En répondant à des demandes émanant des institutions impliquées dans le domaine de la santé, l’Inserm prolonge sa mission de recherche par une activité de diffusion et de partage des connaissances et participe à la réflexion sur les implications collectives de cette recherche. Aujourd’hui intégrée à l’Institut de santé publique dans le cadre de l’Alliance nationale pour les sciences de la vie et de la santé , l’activité d’expertise collective participe au plan stratégique 2010-2015 de l’Inserm : « (...) l’expérience acquise en matière d’expertise collective sera renforcée au service d’une politique active de mise à disposition des connaissances disponibles pour l’aide à la décision des acteurs du système de santé et l’information des citoyens ».In response to demand from the institutions involved in public health, Inserm has taken its research mission further by becoming involved in knowledge sharing and dissemination and in discussions on the implications of its research for society. Now working as a member of the Public Health Institute through the National Alliance for Life and Health Sciences , INSERM’s collective expert studies are contributing to its strategic plan for 2010-2015: “the experience gained in collectively developed expert studies will be strengthened to serve an active policy for delivering available knowledge to support decision-making in the public health system and citizens’ information”. (shrink)

Positive Psychology Interventions as an Opportunity in Arab Countries to Promoting Well-being AbstractIn this perspective paper, we emphasize the importance of further research on culturally-sensitive positive psychology interventions in the Arab region. We argue that these interventions are needed in the region because they not only reduce mental health problems but also promote well-being and flourishing. To achieve this, we shed light on the cultural elements of the Arab region and how the concept of well-being differs from that of (...) Western culture. We review the research conducted in Arabia, briefly evaluate the quality of this research and list some adapted measurements. We furthermore propose guidelines and recommendations for future evidence-based positive psychology interventions research to align with the national culture in various sectors and community samples that contribute to the development of well-being in the Arab world.Introduction Extensive research on Positive Psychology Interventions (PPIs) - defined as activities focus on promoting positive feelings, thoughts, or behaviour (Sin & Lyubomirsky, 2009) - has shown their effectiveness in well-being and mental illness (e.g., Chakhssi et al., 2018; Hendriks et al., 2020). A recent review of 347 studies showed that PPIs have a significant effect on promoting quality of life and well-being and reducing anxiety and depression (Carr et al., 2020). However, the issue is that most of these studies (82%) remain narrow in focus only on Western Educated Industrialised Rich Democratic (WEIRD) countries (Hendriks et al., 2019). Therefore, they may not be effective for other countries such as the Arab countries where there are various cultural differences. This highlights the key role that culture can play in enhancing PPIs engagement, acceptability, and eventually, effectiveness (Hendriks & Graafsma, 2019). Recently, the field of PP in the Arab region has begun to grow (Basurrah et al., 2021; Rao et al., 2015). However, studies conducted in these countries are scant and of poor methodological quality. We have found humble quantity and quality of empirical studies. Yet, Arab countries, home to 5% of the world’s population, have a burden of mental health problems above global levels (GBD 2015 Eastern Mediterranean Region Mental Health Collaborators, 2018). Prevalent stigma, war and conflict were some of the contributors (Maalouf et al., 2019). Thus, to properly address this cultural stigma against mental health problems, PPIs could provide an additional role alongside traditional psychology approaches (e.g., Cognitive Behavioural therapy - CBT). Further, in light of the political conditions that some Arab countries are going through and the negative effects that they cause, it has become necessary to use the method of prevention that is the focus of PP and not only of treatment as a strategy for applications and practice. It has been noted that the mental health care system in the Arab region focuses highly on illnesses treatment and neglects the significant role that PP plays in enhancing human potential and well-being. We - here in Arabia –are becoming more influenced by many global issues particularly the COVID-19 pandemic and their impact on mental health and well-being (e. g. prevalence of stress, anxiety, depression among the general population during the pandemic (Salari et al., 2020). In response, Waters et al. (2021) have recently presented how positive psychological factors can play a significant role in buffering mental illness, enhancing mental health throughout the pandemic, and building positive processes and capacities that can help to promote future mental health.Here in this perspective paper, we highlight the cultural aspects of Arab countries. Specifically, we present previous PPIs research conducted in Arabia and briefly evaluate the quality of this research. Importantly, we discuss the need of developing an indigenous and culturally sensitive PP among the Arab region (Lambert et al., 2015).Arab Culture “Arab World,” which comprises 5% of the world’s population, refers to the Arab countries in the Middle East and North Africa. Despite the increasing pace and progress of different businesses in many Arab countries, individual communities are still limited in certain prominent economic places. Arab people rather gather in collective communities. They generally share the same Arabic Islamic culture, speak the same language, and descend from the same Arab families when going back in history no matter what nationality they have nowadays. Yet, very many changes came to communities before borders were drawn between countries and after. For instance, geography, topography, demography, and socio-economic status affect peoples’ nature of jobs and lifestyles. For example, Arabs in the east, west, or the middle have similar tongues; however, almost every Arab country has its accent. Therefore, people need to go back to the formal Arabic language ‘Fus-ha’ or learn more about different Arabic dialects when communicating cross-countries. According to Hofstede’s model (2011) based on the individualism-collectivism dimension, the Arab countries (Eastern society) have been classified as a collectivist culture, where their identity and decisions are influenced by social systems. In contrast, the United States (Western society) has been classified as an individualist culture focusing on individual decisions. Although there are degrees of individualism among Arabs in certain countries, they still share collective common characteristics. Here, we explore the meaning of collectivistic conceptions of the self, emotions, values, and religion in Arab countries and how they differ from those in individual Western cultures. The Self Since the field of PP focuses on the development of self, it is vital to recognize that self-concept varies across cultures. Individualism generally emphasises the self-directed and autonomous individual (Realo et al., 2002). People in individualist countries focus primarily on their personal characteristics (e.g., motives, abilities) to build their self-concept. On the other hand, collectivism refers to several social structures that highly value the groups to which people belong, such as family and tribe (Realo, 2003). People in collectivist countries such as the Arab countries focus primarily on their relationships with others to build their self-concept (Markus & Kitayama, 1991). Hence, research from Arab countries should focus on the core elements of collectivism when implementing PPIs to make a significant, meaningful impact. For example, people from a collective culture may experience a greater enhancement in well-being when practising interventions that are more prosocial and group-oriented such as compassion, performing acts of kindness, writing a gratitude letter, and using character strengths in everyday context including social context, compared with self-oriented interventions such as identifying character strengths. Emotions, value, and Religion Research shows that Western culture emphasises the goal of maximizing positive emotions, while Eastern culture emphasises embracing and balancing positive and negative emotions (Leu et al., 2011). To illustrate, culture plays an important role in influencing perceptions of happiness. People in individualist countries value happiness highly. In contrast, people from the collective countries value low arousal positive emotions (Leu et al., 2011) and exhibit a fear of happiness (Joshanloo & Weijers, 2014; Joshanloo, 2013). Hence, the influence of positive emotions plays a limited role in the mental health of Eastern society. Speaking of Value, for an Arab, the family is the centre of honour and the most important social unit. This loyalty has an impact on every part of an Arab’s life. Arabs honour their families and highly value their friendships. Therefore, future research could shed more light on group-oriented interventions (e.g., kindness) that focus more on the relationship with family, friends, and community. When it comes to religion, Arab society has a rich culture in values and believes that place a high emphasis on spirituality. Religion is the most important and distinctive aspect of Arab culture. Arab countries vary in terms of religion, with Islam being the predominant religion in most of them. Well-being (Hedonic and Eudaimonic) It is necessary here to clarify what is meant by hedonic and eudaimonic definitions of well-being. While the term ‘Hedonic’ is based on the pursuit of maximum levels of pleasure (feeling good), the term ‘Eudaimonic’, on the other hand, is based on meaning and the development of virtues (functioning well; Keyes & Annas, 2009). Research indicates that cultures are not equally supportive of hedonic and eudaimonic aspects (Joshanloo & Jarden, 2016). In comparison to collectivism, hedonism appears to be more congruent with individualism (Joshanloo, 2014). Pleasure and positive emotions are considered a way to pursue happiness in Western culture, while this method is not highly favoured in Eastern cultures (Lee et al., 2013); Because they consider suffering and negative emotions as contributing factors to spiritual development. Therefore, the eastern perspective is more in line with a eudaimonistic view which emphasises virtues, meaning, and feeling of belongingness. However, although we believe that both approaches can be found to a certain level in both cultures, the differences suggest that there are different routes to happiness. Positive Psychology in the Arab region Positive psychology - "the scientific study of what makes life most worth living" (Seligman & Csikszentmihalyi, 2000) - is one of the newest branches of psychology. It focuses on three main pillars: (1) positive subjective experiences (such as happiness and love); (2) positive individual characters (such as gratitude and compassion); and (3) positive institutions (for the application of positive principles within institutions and organizations; Seligman & Csikszentmiha lyi, 2000). Some of the main topics of interest in positive psychology include character strengths, gratitude, hope, happiness, mindfulness, optimism, positive thinking, and resilience. Within the applications of this science, various domains of well-being (such as happiness, engagement, positive emotions, and meaning) can be enhanced by practising positive psychology interventions (Sin & Lyubomirsky, 2009). Interestingly, these interventions have also produced benefits beyond well-being, such as reduced mental health issues (Chakhssi et al., 2018; Hendriks et al., 2020).Nowadays, PP is increasingly noticed in the Arab world (Lambert & Pasha-Zaidi, 2019; Rao et al., 2015). In recent years, there has been a great effort to explore the PP field across Arab countries. Several initiatives have emerged aimed at promoting well-being and flourishing. For example, the Middle East Journal of Positive Psychology published its first volume in 2015. On the International Day of Happiness in 2017, United Arab Emirates University launched its Emirates Center for Happiness Research. Meanwhile, Effat University in Saudi Arabia started the first Positive Psychology and Well-being Research Lab, the first symposium, and the first PP course. In 2019, Louise Lambert and Nausheen Pasha-Zaidi published the first regional text entitled “Positive Psychology in the Middle East/North Africa.” There are other efforts spent in the region as well; such as the work conducted in Egypt. Ibrahim Younus established the Arab Association for Positive Psychology https://www.psycholearn.com/en/associative.php which provides several courses on PP and also published a book entitled “The Power of Positive Psychology” (Younus, 2017). Despite this development, nothing can compare to the quantity and even quality of research in other countries. In light of our observations, the few PP studies may be attributed to the lack of awareness of the constructive approach and prevention compared to problem-solving. An Arab dentist once said: “people do not come to me until they are badly in pain.” In any case, many studies have taken place in Arab countries in the last decade, more of which are descriptive and less of which experimental. For example, Abdel-Khalek (2010) found positive correlations between quality of life, subjective well-being, and religiosity among students in Kuwait. Abdel-Khalek (2016) developed “the Arabic Scale of Religiosity,” which significantly correlated with PP variables among students in Algeria, Kuwait, and Egypt. Recently, empirical studies on PPIs have arisen in Arab-Islamic countries. More attention has been focused on promoting well-being and alleviating the high burden of mental health problems in the region (GBD 2015 Eastern Mediterranean Region Mental Health Collaborators, 2018). For instance, several studies examined the effectiveness of mindfulness among university students (e.g., Al-Ghalib & Slim, 2018; Awad, 2019; Thomas et al., 2016), parents of children with autism (Rayan & Ahmed, 2016) and addicted adults (Al-Rashidi, 2018). Such an intervention has positive effects. Participants who practised mindfulness reported reduction in stress and depression as well as improvement in well-being and resilience. Moreover, the results of a recent pilot study found positive impacts on enhancing emotional regulations and reducing stress among Arab teachers (Berkovich-Ohana et al., 2020). Some studies have also begun to examine various interventions targeting character strengths (Basurrah et al., 2020; Chérif et al., 2020), self-compassion (Elaiwah, 2017), positive thinking (Mohammed et al., 2014; Hadad, 2014), and hope (Zaki, 2016). Interestingly, a new finding considering the fear of happiness among people from collective countries has been examined. Lambert et al. (2019) provided evidence that a 14-week PPIs programme has an impact on reducing the fear and fragility of happiness beliefs among university students in the United Arab Emirates.Since Arab countries place great emphasis on spirituality, several authors have considered the aspect of religion when implementing PPIs. For instance, an empirical study by Al-Seheel and Noor (2016) found that expressing gratitude towards God “Allah” increases the happiness of the Muslim more than the usual gratitude intervention. Additionally, Al-Ghalib and Salim (2018) examined a religiously sensitive mindfulness-training programme with university students and found a positive effect on life satisfaction and a slight reduction in stress, depression, and anxiety. Hence, the role of religion is vital to make the interventions more relevant to Arab culture where people can connect Islamic philosophy with PP theories and practices. These studies reviewed here provide further support for the need for culturally sensitive interventions among the Arab population. More recently, the first systematic review of PPIs in Arab countries was conducted by Basurrah et al. (2021; the protocol has been published in BMJ Open and the final manuscript has been submitted for publication). Reviewing a total of 39 studies, the most commonly studied interventions were mindfulness, positive thinking, and resilience. Only a handful of studies examined gratitude, character strengths, forgiveness, self-compassion, savouring, or finding flow. Further analysis revealed that most studies from Arab countries have several methodological limitations. This included a lack of protocol guidelines, few well-designed randomized controlled trials (RCTs), blinding issues, small sample sizes, lack of active control groups, and lack of research into certain populations (e.g., teachers, employees, and people in distress in refugee camps). Discussion PP was founded on an individualistic framework (Christopher & Hickinbottom, 2008). To ensure that PPIs are culturally meaningful, this paper includes some cultural elements of the Arab region that should be considered to serve the needs of the Arab population. In the Arab world, some people may believe that PP is solely about happiness and being positive. If so, it is important to educate the public about the findings of rigorous studies evaluating PPIs such as gratitude, hope or flow on health, well-being and performance. To explain the value and effectiveness of these evidence-based approaches, examples might include studies linking gratitude with benefits for people with heart disease (Cousin et al., 2021), or how PPIs can promote quality of life in cancer patients (Casellas-Grau et al., 2014). There is some evidence about PPIs being effective in improving well-being in the Arab region, but research in this region is still in its infancy and little information is available regarding PPIs and the experience of Arabs participating in such interventions. Hence, there is still much more to investigate in this regard. Future research should empirically examine the effectiveness of various unstudied interventions such as savouring, gratitude, self-compassion, character strengths or finding flow. A combination of quantitative and qualitative approaches is required to provide an in-depth understanding of Arabs’ experience and impressions of PPIs and how and why they work. This may provide useful information to inform the appropriate design of PPIs to suit Arab culture and needs. Furthermore, while some research on PPIs has been carried out in the region, most of these studies have been of poor quality that suffered from small sample sizes, confounding factors, and a high degree of bias. To overcome these issues, future research should improve research quality, including protocol guidelines and well-designed RCTs. In particular, research should include randomization, allocation, blinding, power analysis to determine adequate sample size, active control groups to reduce bias, and follow-up periods of at least 12 months.Among the most popular resources that future PP practitioners may refer to are the International Positive Psychology Association (IPPA) and the International Positive Education Network (IPEN). Also, we recommend the Middle East Journal of Positive Psychology and the first regional book (Lambert & Pasha-Zaidi, 2019). To develop and/or adapt a multi-component PPIs, we would recommend referring to Character Strengths (Peterson & Seligman, 2004), the theory of well-being (PERMA Model: Positive Emotion, Engagement, Relationships, Meaning, and Accomplishment; Seligman, 2011), and the Five Ways to Well-being: Connect, Be Active, Take Notice, Keep Learning, and Give (Aked et al., 2008). Finally, single-component PPIs are based on theories like Broaden-And-Build (Fredrickson, 2004), Hope (Snyder et al., 2002), and Self-Determination (Deci & Ryan, 2012) can be also considered. Two other concepts that would be usefully applied are ‘Savouring’ (Bryant & Veroff, 2007) and Phillip Zimbardo’s Time Perspective (Stolarski et al., 2015). For instance, savouring has a positive temporal orientation to reminiscing the good memories from the past, enjoying the hedonic present moments, and willing proactively to make a better future. Now, what is even maybe more interesting for Muslims is “Transcendent Future” where all intentions, words and actions are devoted to that life after death. In addition, there is a model already prepared for the clinical purpose called Positive Psychotherapy (PPT). Tayyab Rashid and Martin Seligman published a PPT manual for clinicians in 2018. And for cross-cultural applications, including Muslim Arab culture, Rashid and Al-Haj Baddar (2019) have written a paper presenting PPT and its efficacy. PPT overview in detail shows sessions, themes, skills, practice, and cultural considerations where a mixture of PPIs based on PERMA, Strengths, and other PP concepts can be found. Regarding PP measurements, it is highly recommended to generate indigenous tools based on cultural backgrounds reviewed here in the article. An example of this is a tool for measuring Muslim well-being by including domains beyond what is found in Western literature. So far, in the Arab region, several attempts have been made to adapt PP tools. For example, Marei Salama-Younes (2018) validated the Arabic versions of different measures of well-being (e.g., satisfaction with life scale, the subjective vitality scale). Other validated scales as well include the self-compassion scale (Alabdulaziz et al., 2020), and the passion scale (Salama-Younes & Hashim, 2018). Conclusion This paper has discussed the cultural aspects of Arab countries and the need of developing culturally sensitive PPIs. The past decade has seen an increase in mental health problems in the Arab region. Stigma and lack of awareness have been always there. Among the issues are also wars, conflicts, and displacement in many Arab countries such as Iraq, Lebanon, and Palestine (Hassan et al., 2016). These indicate an urgent need to prevent mental illness and promote well-being. Indeed, we highlighted the importance of integrating culture with PPIs, following the guidelines for the cultural adaptation of PPIs (Hendriks & Graafsma, 2019) and the ethical guidelines for PP practice (Jarden et al., 2020). Another significant contribution of this paper is to highlight the importance of improving the quality of research conducted in Arab countries. In brief, this paper has several practical implications. It is an open invitation for researchers, policymakers, and practitioners alike to be more exposed to PP; as well as to better conceptualising and adapting interventions and measurement tools to the local culture in different sectors to maximize their effectiveness. And as we consider it as an invitation for us too, here we are starting a PPIs practice guide in Arabic language and for Arab practitioners. The insights gained from this paper may be useful for placing well-being on top of priorities for achieving individual, organizational, and optimal national functioning in different sectors. There is also a need to change the stigma or negative beliefs about seeking health for psychological support, which is an issue for countries in the Middle East (Baess, 2018). (shrink)

