issues. This inevitably leads to several ethical challenges. Aim The aim is to gain insight into ethical challenges related to patient autonomy in home-based care and how home-based care staff handle such challenges. Research design The study is based on a 9-month fieldwork, including participant observation and interviews in home-based care. Data were analysed with a thematic analysis approach. Participants (...) and research context The study took place within home-based care in three municipalities in Eastern Norway, with six staff members as key informants. Ethical considerations The Norwegian Agency for Shared Services in Education and Research evaluated the study. All participants were competent to consent and signed an informed consent form. Findings A main challenge was that staff found it difficult to respect the patient’s autonomy while at the same time practicing appropriate care. We found two main themes: Autonomy and risk in tension; and strategies to balance autonomy and risk. These were explicated in four sub-themes: Refusing and resisting care; when choosing to live at home becomes risky; sweet-talking and coaxing; and building trust over time. Staff’s threshold for considering the use of coercion appeared to be high. Conclusions Arguably, home-based care staff need improved knowledge of coercion and the legislation regulating it. There is also a need for arenas for ethics reflection and building of competence in balancing ethical values in recurrent ethical problems. (shrink)

Delivering healthcare to undocumented migrants presents a complex challenge for healthcare providers. Integrating advocacy efforts into their daily practices can be ambiguous in practical terms, stemming from the intricate task of addressing the health needs of this population while simultaneously advocating for their health rights within the constraints imposed on them. This study seeks to consolidate findings from literature regarding the advocacy approaches employed by healthcare providers and the correlated ethical challenges. We conducted a scoping review of qualitative literature (...) by systematically searching four databases—PubMed/Medline, Embase, Cinahl, and Cochrane Library. For developing our search strategy, we employed the PICO (Population, Intervention, Comparison, Outcome) scheme. Our analysis followed the qualitative content analysis approach proposed by Graneheim and Lundman. 30 studies were included, revealing a cumulative total of 915 healthcare providers who were interviewed. A total of 30 themes emerged comprising 14 advocacy approaches and 16 ethical challenges. Healthcare providers made a deliberate choice to engage in advocacy, responding to injustices experienced by undocumented migrants. The spectrum of advocacy initiatives varied, encompassing voluntary participation in healthcare provision, empathetic understanding, and healthcare-focused strategies. We also identified numerous correlated ethical challenges, necessitating healthcare providers to strike a balance between their eagerness to assist and their professional competence, respect the autonomy of undocumented migrants, and establish trust with them. These findings not only offer practical guidance for healthcare providers to enhance accessibility to healthcare services for undocumented migrant patients but also foster awareness of the ethical challenges that may arise in their advocacy roles. (shrink)

One of Derek Parfit’s greatest legacies was the search for Theory X, a theory of population ethics that avoided all the implausible conclusions and paradoxes that have dogged the field since its inception: the Absurd Conclusion, the Repugnant Conclusion, the Non-Identity Problem, and the Mere Addition Paradox. In recent years, it has been argued that this search is doomed to failure and no satisfactory population axiology is possible. This chapter reviews Parfit’s life’s work in the field (...) and argues that he provided all the necessary components necessary for a Theory X. It then shows how these components can be combined together and applied to the global challenges Parfit argued matter most: preventing human extinction, managing catastrophic risks, and eradicating global poverty and suffering. Finally, it identifies a number of challenges facing his theory and suggests how these may be overcome. (shrink)

Implementation research is increasingly common in developing countries as a way of studying the introduction to the population of health interventions that have been proven to be effective elsewhere. Implementation studies are often conducted as cluster randomized trials, a design that raises ethical and conceptual questions different from those in conventional randomized controlled trials. It is often unclear who the subjects of the research are, informed consent may be difficult or impossible to obtain and controversy surrounds the use of (...) comparison clusters that provide substandard care to the population where the research is carried out. An examination of protocols for this type of research reveals uncertainty on the part of researchers themselves about whom or what they are studying and from whom (if anyone) informed consent is required. (shrink)