Ludwik Fleck is known mainly for his pioneering studies of science as a social activity. This text investigates a different aspect of Fleck’s epistemological thought—his engagement with normative aspects of medicine and public health and their political underpinnings. In his sinuous professional trajectory, Fleck navigated between two distinct thought styles: fundamental microbiological research and practice-oriented investigations of infectious diseases. Fleck’s awareness of tensions between these two approaches favored the genesis of his theoretical reflections. At the same time, (...) his close observation of medical and epidemiological practices led him to the conclusion that collectively produced scientific facts are situated and fragile. Thought collectives, Fleck explained, can err or yield to external pressures, with potentially disastrous consequences. While Fleck the reflexive experimental scientist has been creatively translated into the science studies idiom, Fleck the reflexive practical microbiologist and public health expert still awaits inspired translation. (shrink)

Background Dignity is a central human value supported by nurses’ professional ethics. In previous studies, nurses in clinical practice have experienced that dignity increased their work well-being and pride of work. Dignity is also strictly interweaved to professional identity in the different nursing’ roles, but little is known about dignity among public health nurses and primary care settings. Purpose This study aimed to describe the perceptions of nursing's professional dignity of public health nurses in primary care in Finland. (...) Research design An inductive qualitative descriptive approach with semi-structured focus group interviews was utilised. Participants and research context Twenty-seven Finnish public health nurses were interviewed via eight semi-structured focus group interviews in primary health care settings. Ethical considerations Before data collection, research permissions were obtained from participating health care centres. This type of research in Finland, with competent adult participants, does not require ethical pre-assessment but written and oral informed consent obtained before the interviews. Findings Based on our findings, public health nurses perceived that professional dignity was (1) part of their self-respect, an observed daily value based on their acknowledged competence. Besides, they perceived that (2) service users’ trust in public health nurses was a strong expression of professional dignity, and it could be uncovered when recipients of care utilised their services. In addition, public health nurses experienced that (3) professional dignity was an expression of different intertwined interprofessional and social factors. Discussion and conclusion Professional dignity is simultaneously an essential prerequisite and an outcome of public health nurses’ work. In future, more information would be needed to implement strategies in primary health care to foster nurses’ professional dignity also in international public health arenas. (shrink)

Photo ID 71252867© Stepan Popov| Dreamstime.com Abstract While Medical Assistance in Dying (MAiD) has been legalized in Canada since 2016, it still excludes eligibility for persons who have mental illness as a sole underlying medical condition. This temporary exclusion was set to expire on March 17th, 2024, but was set 3 years further back by the Government of Canada to March 17th, 2027. This paper presents a critical appraisal of the case of MAiD for individuals with mental illness as the (...) sole underlying medical condition through the analysis of three ethical theories: principlism, deontology, and utilitarianism. Through evidence and discussion, it will be demonstrated that MAiD, in this context, may be ethically justifiable on the grounds of upholding human rights, protecting dignity, and minimizing suffering. Introduction In June of 2016, Medical Assistance in Dying (MAiD) was legalized in Canada.[1] Throughout the first six years, a temporary exclusion of eligibility for persons suffering solely from mental illness was extended.[2] The exclusion of mental illness as a sole underlying medical condition was set to expire on March 17, 2024.[3] However, on February 1, 2024, just over a month before the set expiration, the Government of Canada once again extended the exclusion, this time setting it back three years to March 17, 2027. There are currently several countries that allow MAiD for mental illness, including Belgium, the Netherlands, and Luxembourg.[4] Some countries, like Spain,[5] do not give specific guidance, leaving the matter under discussion by ethicists and courts. In these countries, there are specific (although different) requirements for the process; overall, for mental illness, the illness must be verifiable and not simply related to a perception of satisfaction with the length of life. This extension ignited discussion on whether MAiD for persons who have mental illness as a sole underlying medical condition in Canada is ethically acceptable. As a complex, multi-faceted, and interdisciplinary issue, ethicists assessing MAiD must take into account various moral obligations and considerations. This paper analyses MAiD in this context through the application of three ethical theories: principlism, deontology, and utilitarianism. This paper concludes that, based on the current evidence and knowledge of this developing situation, MAiD for persons with mental illness in Canada may be ethically justified on the grounds of upholding human rights, labour obligations, and dignity. Through the exploration of research and discussions, it will be demonstrated that society at large ought to protect liberty and act towards relieving suffering, thereby supporting the potential eligibility of MAiD for persons who have mental illness. Principlism: The Capacity and Ability to Assess and Decide for One’s Own Life Principlism is the application of four principles: autonomy, beneficence, non-maleficence, and justice. Principlism supports permitting MAiD for mental illness due to the importance of autonomy in decision-making, equitable and just practices for MAiD assessors, and reducing suffering for patients and their family member(s) and/or friend(s). Carter v. Canada, the Canadian Supreme Court ruling of 2015—which changed Canadian law to allow for MAiD—held that the prohibition of MAiD infringed on Canadians’ right to “life, liberty, and the security of the person.” In a unanimous decision, the Supreme Court of Canada decided that the criminal prohibition of MAiD violates the Canadian Charter of Rights and Freedoms.[6] The Court concluded that the criminal law prohibiting MAiD interfered with people’s autonomy and dignity, which are protected by the rights of liberty and security of the person.[7] The ruling emphasized that Canada’s constitution reflects the fundamental importance of individual autonomy in personal decision-making. Research provides evidence that MAiD improves autonomy: A study among psychiatric patients found that 8 of 48 psychiatric patients said the mere option of accessing MAiD was enough to assess their future options for living wholly.[8] These findings complement a study entailing interviews with 30 adults who have mental illness, which emphasized that the ability to access MAiD allows individuals to analyze their quality of life, envision their desired future, and make decisions accordingly.[9] Although not all participants agreed that mental illness as the only underlying medical condition was appropriate for MAiD eligibility, many participants agreed that patient autonomy in decision-making was paramount and should be respected. However, autonomy as an ethical principle does not immediately grant all persons with mental illness the option to access MAiD. There are multiple eligibility criteria for those who wish to receive MAiD, which still must be approved and assessed. Currently, eligibility criteria for MAiD states that individuals must “give informed consent to receive MAiD, meaning that the person has consented to receiving MAiD after they have received all information needed to make this decision.”[10] Consent requires capability or capacity, which is the ability to understand relevant information, appreciate its potential consequences, and make an informed decision for oneself.[11] Like for many other diseases, disabilities, and conditions, patient capability is determined on a case-by-case basis.[12] Given the stigma surrounding those struggling with mental health, this thorough case-by-case examination of an individual patient’s capability and capacity without prejudice or partiality should lead to equitable and fair treatment. Without appropriate testing, those with mental illness could be wrongly stripped of their decision-making power. Arguments against MAiD for those with mental illness have raised concerns about the potential for individuals to harm themselves and others. A survey of MAiD providers demonstrated that physicians believed that the bereavement experience following MAiD is challenging and profoundly distinct and that bereavement support for all members involved should be required.[13] However, while watching one die (of MAiD) may cause harm to their families, friends, and support system at large, it is also important to recognize that watching someone suffer and struggle through their mental health journey also poses significant harm. Qualitative studies in Ontario, Canada, have interviewed family members of persons with mental illness as a sole medical condition, and interviewees shared that witnessing the illness and its impacts on their close one's lives was a very difficult experience.[14] As it relates to MAiD, participants emphasized that those living with mental illness are in the best position to understand their own pain and suffering and, in turn, make their own decisions about relief.[15] In an interview, a MAiD provider stated that MAiD may provide less suffering and more peace, and that, although it “depends on the family,... usually the family is more prepared and at peace.”[16] On the contrary, a person who has mental illness may perceive choosing MAiD as beneficial to their family member(s) and/or friend(s). Among those who died by MAiD in 2021, 35.7 percent reported that they perceived themselves as a burden on their family and friends.[17] While some authors report their concerns regarding such social burden as a potential driving factor for MAiD requests, others report that there are other additional burdens associated with requesting MAiD that may be financial, societal, and personal.[18] As such, the extension of MAiD eligibility to those with mental illness will likely only allow a small number of people to be granted MAiD.[19] Many others will be diverted to appropriate services and treatments. Patients’ decision to choose MAID noted their ability to make choices about their own care, reflecting the value of autonomy.[20] Although it is difficult to determine what is good for families in individual cases, MAiD presents an option that is both beneficent and non-maleficent. Therefore, these arguments satisfy the principles which do not necessarily conflict with MAiD. Deontology: The Duty to Recognize Vulnerability and Relieve Suffering The argument here begins with the fundamental focus of deontology—that moral duty lies in an action rather than in its consequences. Further discussion is required to analyze the impact of MAiD on healthcare workers. The Canadian Medical Association (CMA) Code of Ethics and Professionalism requires physicians to abide by virtues, commitments, and responsibilities in delivering health care and service.[21] The code states that “a compassionate physician recognizes suffering and vulnerability, … and alleviate[s] the patient’s suffering.”[22] In the context of MAiD for persons with mental illness as a sole underlying medical condition, vulnerabilities could be wide in range. Many Canadians are concerned with the interaction between mental health and other social determinants of health, such as the lack of medical, disability, financial, housing, and social support and resources.[23] As a result, another layer to the ethical issue arises: Does permitting MAiD for mental illness treat the symptoms of the issue rather than the root problem itself (social, economic, and systemic inequities)? Some argue against MAiD, stating that the nation should first focus on developing better quality care and service.[24] Others support MAiD as a potential harm reduction approach, given that most of these unjust conditions require a higher level of long-term structural and public policy overhaul.[25] The CMA Code also calls upon physicians to recognize and alleviate patients’ suffering. Some argue that while physicians and medical professionals do work to relieve suffering, they are trained to do so through a primary care-based diagnose-and-treat approach.[26] Studies that have captured Canadian physicians’ experiences providing MAiD report that, although physicians stated that the work was rewarding, it came with many challenges, including strained relationships with coworkers, increased workload, and inadequate compensation.[27] Physicians report that a part of the problem is that MAiD rules are written by lawyers and experts who are removed from its reality in medical practice. As a result, there is a lack of clarity surrounding practice norms and a lack of support for physicians.[28] Thus, while healthcare practitioners have a duty to relieve patients’ suffering, they should feel adequately trained and supported in doing so. If physicians and healthcare professionals recognize vulnerability and relieve suffering, then they should act accordingly, regardless of potential associations or outcomes. Making persons with mental illness eligible for MAiD ensures that treatment to relieve their suffering is available. However, it is imperative that there are sufficient resources and support available to healthcare professionals to ensure that they feel prepared and supported to provide MAiD, should they wish to do so. Utilitarianism: Minimizing Intolerable Suffering and Dying with Dignity Overall, utilitarianism is largely concerned with the greatest happiness principle—to increase the amount of happiness for the greatest number of people. So far, this paper has analyzed individual, family, and practitioner-based ethical considerations. But if MAiD were to be extended to those with mental illness as a singular underlying medical condition, what implications would this have for the world and society at large? There is a global drive toward authorizing organized ending of life, with an increasing number of countries legalizing MAiD.[29] The medical system is generally seen as a safe and appropriate system to carry out MAiD, especially when suicide and self-harm are regarded as “alternatives.” Yet despite these worldwide efforts, many argue through the theory of utilitarianism that the inability to see long-term consequences renders MAiD a premature solution, particularly for those who are unable or unwilling to seek other forms of potentially healing treatment or for those who may undergo MAiD only for a technological innovation or biomedical advancement to later come along as a potential cure.[30] While it is true that MAiD does not prevent these “premature deaths,” it is also true that it does not claim to.[31] MAiD provides an option to alleviate intolerable suffering. Some individuals with severe mental illness do describe their condition as intolerable suffering. MAiD is seen as an option to minimize suffering. It can also be seen as a way to die with dignity and relief.[32] While predicting outcomes is difficult, extending MAiD eligibility for persons experiencing mental illness does not undermine its ability to end suffering. It allows eligible individuals to take charge of their health, their life, and their future. Conclusion Based on the current evidence, allowing MAiD for persons with mental illness as their sole underlying medical condition presents as an ethically justifiable action. The right to self-determination and fair accessibility demonstrates that there is more harm done by prohibiting MAiD for mental illness than allowing it. Such liberty is a right, and in the context of relieving suffering, it is a duty that healthcare workers must uphold, although the ability to opt out of providing MAiD is well established. Thus, to recognize vulnerability and relieve suffering means to provide methods, such as MAiD, for those deeply impacted by mental illness. These justifications stand at both the individual level and for society at large. Nevertheless, it remains imperative to take an upstream approach that addresses the social determinants of health and aims to prevent mental illness and promote long-term, beneficial social change for those suffering, struggling, and vulnerable in our communities. - [1] Jaro Kotalik and David W. Shannon, Medical Assistance in Dying (MAID) in Canada Key Multidisciplinary Perspectives, 1st ed. 2023., The International Library of Bioethics, 104 (Cham: Springer International Publishing, 2023), https://doi.org/10.1007/978-3-031-30002-8. [2] Department of Justice Government of Canada, “Canada’s Medical Assistance in Dying (MAID) Law,” February 21, 2024, https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html. [3] Health Canada, “Final Report of the Expert Panel on MAiD and Mental Illness,” transparency - other, May 13, 2022, https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisory-bodies/expert-panel-maid-mental-illness/final-report-expert-panel-maid-mental-illness.html. [4] Federal Public Service (FPS) Health Belgium, “Federal Commission for the Control and Evaluation of Euthanasia,” n.d., https://consultativebodies.health.belgium.be/en/advisory-and-consultative-bodies/federal-commission- control-and-evaluation-euthanasia.; Government of Netherlands, “Is Euthanasia Allowed in the Netherlands?,” n.d., https://www.government.nl/topics/euthanasia/is-euthanasia-allowed.; “Information on Requesting Euthanasia or Assisted Suicide,” n.d., https://guichet.public.lu/en/citoyens/sante/fin-vie/euthanasie/euthanasie-assistance-suicide.html. [5] Luis Espericueta, First official report on euthanasia in Spain: A comparison with the Canadian and New Zealand experiences, Medicina Clínica (English Edition), Volume 161, Issue 10, 2023, Pages 445-447, ISSN 2387-0206, https://doi.org/10.1016/j.medcle.2023.06.021. [6] Government of Canada, “The Canadian Charter of Rights and Freedoms,” March 15, 2021, https://www.justice.gc.ca/eng/csj-sjc/rfc-dlc/ccrf-ccdl/. [7] Supreme Court of Canada, “Carter v. Canada,” Constitutional Law, 2015, https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do.; Kotalik and Shannon, Medical Assistance in Dying (MAID) in Canada Key Multidisciplinary Perspectives. [8] Karandeep Sonu Gaind, “What Does ‘Irremediability’ in Mental Illness Mean?,” Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie 65, no. 9 (September 2020): 604–6, https://doi.org/10.1177/0706743720928656; Lieve Thienpont et al., “Euthanasia Requests, Procedures and Outcomes for 100 Belgian Patients Suffering from Psychiatric Disorders: A Retrospective, Descriptive Study,” BMJ Open 5, no. 7 (July 27, 2015): e007454, https://doi.org/10.1136/bmjopen-2014-007454. [9] Hamer Bastidas-Bilbao et al., “Walking Alongside: Views of Family Members on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition,” Qualitative Health Research 33 (September 29, 2023), https://doi.org/10.1177/10497323231197365. [10] Government of Canada, “Canada’s Medical Assistance in Dying (MAID) Law.” [11] Commission sur les soins de fin de vie, “Les conditions de l’admissibilité à l’aide médicale à mourir au Québec: la constance dans l’évolution de la loi concernant les soins de fin de vie,” June 9, 2023, https://csfv.gouv.qc.ca/ fileadmin/docs/autres_rapports/csfv_lcsfv_conditions_ amm_2023-06-29.pdf.; Trudo Lemmens, “When Death Becomes Therapy: Canada’s Troubling Normalization of Health Care Provider Ending of Life,” The American Journal of Bioethics 23, no. 11 (November 2, 2023): 79–84, https://doi.org/10.1080/15265161.2023.2265265. [12] Justine Dembo, Udo Schuklenk, and Jonathan Reggler, “‘For Their Own Good’: A Response to Popular Arguments Against Permitting Medical Assistance in Dying (MAID) Where Mental Illness Is the Sole Underlying Condition,” Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie 63, no. 7 (July 2018): 451–56, https://doi.org/10.1177/0706743718766055. [13] Konia Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” British Columbia Medical Journal 62, no. 1 (2020). [14] Bastidas-Bilbao et al., “Walking Alongside.” [15] Bastidas-Bilbao et al. [16] Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” 2020. [17] Ramona Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” Palliative & Supportive Care 21, no. 5 (October 2023): 871–78, https://doi.org/10.1017/S1478951523001025; Health Canada, “Third Annual Report on Medical Assistance in Dying in Canada 2021,” report on plans and priorities;transparency - other, July 26, 2022, https://www.canada.ca/en/health-canada/services/publications/health-system-services/annual-report-me dical-assistance-dying-2021.html; Lemmens, “When Death Becomes Therapy.” [18] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023.; Bastidas-Bilbao et al., “Walking Alongside.” [19] Olivia Stefanovich, “Opposition Parties Call for Indefinite Pause to MAID Expansion for Mental Illness | CBC News,” Canadian Broadcasting Corporation, January 28, 2024, https://www.cbc.ca/news/politics/special-joint-committee-maid-mental-illness-report-1.7095679; Benjamin Lopez Steven, “Number of Assisted Deaths Jumped More than 30 per Cent in 2022, Report Says | CBC News,” Canadian Broadcasting Corporation, October 27, 2023, https://www.cbc.ca/news/politics/maid-canada-report-2022-1.7009704. [20] Hamer Bastidas-Bilbao et al., “Searching for Relief from Suffering: A Patient-Oriented Qualitative Study on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition,” Social Science & Medicine 331 (August 1, 2023): 116075, https://doi.org/10.1016/j.socscimed.2023.116075. [21] Canadian Medical Association, “Canadian Medical Association Code of Ethics and Professionalism” (Canada: Canadian Medical Association, December 8, 2018), https://policybase.cma.ca/link/policy13937. [22] Canadian Medical Association. [23] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023; Stefanovich, “Opposition Parties Call for Indefinite Pause to MAID Expansion for Mental Illness | CBC News.” [24] John Paul Tasker, “Liberal Government Promoting a ‘culture of Death’ with Medical Assistance in Dying Law, Conservative MP Says | CBC News,” Canadian Broadcasting Corporation, March 6, 2023, https://www.cbc.ca/news/politics/culture-of-death-medical-assistance-in-dying-mental-illness-1.67695 04. [25] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023; Kayla Wiebe and Amy Mullin, “Choosing Death in Unjust Conditions: Hope, Autonomy and Harm Reduction,” Journal of Medical Ethics, April 26, 2023, https://doi.org/10.1136/jme-2022-108871. [26] Ramona Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” Palliative & Supportive Care 21, no. 5 (October 2023): 871–78, https://doi.org/10.1017/S1478951523001025. [27] Konia Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” British Columbia Medical Journal 62, no. 1 (2020), https://bcmj.org/articles/attitudes-and-expectations-regarding-bereavement-support-patients-family-m embers-and.; William Robert Nielsen, “MAiD in Canada: Ethical Considerations in Medical Assistance in Dying,” Canadian Journal of Bioethics 4, no. 2 (December 9, 2021): 93–98, https://doi.org/10.7202/1084456ar. [28] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023. [29] Lemmens, “When Death Becomes Therapy.” [30] William Robert Nielsen, “MAiD in Canada: Ethical Considerations in Medical Assistance in Dying,” Canadian Journal of Bioethics 4, no. 2 (December 1, 2021): 93–98, https://doi.org/10.7202/1084456ar. [31] Steven, “Number of Assisted Deaths Jumped More than 30 per Cent in 2022, Report Says | CBC News.” [32] A. Plaisance et al., “Quebec Population Highly Supportive of Extending Medical Aid in Dying to Incapacitated Persons and People Suffering Only from a Mental Illness: Content Analysis of Attitudes and Representations,” Ethics, Medicine and Public Health 21 (April 1, 2022): 100759, https://doi.org/10.1016/j.jemep.2022.100759. (shrink)

Surveillance programs supporting the management of One Health issues such as antibiotic resistance are complex systems in themselves. Designing ethical surveillance systems is thus a complex task (retroactive and iterative), yet one that is also complicated to implement and evaluate (e.g., sharing, collaboration, and governance). The governance of health surveillance requires attention to ethical concerns about data and knowledge (e.g., performance, trust, accountability, and transparency) and empowerment ethics, also referred to as a form of responsible self-governance. Ethics in reflexive governance (...) operates as a systematic critical-thinking procedure that aims to define its value: What are the “right” criteria to justify how to govern “good” actions for a “better” future? The objective is to lay the foundations for a methodological framework in empirical bioethics, the rudiments of which have been applied to a case study to building reflexive governance in One Health. This ongoing critical thinking process involves “mapping, framing, and shaping” the dynamics of interests and perspectives that could jeopardize a “better” future. This paper proposes to hybridize methods to combine insights from collective deliberation and expert evaluation through a reflexive governance functioning as a community-based action-ethics methodology. The intention is to empower individuals and associations in a dialogue with society, which operation is carried out using a case study approach on data sharing systems. We based our reasoning on a feasibility study conducted in Québec, Canada (2018–2021), envisioning an antibiotic use surveillance program in animal health for 2023. Using the adaptive cycle and governance techniques and perspectives, we synthesize an alternative governance model rooted in the value of empowerment. The framework, depicted as a new “research and design (R&D)” practice, is linking operation and innovation by bridging the gap between Reflexive, Evaluative, and Deliberative reasonings and by intellectualizing the management of democratizing critical thinking locally (collective ethics) by recognizing its context (social ethics). Drawing on the literature in One Health and sustainable development studies, this article describes how a communitarian and pragmatic approach can broaden the vision of feasibility studies to ease collaboration through public-private-academic partnerships. The result is a process that “reassembles” the One Health paradigm under the perspective of global bioethics to create bridges between the person and the ecosystem through pragmatic ethics. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Ethical, Legal, and Social Implications Research Program at the National Human Genome Research InstituteEric M. Meslin (bio), Elizabeth J. Thomson (bio), and Joy T. Boyer (bio)Organizers of the Human Genome Project (HGP) understood from the beginning that the scientific activities of mapping and sequencing the human genome would raise ethical, legal, and social issues that would require careful attention by scientists, health care (...) professionals, government officials, and the public. The establishment of the ELSI (ethical, legal, and social implications) programs at the National Human Genome Research Institute (NHGRI) and the Department of Energy (DOE) was thought to be vital to the success of the HGP in the United States. It also provided a novel approach to the simultaneous study of ethical, legal, and social issues and basic scientific issues. Eric Juengst, the first director of the ELSI program, described its origins in a previous issue of the Kennedy Institute of Ethics Journal (Juengst 1991). Now in its seventh year, the ELSI program has accomplished much. This article summarizes the evolution and goals of the ELSI program at NHGRI, outlines the program’s current research priorities with examples of activities within each priority area, and provides a look to the future, including the initiation of a strategic planning process.Evolution and Goals of the ELSI Research ProgramThe HGP’s “genomic” goals are unique: to map and sequence the entire human genome—some 3 billion base pairs that make up approximately 80–100,000 genes—and the genomes of related model organisms by the year 2005. This goal was particularly ambitious since, when it was proposed, the technologies for mapping and sequencing had yet to be developed. When the HGP was first established, its organizers also elaborated a set of ELSI goals, which they saw as vital to the success of the genome project. The original ELSI goals were: (1) to anticipate and address the implications of the HGP for individuals and society and (2) to examine the ELSI consequences of mapping and sequencing the human genome in order to stimulate public discussion. To meet these goals, the NHGRI created its ELSI research program in 1990. Along with mapping, sequencing, [End Page 291] and mammalian genetics, ELSI was one of four original branches in the NHGRI Division of Extramural Research that funded research in those areas. Although the individual “branches” no longer exist, the mechanisms for funding research remain much the same. While the overall goals of the program have not changed, the specific ways of achieving the goals have continued to evolve. The importance of the ELSI program lies not in the collection of a full set of data that will be valuable in and of itself, but in the value of using and interpreting this new set of information.Early on, the NHGRI described a set of somewhat more specific goals: (1) to develop a program to help understand the ethical, legal, and social implications of the human genome project and (2) to identify and define the major issues of concern and develop policy options to address them. These more specific goals have been largely met. As the most recent biennial NHGRI Progress Report notes, “a robust ELSI research and education program has been established, many of the most urgent ELSI issues have been identified, and many policy options to address these issues have been proposed” (NCHGR 1995, p. 21). Between 1990 and 1996, ELSI provided more than $32.5 million in funding through 128 research and education grants in more than 30 states and in Canada (Table 1). The ELSI research budget is unique in that when originally created, it was specifically tied to the amount of money provided for the overall NHGRI budget. The NHGRI originally devoted 3 percent of its extramural budget to fund ELSI projects, but in FY 1991, it increased the ELSI budget to 5 percent, a figure that remains today. Table 2 lists the expenditures for each fiscal year since 1990 and the cumulative expenditures to date. The ELSI research budget at NHGRI this year will be about $7 million. When other sources of funding—e.g., co-funding arrangements with other institutes and agencies and the funding of ELSI... (shrink)