Outbreaks of epidemics like Ebola trigger difficult ethical challenges for civilian and military health care personnel. This book offers theoretical reflections combined with reports from recent military and NGO missions in the field. The authors of this volume focus on military medical ethics adding a distinct voice to the topic of epidemics and infectious diseases. While military health care personnel are always crucially involved during disaster relief operations and large-scale public health emergencies, most of the current literature treats ethical (...) issues during epidemics from a more general perspective without taking into account the specifics of the military context. The contributions in this volume provide first-hand insights into some of the ethical issues encountered by military health care personnel in missions during the Ebola outbreak in 2014/2015. This practical perspective is complimented by academic analyses and theoretical reflections on ethical issues associated with epidemics. (shrink)

As mariculture—the cultivation of aquatic organisms in marine environment—intensifies to meet the demands of sustainable blue growth and national policies, novel ethical challenges will arise. In the context of ethics, primary concerns over aquaculture and mariculture tend to stay within differing value-based perspectives focused on benefits to human and non-human subjects, specifically animal welfare and animal rights. Nonetheless, the burgeoning field of feminist blue humanities provides ethical considerations that extend beyond animal subjects (including humans), often because of its concerns (...) with new materialist, posthumanist, and other relations-based theories. This article examines feminist blue humanities and the contributions it may bring to understanding contemporary and future ethical challenges posed by mariculture and its intensification, especially the cultivation of low-trophic organisms. By offering an overview of feminist blue humanities, this article explores some of its particularities by drawing out three major ethical concerns facing contemporary mariculture, specifically material reconfigurations, radical alteration of the lives of low-trophic species through industrialization and increases in maricultural waste products. (shrink)

Background The broad topic of research ethics is one which has been relatively well-investigated and discussed. Unique ethical issues have been identified for such populations as pediatrics, where the issues of consent and assent have received much attention, and obstetrics, with concerns such as the potential for research to cause harm to the fetus. However, little has been written about ethical concerns which are relatively unique to the population of patients seen by the practitioner of rehabilitation medicine. Discussion This (...) paper reviews unique ethical concerns in conducting research in this population, including decision-making capacity, communication, the potential for subject overuse, the timing of recruitment, hope for a cure and therapeutic misconception and the nature of the health care provider-research subject relationship. Summary Researchers in the area of rehabilitation medicine should be aware of some of the unique ethical challenges posed by this patient population and should take steps to address any potential concerns in order to optimize subject safety and ensure that studies meet current ethical guidelines and standards. (shrink)

More than 25 years into the HIV epidemic, in excess of 2 million new infections continue to occur each year. HIV prevention research is crucial for groups at heightened risk for HIV, but the design and conduct of HIV prevention research with vulnerable populations worldwide raises considerable ethical challenges. The HIV Prevention Trials Network (HPTN) is a global collaborative network that conducts clinical and behavioural studies on non-vaccine interventions to reduce the transmission of HIV. In 2003, the HPTN developed ethical (...) guidance to enhance the responsible conduct of its research activities and as a distinctive contribution to global research ethics. In what follows, the developments that motivated the drafting of a revised ethics document in 2009 are described, including the process by which that revision took place and some of the key differences between the HPTN ethics guidance and other relevant guidelines in the field. (shrink)

Vaccination policy is an ethically challenging domain of public policy. It is a matter of collective importance that reaches into the most private sphere of citizens and unavoidably conflicts with individual-based ethics. Policy makers need to walk a tight rope in order to complement utilitarian public health values with individual autonomy rights, protection of privacy, non-discrimination and protection of the worst-off. Whether vaccination is voluntary or compulsory, universal or targeted, every option faces complex ethical hurdles because of the interdependence (...) of humans in infectious disease matters. In this article, we explore the following three policy questions. (i) Ethically, which policy measures should be addressed when vaccination coverage is insufficient in a population? Information campaigns, legal compulsion, or the use of financial incentives can all be effective, but also controversial policy options. (ii) Is it ethical to target vaccination programs at certain risk-groups? If such measures are necessary, we argue that policymakers will often have to decide which is more important to uphold: non-discrimination or the protection of privacy. And (iii), what is the ethical significance of adverse herd immunity effects? Some vaccination programs will improve average population health, but will at the same time increase the risk of severe morbidity and mortality for individuals in the worst-off groups of society. (shrink)