Background:As a highly contagious disease, the COVID-19 pandemic has become a serious health threat and psychological burden for the global communities. From the conceptual perspective of affordances, this research examined the role of social media for health campaign and psychological support during the global crisis.Methods:Data from both social media and a nationwide survey were collected and analyzed. Face mask-related posts on Sina Weibo from January 1, 2020, to June 30, 2020, were retrieved and studied. Face mask wearing (...) as a well-established preventive measure was identified and examined from hashtag topics. A nationwide survey with a randomized experiment embedded was conducted to further investigate the mobilizing dynamics.Results:During the escalation phase in the first half of 2020, the hashtag topic “#national mask campaign#,” initiated by a celebrity, topped the ranking of mask-related topics on Weibo. The findings indicated that prevention activities, solidarity expression, and names of celebrity idols were frequently discussed. With celebrity idols as opinion leaders, millions of fandom publics actively participated in this hashtag health campaign. Results of the nationwide survey show the popularity of fan identity, and the experiment results demonstrate the strong mobilizing power of celebrity idol and fandom community in civic engagement and participation among young Chinese.Conclusions:The research demonstrates how the affordances of social media, such as liking, commenting, reposting, and hashtagging can be influential in promoting health behaviors and expressing solidarity. Implications for public health professionals and policymakers to raise awareness and understanding about health campaigns via social media are discussed. (shrink)

Examining how new forms of currencies diffuse is important to uncover their impact on the organization of communities, and thus motivates our study of community currencies. Community currencies provide a medium of exchange by using alternative banknotes or electronic money, which circulates only within particular communities, allowing members to trade goods, increase social cohesion, and achieve collective goals. In this study, we examine how community currencies help facilitate social commons by serving as a setting for building community (...) relationships and a catalyst for other social activities beyond market relations. We analyze cases of community banks that provide microfinance and issue community currencies in Brazil. We find that microfinance entrepreneurs who involve a greater diversity of stakeholders from public, private, and nonprofit sectors in decision making even prior to startup, while also facilitating the formation of supportive social capital from diverse cross-sector stakeholders, increase opportunities for developing new community currencies. By exploring the implications of entrepreneurial actions that promote inclusive participation of diverse stakeholders for accomplishing collective goals, our findings are relevant for other activities that create a common pool of resources while also developing the vitality of the community, including initiatives that use cryptocurrencies and other emerging forms of currencies for building social commons. (shrink)

Fueled by ever-growing amounts of (digital) data and advances in artificial intelligence, decision-making in contemporary societies is increasingly delegated to automated processes. Drawing from social science theories and from the emerging body of research about algorithmic appreciation and algorithmic perceptions, the current study explores the extent to which personal characteristics can be linked to perceptions of automated decision-making by AI, and the boundary conditions of these perceptions, namely the extent to which such perceptions differ across media, (...) (public) health, and judicial contexts. Data from a scenario-based survey experiment with a national sample (N = 958) show that people are by and large concerned about risks and have mixed opinions about fairness and usefulness of automated decision-making at a societal level, with general attitudes influenced by individual characteristics. Interestingly, decisions taken automatically by AI were often evaluated on par or even better than human experts for specific decisions. Theoretical and societal implications about these findings are discussed. (shrink)

Public collective hunger strikes take place in complex social and political contexts, require medical attention and present ethical challenges to physicians. Empirical research, the ethical debate to date and existing guidelines by the World Medical Association focus almost exclusively on hunger strikes in detention. However, the public space differs substantially with regard to the conditions for the provision of health care and the diverse groups of healthcare providers or stakeholders involved. By reviewing empirical research (...) on the experience of health professionals with public collective hunger strikes, we identified the following ethical challenges: (1) establishment of a trustful physician–striker relationship, (2) balancing of medico‐ethical principles in medical decision‐making, (3) handling of loyalty conflicts and (4) preservation of professional independence and the risk of political instrumentalization. Some of these challenges have already been described and discussed, yet not contextualized for public collective strikes, while others are novel. The presence of voluntary physicians may offer opportunities for a trustful relationship and, hence, for ethical treatment decisions. According to our findings, it requires more attention to how to realise autonomous medical decisions in the complex context of a dynamic, often unstructured and politically charged setting, which ethical norms should shape the professional role of voluntary physicians, and what is the influence of the hunger strikers' collective on individual healthcare decisions. Our article can serve as a starting point for further ethical discussion. It can also provide the basis for the development of potential guidelines to support health professionals involved in public collective hunger strikes. (shrink)

BackgroundThere have been notable investments in large multi-partner research programmes across the agriculture-nutrition-health (ANH) nexus. These studies often involve human participants and commonly require research ethics review. These ANH studies are complex and can raise ethical issues that need pre-field work, ethical oversight and also need an embedded process that can identify, characterise and manage ethical issues as the research work develops, as such more embedded and dynamic ethics processes are needed. This work builds on notions (...) of ‘ethics in practice’ by developing an approach to facilitate ethical reflection within large research programmes. This study explores the application of a novel ‘real-time research ethics approach’ (RTREA) and how this can support ethical mindfulness. This involves embedding ethical analysis and decision-making within research implementation, with a continuous dialogue between participants and researchers. The aim is to improve ethical responsiveness and participant experience, which in turn may ethically support adherence and retention. In this case study, a bioethics team (BT) was embedded in a community-based randomised, controlled trial conducted in rural Malawi, titled the ‘Addressing Hidden Hunger with Agronomy’. To identify ethical issues, the researchers conducted ten focus group discussions, fourteen in-depth interviews with key informants, two workshops, observed two sensitisation and three activity meetings conducted by the trial team, and analysed fifteen reports from pre-trial to trial implementation.ResultsThe RTREA facilitated the identification of social and ethical concerns and made researchers aware of participants’ ‘lived research experience’. To address concerns and experiences, the BT worked with researchers to facilitate conversation spaces where social and ethical issues were discussed. Conversation spaces were designed to create partnerships and promote participatory methods to capture trial participants’ (TPs) perspectives and experiences.ConclusionsThe use of RTREA showed the value of real-time and continuous engagement between TPs and researchers. These real-time processes could be embedded to complement traditional ethical guidance and expert opinions. A deeper engagement appeared to support greater operationalising of principles of inclusion, empowerment, and participant autonomy and supported researchers ‘ethical mindfulness’ which in turn may support instrumental outcomes of high recruitment, retention, and adherence levels. (shrink)

One of most pertinent and acute risks that the world is now facing is emerging or re-emerging zoonotic diseases. This article focuses on culling as a measure for zoonotic disease control, specifically the culling of 11,000 badgers as part of the Randomized Badger Culling Trial in the UK and the culling exercises in Singapore. The independent expert panel that devised the UK study concluded that reactive culling was ineffective in reducing the cases of bovine tuberculosis in cattle. The panel (...) also concluded that proactive culling was not cost-effective. Behind the scarcity of empirical evidence to support culling, the resultant reduction in biodiversity can actually harm both animals and humans. Public health policies should be evidence-based, culturally adaptable and ethically justified; a novel biomedical and public health approach, named One Health, plausibly provides a reasonable ethical framework as well as research and interventional methods that square with that framework. OH recognizes that nonhuman animals and humans are interlinked in both sickness and health, since we all share the same ecosystem. OH could potentially replace standard public health strategies, as it provides alternative evidence-based methods for biomedical research and adds a non-anthropocentric component to an ethical decision-making process. (shrink)

This paper explores public sentiment towards strike action among healthcare workers, as a result of their perceived inadequate pay. By analysing survey data collected in England between 2022 and 2023, the study focuses on NHS nurses and junior doctors, due to their critical role in delivering essential public services. Results indicate higher public support for strikes by nurses and junior doctors compared to other professions such as postal workers, teachers, rail workers, airport workers, civil servants and university (...) lecturers. However, variation in support for strikes by healthcare workers is observed across societal segments. Significant disparities in support are linked to individual political affiliations, left–right ideological positions and trust in the NHS. In short, nonconservative voters, individuals leaning towards left‐wing politics and those with greater trust in the NHS demonstrate higher likelihoods of supporting strikes by health workers. These findings carry implications for future strike decisions and highlight specific target groups for enhanced communication efforts to garner increased public support. (shrink)

Current UK legislation is impacting upon the feasibility and cost-effectiveness of medical record-based research aimed at benefiting the NHS and the public heath. Whereas previous commentators have focused on the Data Protection Act 1998, the Health and Social Care Act 2001 is the key legislation for public health researchers wishing to access medical records without written consent. The Act requires researchers to apply to the Patient Information Advisory Group for permission to access medical records without written (...) permission. We present a case study of the work required to obtain the necessary permissions from PIAG in order to conduct a large scale public health research project. In our experience it took eight months to receive permission to access basic identifying information on individuals registered at general practices, and a decision on whether we could access clinical information in medical records without consent took 18 months. Such delays pose near insurmountable difficulties to grant funded research, and in our case £560 000 of public and charitable money was spent on research staff while a large part of their work was prohibited until the third year of a three year grant. We conclude by arguing that many of the current problems could be avoided by returning PIAG’s responsibilities to research ethics committees, and by allowing “opt-out” consent for many public health research projects. (shrink)

Current UK legislation is impacting upon the feasibility and cost-effectiveness of medical record-based research aimed at benefiting the NHS and the public heath. Whereas previous commentators have focused on the Data Protection Act 1998, the Health and Social Care Act 2001 is the key legislation for public health researchers wishing to access medical records without written consent. The Act requires researchers to apply to the Patient Information Advisory Group for permission to access medical records without written (...) permission. We present a case study of the work required to obtain the necessary permissions from PIAG in order to conduct a large scale public health research project. In our experience it took eight months to receive permission to access basic identifying information on individuals registered at general practices, and a decision on whether we could access clinical information in medical records without consent took 18 months. Such delays pose near insurmountable difficulties to grant funded research, and in our case £560 000 of public and charitable money was spent on research staff while a large part of their work was prohibited until the third year of a three year grant. We conclude by arguing that many of the current problems could be avoided by returning PIAG’s responsibilities to research ethics committees, and by allowing “opt-out” consent for many public health research projects. (shrink)

The book reconstructs the history of Western ethics. The approach chosen focuses the endless dialectic of moral codes, or different kinds of ethos, moral doctrines that are preached in order to bring about a reform of existing ethos, and ethical theories that have taken shape in the context of controversies about the ethos and moral doctrines as means of justifying or reforming moral doctrines. Such dialectic is what is meant here by the phrase ‘moral traditions’, taken as a name for (...) threads of moral discourse, made in turn of other interwoven threads, including transmission of shared codes, appeals to reform of prevailing custom, rational argument about the justification of some precept on the basis of some shared general teaching or principle, and rational argument about the ultimate basis for principles and justification of authoritative teaching. That is, the approach adopted to the reading of ethical texts depends on a firm belief in the fact that philosophers hardly created any ethical doctrine out of nothing. The main point this book tries to highlight is how different philosophical theories emerged and followed each other as a result of attempts at accounting for what was going on in the world of moral traditions. Changes were propelled by controversies between different schools, and highly abstract arguments were the unintended effects of moves made by controversialists forced to transform (and occasionally to turn upside down) their own doctrines in order to face the challenge posed by other arguments. This is the reason why the book examines not only texts that already enjoy pride of place in the history of philosophy (Aristotle, Kant, Hegel), but also other texts usually treated in the histories of religions (the Bible, the Talmud, the Quran), and others considered to be much less philosophical (Plutarchus, Pufendorf). -/- 1. Plato and a response to ethical scepticism. Two different traditions of morality in VI-V century Greece are described. The birth of philosophical questioning of traditional morality and temporal and spatial variation of custom is described within the context of the v century crisis, the demise of traditional aristocratic and tyrannical rule and the birth of democracy. Two conflicting answers to the challenge are reconstructed, namely conventionalist or immoralist theories formulated by the Sophists and the eudemonist and intellectualist Socratic theory. Plato’s own reformulation of Socrates answer to the Sophists is reconstructed. His psychological views, his classification of the four cardinal virtues and his political theory are described as parts of a unitary system, culminating in an extremely realist moral ontology identifying the idea of the good with the essence of the (moral and extra-moral) world itself. -/- 2. Aristotle and the invention of practical philosophy. Aristotle’s invention of practical philosophy as a field separated from first philosophy is shown to be an implication of his break with Plato moral ultra-realism. Aristotle’s agenda in his moral works is arguably dependent on a polemical intention, namely dismantling Socratic intellectualism. The semi-inductive or virtuously circular method of practical philosophy is illustrated, starting with the received opinions of the better and wiser individuals and trying dialectically to sift what is left of mistake and inconsistence in such opinions, finally trying to correct mistakes and make the overall practical science more consistent. The chapter illustrates then the relationship of individual ethics, or ‘monastics’, with the art and the science of the pater familias, or ‘economics’, and the science of the ruler and citizen, or politics. The nature of virtues, or better, excellences of character, is discussed, highlighting the basic role of hexis, or ‘disposition’. Prudence, or better practical wisdom, is the focus of the chapter. Its relationship with bouleusis or deliberation is examined, and its autonomous status vis-à-vis theoretical knowledge is stressed. -/- 3. Diogenes and philosophy as a way of life. The chapter provides an overview of Hellenistic ethics, which almost amounts to Hellenistic schools of philosophy, in so far as ‘philosophy’ became in these centuries primarily the name for a way of life. The typical character of the Cynical movement is highlighted, that of a school of life, not a school aimed at providing any kind of intellectual training was to be provided. -/- 4. Epicurus and ethics as self-care. The peculiar character of the Epicurean school is described, a combination of a science of well-being aiming, more than at pleasure as in the popular view, at reduction of useless suffering, of unnecessary needs, and at a balanced selection of pleasures of the best and most durable kind. -/- 5. Epictetus and ethics as therapy of the passions. The various phases of Stoicism are described, and the shifting place given to ethics in the Stoic system of idea, culminating in the paradoxical view of ethics, its impossibility in principle notwithstanding, as the only truly significant and necessary part of philosophy. Cicero is treated, showing how his own synthesis of various Hellenistic trends is as a truly philosophical enterprise, deserving serious consideration after one or two centuries when he was confined to the role of literate. Epictetus is chosen as the best example of what the Stoic tradition could yield, an art of living based on sophisticated introspection, in turn aimed at making a kind of cognitive therapy possible, dismantling obnoxious passions at their root by systematically correcting false representations. -/- 6. Philo and the reconciliation of Torah and Platonism. A reconstruction of basic ideas from a few books of the Hebrew Bible is provided, starting with the Prophetic tradition and the focus on God’s mercy as the source of motivation and standard for human behaviour. Then a comparative analysis is undertaken of a parallel tradition, namely the three codifications of the Torā (Law or, better, Instruction), highlighting how a core of moral ideas may be recognized as a basis and preamble of codification of civil law, cultural practice, and regulation of ritual purity. The importance of Leviticus is stressed as the turning point when emphasis mercy, typical of the Prophetic tradition, is combined with the legal tradition, yielding the change in sensibility of the Second Temple time. Philo of Alexandria is described as one of the three leading figures – together with Rabbi Hillel and Rabbi Yeshua – at the apex the emergence of the mentioned new sensibility, gradually including mercy as an essential part of justice and establishing the starting point of both the Rabbinic and the Christian tradition. This consists precisely in the precept of one’s neighbour’s love or of the golden rule, two eventually identical precepts whose meaning is arguably more sober and sensible than the long-lasting Christian tradition deriving from John and Augustine has made us believe and no novelty vis-à-vis so-called Ancient-Testament teachings. -/- 7. Augustine and Christianity as Neo-Platonism. The first section examines the moral doctrines of so-called 'ethical Treaties' from the Talmud, a group of treaties, among which the best known is Pirqé Avot, that were left out of the six "orders" of the canon as they did not fit in any of the six groups of issues ritual or legal on which the division was based. According to Maimonides, their peculiar theme is provided by the Deòt, 'opinions', i.e., mental dispositions, that is, the translation of the Greek term hexeis and Arab akhlak (in turn providing in this language the name for ethics as such). The three topics I reconstruct are: i) the notion of Torah: The Torah is understood as the world order itself, or as the ‘Wisdom’ that existed even before creation and was ‘the tool by which the world was built’; however, the Torah is an earthly and human entity, as it was "received" by humans, and from that very moment belongs to them; ii) the relationship between love of God and love of neighbour; the treaties require us to study and practice the Torah ‘for its own sake’, that is, require us to act out of love, not out of fear or hope of reward; iii) the idea of sanctification of daily life: having disappeared with the destruction of the Temple the possibility of any conflict between liturgical service and everyday life, the latter is assumed to be in itself divine service: to give food to the poor has the same value as sacrifices in the Temple, and as an implication, the insistence become recurrent on the goodness of created things in themselves along with a polemic against ascetic currents. The conclusions drawn are: i) the moral teachings of the Talmud and those of Yeshua are, rather than similar, virtually identical; one may safely say that the precept of love and the golden rule are central ones for all Talmudic rabbis, that mercy plays an indispensable role alongside with justice, and the latter is not a different thing from one’s neighbour’s love; ii) a peculiarity of Talmud rabbis facing Yeshua is the idea of study as worship, and knowledge as a source of justice; but this is an idea of Judaism after the Temple's destruction that cannot be attributed to the Pharisees of Yeshua’s time; iii) the relation of study and practice in the Talmud parallels that between faith and deeds in Paul's epistles, that is, respectively faith or learning are a necessary and sufficient condition to be recognized as righteous , but deeds are the inevitable effect of either faith or learning. The sayings ascribed to Yeshua are examined first, yielding the conclusion that a close equivalent may be found for every saying in Talmudic literature and yet the whole is ascribed to one rabbi, with rather consistent stress on God’s mercy and unconditional forgiving as the mark of true imitation of God. Thus, Yeshua’s teaching is pure Judaism. The third section describes briefly the galaxy of Gnostic currents and Manichaeism, trying to sketch the profile of moral teachings resulting from an encounter of Asian spiritual traditions, Hellenistic lore and sparks of teachings from apocalyptic Jewish currents. The last section summarizes the turbulent history of several encounters between Christian currents and Hellenistic philosophical schools. The first one was with late Cynicism. Recent, rather controversial, literature discovered the jargon and a few topics from the Stoic-Cynical popular philosophy in a few books from the New Testament itself. This, far from proving that Rabbi Yeshua had been influenced by cynic preachers, is a proof of the necessity felt by Christian preachers to translate the original ‘Christian’ teaching into a Greek lexicon deeply impregnated with cynic terminology. The second was with Platonism, yielding the mild and temperate moral teaching of Clemens of Alexandria, teaching the sanctity of nature and the human body, the joy of moderate fruition of ‘natural’ kinds of pleasures, and the beauty of the marital life – in short, the opposite of the standard picture of Medieval Christianity. Ambrose of Milan brings about a different kind of synthesis, namely with Middle Platonism, where Stoic themes prevail. The most shocking case is Augustine, where an early Manichean education is overcome in a former phase by a synthesis of Plotinian Neo-Platonism and Christian preaching, yielding a sustained polemic with the Manicheans and rather optimistic views on life and Creation, the body and sexuality, and Hebrew-Judaic tradition not far from Clemens of Alexandria. In a later phase, occasioned by controversy on the opposite front, with such Christian currents as the Pelagians and Donatists, Augustine comes back to heavily anti-Judaic and world-denying ascetic attitudes where is earlier Manichean upbringing seems to emerge again. The tragedy of medieval Christianity will be the later Augustine’s overwhelming influence. A final section is dedicated to the monastic tradition where a curious mixture of world-denying asceticism with an astonishingly penetrating ‘science’ of introspection emerges. -/- 8. Al Farabi and the reconciliation of Islam and Platonism. The Qurān and the qadit, that is, collections of sayings ascribed to the prophet Muhammad contain a wealth of precepts and catalogues of virtues mirroring moral contents from the Jewish and the Christian traditions, among them the basic notion of imitation of the Deity, where mercy is assumed to be its basic trait. An important tradition within Islam, namely Sufism, stressed to the utmost degree the role of mercy, turning Islam into a mystic doctrine centred on retreat from the world, abandonment to God’s will, and a peaceful and fraternal attitude to our fellow-beings. A secular literary tradition originating in the Sassanid Empire, the literature of advice to the Prince had for a time a widespread influence in the newly constituted Arabic-Islamic commonwealth. In a later phase, the legacy of Hellenic philosophy made its way into the intellectual elite of the Islamic world. The first important legacy was Platonic, and the Republic became the main text for Islamic Platonism. Al-Farabi wrote an enjoyable remake of the Platonic Republic, arguing that the citizen’s virtues were the basis on which the political building needs to rest. The secular lawgiver is enlightened by the light of reason in his everyday practice of governance, but room is made for the Prophet as the voice of revealed truth that confirms and completes the rational truth that philosophy may afford. In a second phase also Aristotelian and Stoic influence were assimilated. Miskawayh’s treatise was the masterwork at the time Arabic philosophy reached its Zenith. It is a treatment of the soul’s diseases and their remedies, combining the Aristotelian doctrine of the golden mean with the Stoic doctrine of the passions and elements of Galenic medicine. Towards the eleventh-twelve centuries a war raged among theologians and philosophers, finally won by the former with disappearance of philosophy as such. The newly established mainstream, yet, was no kind of intolerant fanaticism. It drew from the work of mystic theologian Al-Ghazālī, the best heir of Sufism, teaching a tolerant and peaceful attitude to our fellow-beings and a passive attitude to destiny as an expression of the Divine will. -/- 9. Moshe ben Maimon and the reconciliation of Torah and Aristotelian ethics. The encounter between the Talmudic tradition and Hellenic philosophy had taken place a first time in Alexandria at the time of Philo but the two traditions had parted way again. In fact, the kind of Platonic Judaism founded by Philo survived only within Christianity, in the fourth Gospel and then in writings by Clemens of Alexandria. The Talmudic literature had absorbed just less striking traits from the Hellenic Philosophy, namely an idea of ethics as care of the self and a role for the education of character as propaedeutic to theoretical knowledge. In the Arabic-Islamic world, a second round started when Jewish authors writing in Arabic undertook the task to prove the full compatibility of the tradition deriving from Torah and Platonic philosophy. The culmination of this attempt is provided by Moshe ben Maimon who tried to use Aristotelian ethics as a language into which the teaching from the Pirké Avot could be translated. -/- 10. Thomas Aquinas and the reconciliation of Christian morality and Aristotelian ethics. In the first section the fresh start is described of philosophical ethics in Latin Europe at the turn of the Millennium. In a first phase, Anselm and Peter Abelard built on a Platonic and Augustinian legacy. In this phase. remarkable innovations are introduced, including Abelard’s claim of the obliging character of erring consciousness. In a second phase, the rediscovery of Nicomachean Ethics thanks to Latin translation of Arabic versions gives birth to a new wave of ethical studies, recovering the very idea of Aristotelian practical philosophy, with the potential implication of full legitimization of natural morality, i.e. ethics without Revelation. Aquinas’s ethics is a theological ethics out of which it would be vain to try to extract a self-contained philosophical ethics. His treatment of topics in philosophical ethics, yet, does not boil down to repetition of Aristotelian arguments but is rather a creative reshaping of such arguments. For example, he introduces also in the practical philosophy a first principle parallel to the principle of non-contradiction; and he also carries out a synthesis of Aristotelianism, Stoicism, and neo-Platonism. Even though it is essentially moral theology, Aquinas’s doctrine - unlike Augustine – grants full citizenship to "natural" morality, firstly by rejecting the claim that the corruption of human nature due to the original sin is so radical as to leave "pure nature" incapable of moral goodness. The doctrine is presented in a more sophisticated formulation in a few of the Quaestiones, such as De Malo and De Veritate, in the Summa contra Gentes and in the commentaries to Aristotle than in the famous Summa Theologica, but the latter work includes the only or the largest exposition of some decisive part of the theory. Thus, the Summa Theologica should be read for what it is more than criticized for not being what it was not meant to be. It was not meant to be the brilliant synthesis of all that Reason he had been able to produce with what Revelation had added about which the Neo-Thomists used to dream, but rather a manual for the training of preachers and confessors, where theoretical claims are not too demanding and a few serious tensions are left. Besides a jump between the Prima Secundae and the Secunda Secundae, being the former an essay in virtue theory and the latter a handbook for confessors, the most serious tension is perhaps the one between the ethics of right reason presented in most of Ia-IIae and the eudemonistic ethics developed in quaestiones 1-5 of the same part; the alternative ethical theory which also may be found in Augustine, the Stoic view of a cosmic reason eventually coincident with the moral law, was believed by Anselm (followed by John Duns Scotus and William of Ockham) to be incompatible with eudemonism. It is questionable whether Thomas could reduce the tension proving that it is just an apparent tension, in so far as the right reason and bliss derived from knowledge of God tend to coincide, but this is just a conjecture. Thomas’s ethics is a virtue ethic, not a law-based one, and moral judgment focuses on the virtues, particularly charity, not on the commandments and even less on absolute prohibitions; Thomas, however, would not have considered a drastic alternative between law and the virtues such as the one which has been advanced in late twentieth-century philosophy to be justified. Nonetheless, when it discusses ‘special’ virtues, it ceases to be an ethics of virtue and becomes a disappointing and often contradictory discussion of legal and illegal acts. Such a discussion takes most of the time ‘reasonable’ middle positions on controversial issues but not the alternative approach that Aristotelianism would have made possible; even when some occasional Aristotelian claim shows up, such as money’s barrenness as a reason against usury, this seems to be made by an author who apparently ignores the Aristotelian Thomas of the Prima Secundae. It is an ethic of human autonomy which recognizes the binding character of the individual conscience and, potentially, even a duty to disobey unjust laws. It is true that what Thomas writes in his discussion of death penalty and persecution of heretics is simply disgusting, and yet we should blame Thomas the man, not Thomist ethical theory. Finally, Thomas’s ethics is not ethical ‘absolutism’, as both traditionalist Catholic theologians and secularist enemies of dogmatic morality tend to believe. It is instead an ethic of prudential judgment. Exceptions to this approach – or better results of logical fallacies – are such claims as the absolute character of negative precepts and of the existence of "intrinsically evil acts", claims that simply cease to make sense in the light of Thomas’s own distinction between human act and natural act, carrying consequences Thomas did not live long enough to draw or was not consistent enough to dare to draw. -/- 11. Francisco de Vitoria and casuistry. The first topic illustrated is the discussion about the notion of pura natura, namely the human condition after the original sin and before divine revelation. The core notion was already there in Aquinas but was later developed by Caietanus (Thomas de Vio) with a number of interesting implications: firstly a view of human nature as such much more positive than Augustine’s and his followers’ view, including both Calvinists and Jansenists; secondly, the implication that the philosopher’s morality, as opposed to the Christian’s morality, is a quite respectable kind of morality; thirdly, that