The year 2020 is facing one of the worst public health situations in decades. The world is experiencing a pandemic that has triggered significant challenges to healthcare systems in both high and low‐middle income countries (LMICs). Government policymakers and healthcare personnel are experiencing real‐life ethical dilemmas and are pressed to respond to these situations. Many possible treatments are being investigated, one of which is the use of hydroxychloroquine or chloroquine. These drugs are approved for use by patients with systemic lupus (...) erythematosus (SLE), rheumatoid arthritis, and malaria. The demand for these products has increased, and the stocks are depleting for the patient population for whom the drugs are intended initially. Although both innovator and generic pharmaceutical manufacturers are making plans for increased production, there are challenges with global supply chains disruption and the retention of supplies for local markets. This may cause countries that rely on the importation of pharmaceuticals to be out of stock of supplies for an extended period. There are allegations of off‐label prescribing and hoarding. Pharmacists are the custodians and dispensers of medications and are faced with the task of assessing prescriptions and making decisions about the allocation of these products. This paper seeks to 1) highlight some of the ethical challenges of dispensing hydroxychloroquine by pharmacists during the COVID‐19 pandemic, 2) identify some of the responses to these issues from various regulatory authorities in the USA, and 3) recommend approaches to assist pharmacists in their decision‐making process, especially in LMICs. (shrink)

The challenge for those responsible for funding, brokering and assessing the merit of proposed Indigenous research is to identify and then work co-operatively with appropriate representatives of Indigenous interests in order to increase the flow of benefits from research to Indigenous peoples. Experience in Australia has shown that this is not a straightforward process. In this paper we indicate some reasons why it is important for the research community to broker research with representative Indigenous organisations and to involve Indigenous peoples (...) in the ethical assessment and conduct of research. We then identify some barriers to the achievement of these objectives and outline recently developed interventions from the field of health research that aim to promote a more effective working relationship between Indigenous peoples and members of the research community. (shrink)

New advances in genomics changed the research landscape significantly in the last few years. The power and significance of already existing tissue collections is enhanced by their growing size, and all over the world national projects aim to connect with each other at the international level, calling for integrated and common regulations in the transnational research field. The post genomics era faces problems that are partially different from those within the classical bioethical framework. The challenge is to find new (...) ways to deal with regulations in order to facilitate research without frustrating personal rights. Informed Consent has been the center of this wide debate. We propose a model for rethinking consent in an open-time/open-goal framework suitable to genomics research. Consensus becomes more than a single legal step and goes more in the direction of a participated governance mechanism, a circular open process of communication which the IC sheet signature is just one instance of. This approach provides a governance framework based on different levels of consensus and participation that already contains mechanisms to resolve conflicts between different instances and to protect both the interest of research and the rights of participants. (shrink)

Care staff in Norway usually work in the private homes of people with intellectual disabilities. Staff experience ethical challenges daily in their interactions with their clients. The aim of this paper is to introduce a vignette validation procedure for selection of practice-close vignettes that can be used to elicit and explore staff reflections on ethical challenges in their work. Staff participants were recruited from different municipalities in one county of Norway. To develop vignettes with good internal validity, the validation process (...) consisted of (1) a field study to identify situations to be included as vignettes, (2) a six-step categorization process to select vignettes with good internal validity, (3) transforming the situations into vignettes, including removal of elements that were too leading or constricting, (4) testing the familiarity and relevance of the preliminary sample of vignettes (external validation), (5) final selection of four vignettes to be included in the investigation, and (6) a validation of the four vignettes? familiarity and practical relevance as ethical challenges by the final sample of interviewees. Our preliminary experience indicates that the validation procedure enhanced the selection of vignettes to elicit staff perceptions and reflections on daily ethical challenges. (shrink)

For over 100 years, the field of contemporary public health has existed to improve the health of communities and populations. As public health practitioners conduct their work – be it focused on preventing transmission of infectious diseases, or prevention of injury, or prevention of and cures for chronic conditions – ethical dimensions arise. Borrowing heavily from the ethical tools developed for research ethics and bioethics, the nascent field of public health ethics soon began to feel the limits of (...) the clinical model and began creating different frameworks to guide its ethical challenges. Several public health ethics frameworks have been introduced since the late 1990s, ranging from extensions of principle-based models to human rights and social justice perspectives to those based on political philosophy. None has coalesced as the framework of choice in the discipline of public health. This paper examines several of the most-known frameworks of public health ethics for their common theoretical underpinnings and values, and suggests next steps toward the formulation of a single framework. (shrink)