theocracy and prosecution of the unfaithful lacked justification, with more far-fetching consequences than Aquinas himself had dared to draw. The second topic is casuistry, a new name for a comparatively older way of thinking, which was already there in late Stoicism and Cicero as well as in the Talmudic literature. This is an approach aimed at yielding probable enough solutions for doubtful cases even in absence of completely safe staring points. The genre developed from medieval reference books for confessors and became by the sixteenth-century a sophisticated tool-box for dealing with various fields of applied ethics. Francisco Vitoria, the main authority of Baroque Scholasticism, was a controversial figure, among the proponents of the new discipline of casuistry and a consistent proponent of more separation between the religious and the civil authority, stricter limits to the legitimacy of war, innate rights of non-Christian nations in the New World based on the notion of pura natura, providing a standard of ‘natural’ goodness, previous to revelation, on which the Indian nations were judged to live in a naturally good condition, provided with the institutions of family, justice, and religion had accordingly a right to full respect by Christian sovereigns. Bartolomé de Las Casas, arguing along similar lines, was the leader of a historical battle in defence of the rights of the Indios. -/- 12. Michel de Montaigne and the art of living. A short description of one of the Renaissance Phyrronism, one of the classical philosophies revived in the fifteenth and sixteenth century. Montaigne combines the sceptical epistemology with an understanding of ethics – indeed of philosophy as a whole – in terms of an art of living inspired by two basic ideas, sagesse, that is, practical wisdom as the only kind of rationality available after theology, science, and tradition have declared bankrupt, and an aesthetic ideal of self-transformation through the art of writing and introspection. -/- 13. Pierre Nicole and neo-Augustinianism. The chapter illustrates first the vicissitudes of Augustinianism newly born after the late medieval triumph of Thomist Aristotelianism in the alternative Protestant and Catholic versions processed by the Calvinists and the Jansenists. Then it illustrates the doctrines of Pierre Nicole, Blaise Pascal’s best disciple, on the impossibility of introspection, on the ubiquity of self-deception, on the incurably evil character of the passion of love, and on the two moralities, the one of the man of the world, the morality of honesty which is indispensable for granting peace and order but devoid of any true value for eternal salvation, since the same external behaviour may be prompted by opposite motivations, and the morality of charity, the only true one but also useless to society. The third topic is Pierre Malebranche’s view of self-deception as a ubiquitous phenomenon accounting for human action and responsibility and his reformulated theory of self-love, no less ubiquitous than for Nicole and yet not as incurably evil, given the distinction between morally indifferent and even necessary amour de soi and vicious amour proper, a distinction on which the whole of Rousseau’s moral and political theory rests. -/- 14. Samuel von Pufendorf and the new science of morality. The chapter is dedicated to the discovery of the idea of a ‘new moral science’. Hugo Grotius is discussed first highlighting the real character of his project, much closer to the Thomist idea of a natural law accessible to non-corrupted human reason when human beings are living in a state of pura natura. Then Hobbes’s combination of scepticism, voluntarism, and conventionalism is described and both the continuity with Grotius’s new science, in the search for non-revealed rational morality, and the break with him, in the adoption of voluntarism and refusal of an intellectualist view of natural law, are illustrated. Pufendorf’s work is illustrated as a synthesis of the two previous attempts and the – up to Schneewind underestimated – paradigmatic example of the new science of morality. -/- 15. Richard Cumberland and consequentialist voluntarism. The chapter gives an overview of eighteenth-century Anglican ethics, noticing how the Cambridge tradition gave special weight to natural theology as opposed to positive or revealed theology – and how two Cambridge fellows, John Gay and Thomas Brown, elaborated on Cumberland’s (and Malebranche’s, as well as Leibniz’s) strategy for finding a third way between intellectualist view and voluntarist view of the laws of nature. The result of their elaboration was a kind of a rational-choice account of the origins of natural laws, where a law-giver God chooses among a number possible sets of laws on a maximizing criterion, and God’s maximandum is happiness for his creatures. The chapter notices also how such a solution aimed at solving at once the problem of evil and that of the foundation of moral obligation by proving how God’s choice was justified as far as it was the one minimising the amount of suffering in the world. 16. Richard Price and intuitionism. The chapter describes first the doctrines of the Cambridge Platonists, an example of hyper-rationalist reaction to Calvinism. Secondly it describes the sophisticated and universally ignored – from Sidgwick to Anscombe –version of what was later labelled ‘ethical intuitionism’ – showing how it escapes familiar objections and misrepresentations of intuitionism – from Mill to Rawls – in grounding its argument on transcendental arguments while carefully avoiding recourse to introspection and psychological evidence, which has been taken as a too easy target by critics of intuitionism. Thirdly, the chapter discusses Whewell’s ‘philosophy of morality’, as opposed to ‘systematic morality’, not unlike Kant’s distinction between a pure and an empirical moral philosophy. Whewell worked out a systematization of traditional normative ethics as a first step before its rational justification; he believed that the point in the philosophy of morality is justifying a few rational truths about the structure of morality such as to rule hedonism, eudemonism, and consequentialism; yet a system of positive morality cannot be derived solely from such rational truths but requires consideration of the ongoing dialectics between idea and fact in historically given moralities. Whewell’s intuitionism turns out closer to Kantian ethics than commentators have made us believe until now, and quite different from what Sidgwick meant by intuitionism. -/- 17. Adam Smith and the morality of role-switch. The chapter describes first, Hutcheson’s attempt at basing the ‘new science’ of natural law on different bedrock than Pufendorf and the English Platonists, namely a moral sense, a faculty whose existence is assumed to be proved on an empirical basis. The second step is a reconstruction of Hume’s rejoinder in terms of a new science of man including morality on an ‘experimental’ basis, that is, a ‘Newtonian’ hypothetical-deductive approach, distinguished from Hutcheson’s allegedly uncritical descriptive approach to human nature. The third step is a reconstruction of Adam Smith theory of morality understood as emerging from a spontaneous interplay of exchanges of situations (the most basic meaning of the word ‘sympathy’ as construed by this author). -/- 18. Jeremy Bentham and utilitarianism. The bulk of the chapter is dedicated to the doctrines of Jeremy Bentham. The Enlightenment spirit that suggested the idea of a new morality, free from religion, is illustrated. The notion of utility is illustrated as well as the subsequent formulations of the principle of utility. The idea of felicific calculus is discussed, showing how its inner difficulties prompted several reformulations of the principle of utility in order to avoid undesirable implications of proposed formulations. The role of the thesis of spontaneous convergence between interest and duty is discussed, showing how it left numberless questions open, and the distinction between the virtues of prudence, justice and beneficence is described as a way out of the deadlocks of classical utilitarianism. After Bentham, Mill’s reformed utilitarianism is reconstructed, showing how it is a kind of mixed system – as closer to common sense as it gives up Bentham’s claims to consistency and simplicity – resulting as unintended consequences from the controversies in which Mill was too keen to engage. The hidden agenda of the controversy between Utilitarianism and Intuitionism, going beyond the image of the battle between Prejudice and Reason, is described, showing how both competing philosophical outlooks turn out to be more research programs than self-contained doctrinal bodies, and such programs appear to be implemented, and indeed radically transformed while in progress thanks to their enemies no less than to their supporters. -/- 19. Immanuel Kant, practical reason and judgment. The chapter argues that Kant took from Moses Mendelssohn the idea of a distinction between geometry of morals and a practical ethic. He was drastically misunderstood by his followers precisely on this point. He had learned from the sceptics and the Jansenists the lesson that men are prompted to act by deceptive ends, and he was aware that human actions are also empirical phenomena, where laws like the laws of Nature may be detected. His practical ethics made room for judgment as a holistic procedure for assessing the saliency of relevant moral qualities in one given situation; this procedure yields the same results as the geometry of morals does for abstract cases but does so immediately and without balancing conflicting duties with each other, since what makes for the salient quality of a situation is perceived from the very beginning. Kant's practical philosophy is richer than the received image, making room for an ‘empirical moral philosophy’ or moral anthropology including treatment of commerce, needs, value and price, happiness and well-being; the overall social theory and philosophy of history is less different from Adam Smith's than the received image makes believe; the paradox of happiness is central to Kant's philosophy; a distinction between happiness and well-being is clearly drawn; the distinction plays a basic role in establishing a link between the economic and the moral life. -/- 20. Georg Wilhelm Friedrich Hegel and the critique of abstract universalism. The chapter describes first the Romantic movement and the implications some of its concerns, rescuing passions, community, tradition, the individual as the bearer of a unique destiny, and the longing for organic unity between the individual, mankind and nature. Hegel’s contribution is discussed then, highlighting how, on the one hand, he shared a number of these concerns and on the other he had more rationalist leanings. The notion of morality is the pivotal point of the reconstruction, highlighting how Hegel construes this notion as a key to his own diagnosis of the malaise of modernity – the separation of individual and Gemeinschaft – and how his attack on Kant turns around this very idea. -/- 21. Friedrich Nietzsche against Christianity and the Enlightenment. The chapter illustrates first the idea of deconstruction of the back-world of values. Nietzsche claims to be legitimate heir of the French moralists, Leibniz, Kant and Hegel, in so far as he allegedly carries out to its deepest implications their discovery of what lies behind traditional naïve belief in the existence of an objective realm of values just waiting for description by the philosopher. The two exemplars form which genealogy draws inspiration are the classical philologist’s historical reconstructions of lost meanings and the chemist’s decomposition of elements. Then the genealogy of the notions of good and evil carried out in the first dissertation of Genealogy of morals is illustrated with its paradoxical conclusion that will to power is in fact the only ‘genuine’ kind of goodness. The third point illustrated is the dialectic of ascetism and self-realization with its ambiguous outcome. The suggested interpretation of such outcome is that Nietzsche’s normative ethics is a kind of virtue ethics taking an aesthetic ideal as a normative standard -/- 22. George Edward Moore and ideal utilitarianism. The chapter discusses the ideas of common sense and common-sense morality in Sidgwick. I argue that, far from aiming at overcoming common-sense morality, Sidgwick aimed purposely at grounding a consist code of morality by methods allegedly taken from the natural sciences to reach, also in ethics, the same kind of “mature” knowledge as in the natural sciences. His whole polemics with intuitionism was vitiated by the a priori assumption that the widespread ethos of the educated part of humankind, not the theories of the intuitionist philosophers, was what was worth considering as the expression of intuitionist ethics. In spite of a naïve positivist starting-point, Sidgwick was encouraged by his own approach in exploring the fruitfulness of coherentist methods for normative ethics. Thus, Sidgwick left an ambivalent legacy to twentieth-century ethics: the dogmatic idea of a “new” morality of a consequentialist kind, and the fruitful idea that we can argue rationally in normative ethics albeit without shared foundations. Then it reconstructs the background of ideas, concerns and intentions out of which Moore’s early essays, the preliminary version, and then the final version of Principia Ethica originated. I stress the role of religious concerns, as well as that of the Idealist legacy. I argue that PE is more a patchwork of rather diverging contributions than a unitary work, not to say the paradigm of a new school in Ethics. I add a comparison with Rashdall’s almost contemporary ethical work, suggesting that the latter defends the same general claims in a different way, one that manages to pave decisive objections in a more plausible way. I end by suggesting that the emergence of Analytic Ethics was a more ambiguous phenomenon than the received view would make us believe, and that the wheat (or some other gluten-free grain) of this tradition, that is, what logic can do for philosophy, should be separated from the chaff, that is, the confused and mutually incompatible legacies of Utilitarianism and Idealism. -/- 23. Edmund Husserl and the a-priori of action. The chapter illustrates first the idea of phenomenology and the Husserl’s project of a phenomenological ethic as illustrated in his 1908-1914 lectures. The key idea is dismissing psychology and trying to ground a new science of the a priori of action, within which a more restricted field of inquiry will be the science of right actions. Then the chapter illustrates the criticism of modern moral philosophy carried out in the 1920 lectures, where the main target is naturalism, understood in the Kantian meaning of primacy of common sense. The third point illustrate is Adolph Reinach’s theory of social acts as a key the grounding of norms, a view that basically sketches the very ideas ‘discovered’ later by Clarence I. Lewis, John Searle, Karl-Otto Apel and Jürgen Habermas. A final section is dedicated to Nicolai Hartman, who always refused to define himself a phenomenologist and yet developed a more articulated and detailed theory of ‘values’ – with surprising affinities with George E. Moore - than philosophers such as Max Scheler who claimed to Husserl’s legitimate heirs. -/- 24. Bertrand Russell and non-cognitivism. The chapter reconstructs first the discussion after Moore. The naturalistic-fallacy argument was widely accepted but twisted to prove instead that the intuitive character of the definition of ‘good’, its non-cognitive meaning, in a first phase identified with ‘emotive’ meaning. Alfred Julius Ayer is indicated as a typical proponent of such non-cognitivist meta-ethics. More detailed discussion is dedicated to Bertrand Russell’s ethics, a more nuanced and sophisticated doctrine, arguing that non-cognitivism does not condemn morality to arbitrariness and that the project of a rational normative ethics is still possible, heading finally to the justification of a kind of non-hedonist utilitarianism. Stevenson’s theory, another moderate version of emotivism is discussed at some length, showing how the author comes close to the discovery of the role of a pragmatic dimension of language as a basis for ethical argument. Last of all, the discussion from the Forties about Hume’s law is described, mentioning Karl Popper’s argument and Richard Hare’s early non-cognitivist but non-emotivist doctrine named prescriptivism. -/- 25. Elizabeth Anscombe and the revival of virtue ethics. The chapter discusses the three theses defended by Anscombe in 'Modern Moral Philosophy'. I argue that: a) her answer to the question "why should I be moral?" requires a solution of the problem of theodicy, and ignores any attempts to save the moral point of view without recourse to divine retribution; b) her notion of divine law is an odd one more neo-Augustinian than Biblical or Scholastic; c) her image of Kantian ethics and intuitionism is the impoverished image manufactured by consequentialist opponents for polemical purposes and that she seems strangely accept it; d) the difficulty of identifying the "relevant descriptions" of acts is not an argument in favour of an ethics of virtue and against consequentialism or Kantian ethics, and indeed the role of judgment in the latter is a response to the difficulties raised by the case of judgment concerning future action. A short look at further developments in the neo-naturalist current is given trough a reconstruction of Philippa Foot’s and Peter Geach’s critiques to the naturalist-fallacy argument and Alasdair MacIntyre’s grand reconstruction of the origins and allegedly unavoidable failure of the Enlightenment project of an autonomous ethic. -/- 26. Richard Hare and neo-Utilitarianism. The chapter addresses the issue of the complex process of self-transformation Utilitarianism underwent after Sidgwick’s and Moore’s fatal criticism and the unexpected Phoenix-like process of rebirth of a doctrine definitely refuted. A glimpse at this uproarious process is given through two examples. The first is Roy Harrod Wittgensteinian transformation of Utilitarianism in pure normative ethics depurated from hedonism as well as from whatsoever theory of the good. This results in preference utilitarianism combined with a ‘Kantian’ version of rule utilitarianism. The second is Richard Hare’s two-level preference utilitarianism where act utilitarianism plays the function of eventual rational justification of moral judgments and rule-utilitarianism that of action-guiding practical device. -/- 27. Hans-Georg Gadamer and rehabilitation of practical philosophy. The post-war rediscovery of ethics by many German thinkers and its culmination in the Sixties in the movement named ‘Rehabilitation of practical philosophy’ is described. Among the actors of such rehabilitation there were a few of Heidegger’s most brilliant disciples, and Hans-Georg Gadamer is chosen as a paradigmatic example. His reading of Aristotle’s lesson I reconstructed, starting with Heidegger’s lesson but then subtly subverting its outcome thanks to the recovery of the central role of the notion of phronesis. -/- 28. Karl-Otto Apel and the revival of Kantian ethics. Parallel to the neo-Aristotelian trend, there was in the Rehabilitation of practical philosophy a Kantian current. This started, instead than the rehabilitation of prudence, with the discovery of the pragmatic dimension of language carried out by Charles Peirce and the Oxford linguistic philosophy. On this basis, Karl-Otto Apel singled out as the decisive proponent of the linguistic and Kantian turn in German-speaking ethics, worked out the performative-contradiction argument while claiming that this was able to provide a new rational and universal basis for normative ethics. An examination of his argument is some detail is offered, followed by a more cursory reconstruction of Jürgen Habermas’s elaboration on Apel’s theory. -/- 29. John Rawls and public ethics as applied ethics. Rawls’s distinction between a “political” and a “metaphysical” approach to one central part of ethical theory, namely the theory of justice, is interpreted as a formulation of the same basic idea at the root of both the principles approach and neo-casuistry, both discussed in the following chapter, namely that it is possible to reach an agreement concerning positive moral judgments even though the discussion is still open – and in Rawls’ view never will be close – on the basic criteria for judgment. -/- 30. Beauchamp and Childress and bioethics as applied ethics. The chapter presents the revolution of applied ethics while stressing its methodological novelty, exemplified primarily by Beauchamp and Childress principles approach and then by Jonsen and Toulmin’s new casuistry. -/- . (shrink)