The COVID-19 pandemic crisis has had profound effects on global health, healthcare, and public health policy. It has also impacted education. Within undergraduate healthcare education of doctors, nurses, and allied professions, rapid shifts to distance learning and pedagogic content creation within new realities, demands of healthcare practice settings, shortened curricula, and/or earlier graduation have also challenged ethics teaching in terms of curriculum allotments or content specification. We propose expanding the notion of resilience to the field of ethics education under (...) the conditions of remote learning. Educational resilience starts in the virtual classroom of ethics teaching, initially constituted as an “unpurposed space” of exchange about the pandemic’s challenging impact on students and educators. This continuously transforms into “purposed space” of reflection, discovering ethics as a repertory of orientative knowledge for addressing the pandemic’s challenges on personal, professional, societal, and global levels and for discovering (and then addressing) that the health of individuals and populations also has moral determinants. As such, an educational resilience framework with inherent adaptability rises to the challenge of supporting the moral agency of students acting both as professionals and as global citizens. Educational resilience is key in supporting and sustaining professional identify formation and facilitating the development of students’ moral resilience and leadership amid moral complexity and potential moral transgression—not only but especially in times of pandemic. (shrink)

Simple Summary Are we morally justified in using animals in biomedical research and if so, how can we make sure that the experiments are conducted in a scientifically and morally acceptable manner? Based on our own experiences as scholars from various academic backgrounds, we argue that this question can only be answered as an interdisciplinary and international endeavor. Thus, our article aims to contribute to the foundation of the emerging field of animal research ethics, combining perspectives from research ethics, (...) animal ethics, science, and law. In doing so, we describe the following seven phases that animal experiments typically run through: ethical, legal and social presumptions (phase 0), planning (phase I), review (phase II), conduct of experiments (phase III), publication/dissemination (phase IV), further exploitation of results (phase V), and evaluation (phase VI). Here, 20 key ethical, legal, and practical challenges are identified and analyzed that need to be addressed. Apart from challenges arising at the level of the experiments themselves, there are also so-called meta-challenges associated with animal research ethics as a field. Four of these are presented and further discussed, also in relation to their opportunities for the further development of animal research ethics that takes into account interdisciplinary and international perspectives. Abstract Can nonhuman animals be used for the benefit of humans in a scientifically and morally justified manner and, if yes, how? Based on our own experiences as scholars from various academic backgrounds, we argue that this question can only be answered as an interdisciplinary and international endeavor, considering insights from research ethics and animal ethics as well as scientific and legal aspects. The aim of this article is to contribute to the foundation of the emerging field of animal research ethics. In doing so, we describe the following seven phases of animal research experiments: ethical, legal and social presumptions (phase 0), planning (phase I), review (phase II), conduct of experiments (phase III), publication/dissemination (phase IV), further exploitation of results (phase V), and evaluation (phase VI). In total, 20 key ethical, legal, and practical challenges that an ethical framework for the use of animals in research needs to address are identified and analyzed. Finally, we characterize the following four meta-challenges and opportunities associated with animal research ethics as a field: (1) moral pluralism, (2) the integration of views and positions outside the laboratory, (3) international plurality of conduct, standards, and legal norms, and (4) interdisciplinary education. (shrink)

Providing high quality and user oriented information about mammographic screening is no easy task, as screening has been subject to heated professional and public debates. Although the information has to be developed and provided in context for each screening program, the basic challenges are very much the same for all programs. Accordingly, the objective of this article is to analyze key ethical challenges in informing about mammographic screening, and based on these, to suggest some guiding principles for practical solutions. A (...) literature review identifies five crucial issues with respect to informing women about mammographic screening. By analyzing and addressing these issues, five guiding principles are suggested: the content and the form of information should be developed through open and transparent processes with strong stakeholder involvement. Facts should be presented in a balanced way and uncertainties should be acknowledged, e.g., by presenting outcomes in ranges. Information should be layered without attempts to frame information. Attending mammographic screening should be as easy as not attending. Although apparently trivial, the suggested principles can be useful for elaborating specific information material about mammographic screening in a field of great ethical controversy. (shrink)