The trend to centralization of the Mizrahi narrative has become an integral part of the nationalistic, ethnic, religious, and ideological-political dimensions of the emerging, complex Israeli identity. This trend includes several forms of opposition: strong opposition to "melting pot" policies and their ideological leaders; opposition to the view that ethnicity is a dimension of the tension and schisms that threaten Israeli society; and, direct repulsion of attempts to silence and to dismiss Mizrahim and so marginalize them hegemonically. The Mizrahi Democratic (...) Rainbow [The Keshet], the most prominent proponent and representative of this trend, was established in the 1990s with the intention of being a leading civic and political body in Israeli society. While it was the Mizrahi worldview that led to selection of the organization's name and aims, their vision was to be involved in social struggle on behalf of other groups in Israeli society. Since it was established, The Keshet has aimed to function as an assertive, long-term alternative coalition exerting influence, power, and pressure on the Israeli narrative network. And, indeed, the organization has succeeded in disrupting Israeli discourse, principally, by challenging the ideological foundations of the Zionist meta-narrative. Nearing the end of the first decade of the 21st century and nearly a decade since it was established, The Keshet not only represents the most current wave of Mizrahi discourse, it has changed it to such a great degree that it is impossible to ignore its influence. Further, this alternative narrative may have significant potential to advance the internal Jewish discourse so fundamental at this time given the changing Israeli situation and regional conditions. And, while it is possible to view The Keshet and this new narrative as a continuation of the Mizrahi struggle, as a narrative The Keshet's agenda represents a post-colonial perspective and multi-cultural alternative to Zionism as a social vehicle. Amidst all of this, The Keshet continues to offer concrete proposals to change the Jewish character of the state as well as its internal and external relations. One of the primary goals of this study was to examine the rise of the Mizrahi narrative over the last two decades and the new Mizrahi discourse in Israeli society. More specifically, the study sought to attain an in-depth understanding of the central narrative created and represented by The Keshet. An additional goal was to investigate the influence of The Keshet's activity and the narrative it constructed in regard to other narratives. In particular, the study focused on The Keshet's opposition to the central Zionist narrative that infuses civic, political, and academic frameworks in Israel. Accordingly, the primary research questions investigated in the study sought to determine: What has been the influence of the Mizrahi Democratic Rainbow on the Mizrahi narrative in Israel? And, what are implications of such influence for the central Zionist narrative? Methodologically, the study was based on narrative and comparative analyses of texts from different periods of the older and newer Mizrahi narratives. The corpus included two types of texts: First, academic texts and opinion pieces, both philosophical and programmatic in nature, published in magazines, journals, books, as well as position papers; second, all of the texts published by prominent and influential figures who charted the path of The Keshet or led it organizationally and/or intellectually over the last twenty years (e. g., Yehudah Shenhav, Yossi Yona, Moshe Krief among others). All texts were examined by means of philosophical, historical and critical hermeneutic tools. This analysis revealed different levels of Mizrahi and civic discourse in Israel as well as among The Keshet's founders and leading ideologues. The study was based on a three stage process model, developed for purposes of this study, for investigation and analysis of the new Mizrahi narrative as well as other oppositional narratives, in particular opposition to the hegemonic meta-narrative. The stages are: issuing the challenge, dissolution and, liberation; that is, liberation is the measure of the ultimate success of the struggle for narrative change. Such change is not based on success in the field, but rather on a radical, fundamental reversal of thought, discourse patterns, stylistic structures, as well as forms of questioning - in this case of taken-for-granted racist mechanisms. However, the principal change is in achieving a deep, inner de-legitimization of the signifiers, categories, and reproductions of all manner of mockery that are based on immoral colonialist processes that are reinforced by regimes of fear and intimidation whose self-destruction began upon their very creation. This three stage model charts the course of the oppositional Mizrahi narrative from: accounting for the past (passing judgment on the so-called historic colonialist Zionism) to writing a new (pure Mizrahi) history and creation of a Mizrahi-Arab identity separate from the Ashkenazic, identified as Zionist. Contemporary post-colonialist discourse is integral in these stages. Such a perspective has been transformed by transitions from - binarism to hybridity, Orientalism to Occidentalism, the politics of "liberation" to "constructive" politics, from the history of consciousness to the history of change, as well as from nationalist to post-nationalist questions. Fundamentally, according to this approach, political and other struggles for the emerging narrative of Mizrahi (or Arab) history seek to centralize it in society and weave it amidst the models of multiculturalism. Undertaken in parallel, the central characteristics of all these stages are borrowed from countries in which the need for national reconciliation led to renunciation of apartheid and racist policies and historical judgment of the hegemony supported by racist leaders. In addition, these three moves were undertaken in Keshet and its ideologues by means of substantive symbolic violence directed at the hegemonic Ashkenazic discourse, which included creation of hatred of it, use of stereotypes the opposite of oppressive discourse, and adoption of an arrogant point of view toward it. This stands in stark contrast to the claims of the self-proclaimed new Mizrahi stance of a discourse established on purely ethical grounds that sought to cleanse itself of these very same oppressive elements. The model developed for and demonstrated in this study allows for analysis of oppositional narratives in which the libratory stage evolves into a form of entrapment, as appears to be occurring to the new Mizrahi discourse. This conclusion is based on the observations shared by many Keshet proponents including leading intellectuals who worked on the manifestos that were the subject of criticism from the Zionist camp. The study identified and defined the following six interwoven strata, which for purposes of explication are each discussed in a separate chapter: The first chapter presents a general theoretical discussion of the issue of the narrative and the inter-narrative struggle that has become central and applicable in various ways in the latest generation (e. g., anthropologically, hermeneutically, and philosophically). The analysis surveys different discussions in the inter-narrative struggle and locates them in the contexts, relations, and meanings derived from, representing, and indeed reproducing the narrative of national identity. The second chapter includes a historical survey of the older Mizrahi struggle that existed prior to the ascendance of the new Mizrahi narrative. Initially, Mizrahi discourse focused on expressing the ethnic protest that grew in years to follow. These feelings of discrimination and social distancing of the immigrants from Islamic countries gave birth to expressions of protest, the most prominent of which were Wadi Salib and the Black Panther Movement's various activities. The research literature contains many explanations for the exacerbation of the ethnic problem and creation of a situation that could not be ignored. The consensus academic view reached at the end of the 1970s identified a number of primary factors for this situation: the existence and extensive numbers of different ethnic groups; the relative or absolute segregation of frameworks within which members of these ethnic groups lived and acted; and the significant overlap between socio-economic status and feelings of discrimination retained by members of the Mizrahi group due years of neglect by the Ashkenazic establishment, the strengthening of Mizrahi social, cultural, and political power, as well as the emergence of a Mizrahi elite that identified with Mizrahi problems. The severe consequences of feelings of discrimination were expressed in a long series of events, such as: rioting by residents of the Rehovot Sharayim neighborhood in 1956; events of Wadi Salib in Haifa in 1959; and a chain of activities involving the Black Panthers in the 1970s. Protest was also an aspect of the "tent movement" in the 1970s and 1980s. Political activities were advanced by the Tami Movement that competed in the election for the 10th Knesset in 1981 and the Shas Movement that has continued to garner political power since being found in 1984. The 1980s and 1990s were characterized as the era of radical consciousness of Mizrahi discourse as well as by the rise to power, in consecutive order, of the political parties – Tami, Shas, and the Mizrahim HaHadashim [the New Mizrahi]. The latter party laid the foundations of the new radical Mizrahi discourse from which emerged such cultural activities as: Iton Aher [A Different Newspaper]; Bimat Kivon Aher [Another Direction Forum]; Efir'yon journal; the Halah Organization for Education in Neighborhoods, Development Towns, and Villages; Kedma; the newspaper – Patish [Hammer]; and, eventually the establishment of Keshet. The third chapter presents an examination of the materialization of the inter-narrative struggle in the case of Israel, with a specific focus on The Keshet and the new Mizrahi narrative advanced by it and intellectuals. The Keshet ideology is examined in the context of its grounding in post-colonial thought, especially that of Edward Said; the directions proposed by Ella Shohat and her followers; the central thinkers of the narrative in Israel in the last decade; and the harsh critique leveled at the Ashkenazic-Zionist narrative. The practical steps proposed for implementation within the multicultural model are also examined. Here the effort to reduce the centrality of Zionism while revealing its oppressive mechanisms was undertaken in parallel with use of these mechanisms in order to create a Mizrahi space with broad margins inclusive of alternative forms of Israeli identity in the Middle East and in conjunction with Arabs within and beyond Israel. Mizrahi traditionalism is examined in the fourth chapter in two particular respects. First, the criticism of the new Mizrahi narrative leveled by the renewed view and, second, the implications of the alternative in terms of creating a Mizrahi space that does not oppose Zionism. Rather, in opposing the post-colonialist perspective, this renewed traditionalist perspective criticizes as well as values Zionism. This space seeks to be both Jewish and Mizrahi. It does not detach itself from nationalist Zionism but rather views itself as a continuation of this tradition and, accordingly, is an effort to develop a next stage in its development. For example, an essential dimension of the traditionalist perspective, "commitment," is considered in this stage to be a fertile basis for dialogue with the past and as an anchor for contemporary interpretation of Mizrahi and other Jews' identities in Israel. The fifth and sixth chapters deal with all of the vectors of criticism directed at the new Mizrahi narrative, including its ideological foundations, philosophical stance, as well as intellectual and practical basis in the Israeli sphere in the face of Palestinian nationalism. These vectors of criticism from within and beyond The Keshet deal with issues, such as, the meaning of the movement's activities and the narrative that it offers regarding questions of Israeli identity, Israeli collective memory, and Mizrahi self-perception. At the same time, it must confront the capitalist neo-liberal narrative in a global world and thrive in a context in which it must make itself manifest amidst oppositional narratives. The final chapter presents a comprehensive, critical analysis of the new Mizrahi narrative. It does so by means of a theoretical model that examines it as an oppositional narrative – one that seeks to challenge the hegemonic meta-narrative, to dissolve the boundaries of the narrative discourse, and to propose liberation and redemption that may led to entrapment amidst a changing, a-dichotomous realities (e. g., global economic development in the face of Zionist nationalisms that display ideological strength as well as development of the sense of being an Israeli that maintains its vitality and continuity while being constituted by sectors that challenge being a Mizrahi, such as co-ethnic subjects. The Keshet's influence is dramatic and extends in a number of central directions. Its political activity and non-entry into the domains of the Israeli parliament granted the movement significant power in civic discourse and contributed to changing the persona of the Mizrahi discourse; for example, from political-party struggles over budgets and obtaining shares of the regime to changing the face of Israeli society and the centrality of the Mizrahi narrative. This change included deconstructing the Ashkenazic narrative and constructing comprehensive Ashkenazic-Zionist guilt, as evident in the Ehud Barak's request for collective forgiveness. This was accomplished through the participation of leading members of Keshet who appeared in prominent intellectual forums and engaged in lively discourse - principally in academic, social, and media domains. Such participation gave new meaning to various aspects of Israeli society while establishing different models of multiculturalism. The rise of the new Mizrahi narrative is a significant marker in the inter-narrative struggle as it represents a desire for separate or hybrid identities. And, the deep probing of the narrative constructed by leaders of The Keshet and those who identify with the movement produced a number of clear ways to distinguish it from the old Mizrahi struggle, whose history was portrayed through social protests, in a manner similar to linear vectors marked with wars and elections. The old Mizrahi struggle selected the traditional tactical struggle identified usually with social and political movements that seek to change political, social, and economic reality - from the bottom up. Their primary demand was to change decisions as well as the division of social goods and resources. Hence, this older period of struggle was not aimed at opposing the ideological foundations of the hegemonic narrative nor did it seek to undermine in a radical manner the unique nature of the state of Israel as a revolutionary solution for the problems of the Jews according to the Zionist approach, as a national home for the Jewish people, and recognition of the right to an preferred and meta-definition of Jewish nationalism. In contrast, the top down struggle advanced by the new narrative is part of an ideological movement led by the educated that is assertive and ground in post-colonialist theory. Accordingly, it was critical of the techniques and mechanisms of oppression as well as sought to attack the Zionist ideological foundations and to reveal its racist operations and the regimes that have preserved it so efficiently for many years. The uniqueness of this narrative is the intellectual offensive that continues to be advanced and, in parallel, development of the discourse struggle in Israel concerning the justification for Zionism and the concrete political proposal that Jews reject the taken-for-granted status of it as an ideology. This new narrative recognizes the historic difficulties of subversion as an emancipatory and, principally, moral effort. In addition, the new Mizrahi narrative shares the foundations and narrative of Palestinian victimization. In its radical version, the new Mizrahi narrative seeks to connect to the Palestinian narrative in order to create a new space here. According to this version, this action will take place gradually. The first stage will be characterized by opposition to Western European, Ashkenazic Zionism. The Eurocentric Zionism will surrender in the second stage, to be followed in the last stage by creation of a coalition of Jews and Arabs that will be establish through concrete actualization of the refugee status and victimization that is shared by both Palestinians and Mizrahim (whether as Mizrahim or Jewish-Arab). Not a speculative academic exercise, the goal sought by this narrative is delineate and to achieve a multicultural model in which equality, liberty, and social justice will overcome the nationalism and colonialism of either side; that is it will be neither Zionist nor Jewish. Thus, this approach stresses what is shared (e.g., acceptance of the Arab space and not a rejection of it; the legitimacy of the Arab language and culture). This is part of detachment from and historic judgment of the colonialist Zionist enterprise. This possibility includes moral elements that remove the evil and harm caused by Zionism for many years as well as inner cleansing – primarily among Ashkenazim – of attitudes towards Jews and non-Jews. Though, in this regard, it should be noted that, to date, the new narrative has not made similar claims that Palestinians undergo a similar process. The assumption seems to be that this should be tested, that the coalition proposed is a possibility that will be recognized by the Palestinians, and that they are prepared to undergo a similar, shared moral process that involves negating the state of Israel as a Jewish, Western state, a state of the Jewish people, and not only for those who live within it. These Mizrahi thinkers conducted a significant move through deconstruction and substitution of the Eurocentric narrative with a multi-cultural proposal that is optimistic and even attractively naïve. Today, they acknowledge that they did not take into account Palestinian nationalist violence directed to citizens, the traditionalist alternative, and widespread opposition within the Mizrahi community toward what is perceived to be Mizrahi seclusion. They also did not take into account the harsh criticism rendered by young and educated Mizrahim who claim that they were born into a complex, multi-dimensional, multi-layered identity that includes internalization of the language of the West and rules of the game of this complex identity. And, though they are critical of some of its values, this makes it difficult to mount internal emotional opposition to the West and to the globalization contained within this world. Hence, this more familiar world is preferred over the values of the Mizrahi-Arab alternative, particularly in regard to problems in the domains of democratic citizenship, stance taken toward women, and freedom of speech. Further, educated Mizrachim reject the post-colonialist perspective and are stridently critical of its dichotomization. They claim that such a division is irrelevant in a world in which older ideologies have collapsed and new spheres – such as cyberspace and others – are open to them in which they can present themselves with an Israeli identity that is not categorized as necessarily Mizrahi. (shrink)