An increase in global violence has forced the displacement of more than 70 million people, including 26 million refugees and 3.5 asylum seekers. Refugees and asylum seekers face serious socioeconomic and healthcare barriers and are therefore particularly vulnerable to physical and mental health risks, which are sometimes exacerbated by immigration policies and local social discriminations. Calls for a strong evidence base for humanitarian action have encouraged conducting research to address the barriers and needs of refugees and asylum seekers. Given the (...) role of epigenetics factors to mediate the effect of psychological and environmental exposures, epigenetic modifications have been used as biomarkers for life adversity and disease states. Therefore, epigenetic research can be potentially beneficial to address some of the issues associated with refugees and asylum seekers. Here, we review the value of previous and ongoing epigenetic studies with traumatized populations, explore some of the ethical challenges associated with epigenetic research with refugees and asylees and offer suggestions to address or mitigate some of these challenges. Researchers have an ethical responsibility to implement strategies to minimize the harms and maximize the short and long-term benefits to refugee and asylee participants. (shrink)

This article talks about both clinical research ethics and public health research ethics. Clinical research ethics are defined as set of relevant ethics considered necessary for the conduct of clinical trials in field of the clinical research. While public health research ethics is mainly aimed at finding out what is best for the communities and the populations rather than the individuals. Research ethics is mainly focused on the protection of individual participants and some of the research norms and accepted (...) principles may be challenging when applying in some of the research contexts. (shrink)

This new edition of Professionalism and Ethics: Q & A Self-Study Guide for Mental Health Professionals thoroughly updates the highly regarded and groundbreaking first edition, offering the contemporary reader clinical wisdom and ethical guidance for challenging times. As with its predecessor, the second edition features commentaries by leaders in psychiatric ethics, plus two foundational chapters on ethics and professionalism in the field of mental health. These commentaries and introductory chapters provide an overview of essential ethical principles and concepts, (...) the professional obligations of the mental health clinician, common ethical tensions found in practice, ethical aspects of caring for special populations, and ethical issues in professional training and research. The introductory chapters are followed by case-oriented questions and answers on core concepts and topics in clinical care, medical research, and interactions with colleagues and trainees. Topics explored in-depth include authorship, disclosure, and ethical peer review for scientific publications; assisted suicide and euthanasia; professional voyeurism versus patient privacy online and on social media; the appropriate process for reporting an impaired colleague; and problems of burnout, work-life balance, and professional well-being. Professionalism and Ethics: Q & A Self-Study Guide for Mental Health Professionals poses and plumbs critically important ethical dilemmas in a compelling, down-to-earth way for today's practitioners and learners. (shrink)

Background: Nursing home residents are a vulnerable population. Most of them suffer from multi-morbidity, while many have cognitive impairment or dementia and need care around the clock. Several ethical challenges in nursing homes have been described in the scientific literature. Most studies have used staff members as informants, some have focused on the relatives’ view, but substantial knowledge about the residents’ perspective is lacking. Objective: To study what nursing home residents and their relatives perceive as ethical challenges in Norwegian (...) nursing homes. Research design: A qualitative design with in-depth interviews with nursing home residents, and focus-group interviews with relatives of nursing home residents. The digitally recorded interviews were transcribed verbatim. Analysis was based on Interpretive Description. Participants and research context: A total of 25 nursing home residents from nine nursing homes in Norway, and 18 relatives of nursing home residents from three of these nursing homes. Ethical considerations: This study was reported to and approved by the Regional Ethics Committee in Oslo, Norway. Findings and discussion: The main ethical challenges in Norwegian nursing homes from the residents’ and relatives’ perspective were as follows: (a) acceptance and adaptation, (b) well-being and a good life, (c) autonomy and self-determination, and (d) lack of resources. The relationship with the staff was of outmost importance and was experienced as both rewarding and problematic. None of the residents in our study mentioned ethical challenges connected to end-of-life care. Conclusion: Residents and relatives experience ethical challenges in Norwegian nursing homes, mostly connected to “everyday ethical issues.”. (shrink)