This paper provides practitioner and academic insights into the importance of examining non-technical skills in a multiteam system emergency response. The case of public health professionals is highlighted, illustrated with unique qualitative field data which focused upon the use of non-technical skills at a meso level of analysis. Results reflected the importance of context upon the multiteam system and highlighted seven non-technical skills used by public health professionals to support an effective response. Recommendations for future research and (...) implications for practice are noted for this hard to access professional group, located within emerging advances in the scientific inquiry of complex and increasingly evident, multi-team systems. (shrink)

New technologies are transforming and reconfiguring the boundaries between patients, research participants and consumers, between research and clinical practice, and between public and private domains. From personalised medicine to big data and social media, these platforms facilitate new kinds of interactions, challenge longstanding understandings of privacy and consent, and raise fundamental questions about how the translational patient pathway should be organised.This editorial introduces the cross-journal article collection "Translation in healthcare: ethical, legal, and social implications", (...) briefly outlining the genesis of the collection in the 2015 Translation in healthcare conference in Oxford, UK and providing an introduction to the contemporary ethical challenges of translational research in biology and medicine accompanied by a summary of the papers included in this collection. (shrink)

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of (...) a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS l. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[1] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[2] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. ll. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[3] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[4] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[5] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[6] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[7] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[8] In democratic societies, one must take into consideration community morals and values.[9] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[10] lll. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[11] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[12] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[13] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[14] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. lV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[15] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[16] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[17] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[18] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[19] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[20] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[21] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. Vl. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[22] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[23] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[24] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. Vll. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [1] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [2] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [3] Moss, p. 1295-1298. [4] Moss, p. 1296. [5] Moss, p. 1295-1298. [6] Moss, p. 1295-1298. [7] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [8] Cohen, p. 1299-1301. [9] Moss, p. 1297. [10] Cohen, p. 1300. [11] Cappelen, p. 478-480. [12] Cappalen, p. 478-480. [13] Cappelen, p.479. [14] Cappelen, p. 479. [15] Cappelen, p. 479 [16] Cohen, p. 1301. [17] Cappelen, p. 478. [18] Cohen, p. 1299-1301. [19] Cohen, p. 1301. [20] Cappelen, p. 476-480. [21] Cappelen, p. 476-480. [22] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [23] Kawachi, p. 18-33. [24] Kawachi, p. 18-33. (shrink)

This paper presents a systematic account of ethical issues actualised in different areas, as well as at different levels and stages of health care, by introducing organisational and other procedures that embody a shift towards person centred care and shared decision-making (PCC/SDM). The analysis builds on general ethical theory and earlier work on aspects of PCC/SDM relevant from an ethics perspective. This account leads up to a number of theoretical as well as empirical and practice oriented issues that, in (...) view of broad advancements towards PCC/SDM, need to be considered by health care ethics researchers. Given a PCC/SDM-based reorientation of health care practice, such ethics research is essential from a quality assurance perspective. (shrink)

Purpose Digital transformation leverages digital technologies to change current processes and introduce new processes in any organisation’s business model, customer/user experience and operational processes. Artificial intelligence plays a significant role in achieving DT. As DT is touching each sphere of humanity, AI led DT is raising many fundamental questions. These questions raise concerns for the systems deployed, how they should behave, what risks they carry, the monitoring and evaluation control we have in hand, etc. These issues call for the need (...) to integrate ethics in AI led DT. The purpose of this study is to develop an “AI led ethical digital transformation framework”. Design/methodology/approach Based on the literature survey, various existing business ethics decision-making models were synthesised. The authors mapped essential characteristics such as intensity and the individual, organisational and opportunity factors of ethics models with the proposed AI led ethical DT. The DT framework is evaluated using a thematic analysis of 23 expert interviews with relevant AI ethics personas from industry and society. The qualitative data of the interviews and opinion data has been analysed using MAXQDA software. Findings The authors have explored how AI can drive the ethical DT framework and have identified the core constituents of developing an AI led ethical DT framework. Backed by established ethical theories, the paper presents how DT pillars are related and sequenced to ethical factors. This research provides the potential to examine theoretically sequenced ethical factors with practical DT pillars. Originality/value The study establishes deduced and induced ethical value codes based on thematic analysis to develop guidelines for the pursuit of ethical DT. The authors identify four unique induced themes, namely, corporate social responsibility, perceived value, standard benchmarking and learning willingness. The comprehensive findings of this research, supported by a robust theoretical background, have substantial implications for academic research and corporate applicability. The proposed AI led ethical DT framework is unique and can be used for integrated social, technological and economic ethical research. (shrink)

Global health emergencies such as the COVID-19 pandemic are contexts in which it is critical to draw upon learning from prior research and to conduct novel research to inform real-time decision-making and pandemic responses. While research is vitally important, however, emergencies are radically non-ideal contexts for its conduct, due to exceptional uncertainty, urgency, disruption, health needs, and strain on existing health systems, amongst other challenges. This generates novel ethical challenges and a broader conception of research (...) ethics is necessary to effectively address the complexity of pandemic research contexts. Going beyond traditional approaches to research ethics centring on the design of specific studies, this broader conception requires consideration of fundamental questions relating to the exercise of power and influence throughout research pathways, and a broader attention to both salient ethical issues, and the ethical responsibilities of stakeholders. These include important questions about responsibilities to gather evidence and generate knowledge systematically during emergencies, to implement policy responses in ways that are amenable to evaluation, and even potential moral obligations to participate in research. In situations of heightened uncertainty, additional questions arise about what constitutes sufficient evidence to justify the development and implementation of policy responses, and the responsibilities of scientific and social science researchers involved in policy-making processes. The four cases in this chapter prompt reflection on evolving and at times competing values and responsibilities of policy-makers, regulators, health authorities and researchers during the design and conduct of research, and proposed early implementation of research findings. These cases highlight issues arising when conducting research of national importance in a pandemic, where researchers are required to liaise with authorities responsible for pandemic responses and address complex ethical issues, including protecting the interests of participants and publics when tensions arise between prioritising the completion of research and accelerating the rollout of novel health interventions. This chapter invites reflection on the practical ethical implications of commitments to undertake research during emergencies, including the nature and scope of the relevant responsibilities of a range of stakeholders. (shrink)

BackgroundThe participant recruitment process is a key ethical pivot point when conducting robust research. There is a need to continuously review and improve recruitment processes in research trials and to build fair and effective partnerships between researchers and participants as an important core element in ensuring the ethical delivery of high-quality research. When participants make a fair, informed, and voluntary decision to enroll in a study, they agree to fulfill their roles. However, supporting study participants to (...) fulfill study requirements is an important ethical obligation for researchers, yet evidenced as challenging to achieve. This paper reports on participants’ motivations to volunteer and remain part of a dietary study conducted in Kasungu District, Malawi.MethodsWe conducted twenty in-depth interviews (with chiefs, religious leaders, trial participants, and health surveillance assistants), five systematic ethnographic observations, and fourteen focus group discussions with trial participants and their partners. Interviews were audio-recorded and transcribed verbatim. We used a grounded theory methodology to analyse data that included coding, detailed memo writing, and data interpretation.FindingsThe findings reveal that many participants had concerns during the trial. Thematically, experiences included anxieties, mistrust of researchers, rumours, fears of exploitation, and misconceptions. Anonymous concerns collected from the participants were reported to the trial team which enabled the researchers to appropriately support participants. Despite initial concerns, participants described being supported and expressed motivation to take up their role.ConclusionThese findings highlight a diverse map of multiple notions of what is ethically relevant and what can impact participation and retention within a study. The study has revealed how embedding a responsive approach to address participants’ concerns and ethical issues can support trust relationships. We argue for the need to employ embedded ethics strategies that enhance informed consent, focus on participants’ needs and positive experiences, and support researchers to fulfill their roles. This work highlights the need for research ethics committees to focus on the risks of undue influence and prevent exploitation especially in settings with a high asymmetry in resources and power between researcher and participant groups.Trial Registration: The Addressing Hidden Hunger with Agronomy (Malawi) trial was registered on 5th March 2019 (ISCRTN85899451). (shrink)

BackgroundA growing number of studies show the potential of loyalty card data for use in health research. However, research into public perceptions of using this data is limited. This study aimed to investigate public attitudes towards donating loyalty card data for academic health research, and the safeguards the public would want to see implemented. The way in which participant attitudes varied according to whether loyalty card data would be used for either cancer or COVID-19 (...) research was also examined.MethodsParticipants were recruited via Prolific Academic to take part in semi-structured telephone interviews, with questions focused on data sharing related to either COVID-19 or ovarian/bowel cancer as the proposed health condition to be researched. Content analysis was used to identify sub-themes corresponding to the two a priori themes, attitudes and safeguards.ResultsParticipant attitudes were found to fall into two categories, either rational or emotional. Under rational, most participants were in favour of sharing loyalty card data. Support of health research was seen as an important reason to donate such data, with loyalty card logs being considered as already within the public domain. With increased understanding of research purpose, participants expressed higher willingness to donate data. Within the emotional category, participants shared fears about revealing location information and of third parties obtaining their data. With regards to safeguards, participants described the importance of anonymisation and the level of data detail; the control, convenience and choice they desired in sharing data; and the need for transparency and data security. The change in hypothetical purpose of the data sharing, from Covid-19 to cancer research, had no impact on participants’ decision to donate, although did affect their understanding of how loyalty card data could be used.ConclusionsBased on interviews with the public, this study contributes recommendations for those researchers and the wider policy community seeking to obtain loyalty card data for health research. Whilst participants were largely in favour of donating loyalty card data for academic health research, information, choice and appropriate safeguards are all exposed as prerequisites upon which decisions are made. (shrink)

BackgroundThe last few decades have seen the rising global acknowledgment of the importance of ethics in the conduct of health research. But research ethics committees or institutional review boards (IRBs) have also been criticized for being barriers to research. This article examines the case of the Philippines, where little has been done to interrogate the health research and IRB culture, and whose circumstances can serve as reflection points for other low- and middle-income countries.MethodsSemi-structured interviews were conducted (...) from July to October 2020 to elicit health researchers’ perspectives and experiences regarding IRBs and the ethics approval process in the country, as well as counterpoint narratives from researchers who have also worked for IRBs.ResultsAcross the fields of clinical, public health, and social science research, the issue of ethics review revealed itself to be foremost an issue of inequity. IRB processes serve as a barrier for those outside the academe; those belonging to institutions, cities, or entire regions without their own accredited IRBs; and researchers working independently, without ample budget, or on highly specialized topics—more so for non-clinical researchers who must grapple with the primarily biomedical framework of most IRBs. Consequently, the research landscape invariably favors those with the resources to do research, and researches that tend to attract funding.ConclusionThe broader challenge of equity in health research will entail more fundamental reforms, but proximal interventions can be done to make the ethics approval process more equitable, such as enhancing institutional oversight, regulating IRB fees, and enabling a more supportive and welcoming environment for early-career, student, independent, and non-clinical health researchers. This article ends by reflecting on the implications of our findings toward the larger research culture. (shrink)

This paper offers the Eastern Mediterranean Region (EMR) viewpoint with Qatar as a case for lasting transformation of health systems. The Qatar case study illustrates the importance of research in the development of health policy. It provides description of a series of projects that have been undertaken in relevant national areas such as autism, dementia, genomics, palliative care and patient safety. The paper discourse draws attention to investment requirement in health research systems to respond to country national health (...) priorities and to strengthen public health policies for improving health and social outcomes by narrowing the gap between research and politics. In short, the discussion highlights the following: i) health is a human right marching towards universal health care, with research underpinning every advance in health care and quality medical services; ii) evidence-based research is emerging as a critical tool to aid policy- and decision-makers; iii) investment necessity in healthcare research/systems to enable responding to a country’s national health priorities and to strengthen public health policies; and iv) need for multi-sectoral involvement of stakeholders to bridge the gap between research and politics. Finally, atypical stakeholders’ engagement and bond to politics is a prerequisite to achieve healthcare objectives and policy success so as to reap the benefits of public health results. (shrink)

Background Ethical sensitivity is a prerequisite for ethical nursing practices. Efforts to improve nurses’ ethical sensitivity are required to correctly recognise ethical conflicts and for sound decision-making. Because an emerging infectious disease response involves complex ethical issues, it is important to understand the factors that influence public health nurses’ ethical sensitivity while caring for patients with COVID-19, an emerging infectious disease. Objectives This study aims to identify the relationship between nursing professionalism, the organisation’s ethical climate, and the ethical (...) sensitivity of nurses who care for emerging infectious disease patients in Korean public health centres. Further, it sought to identify factors influencing ethical sensitivity and the mediating effect of the organisational ethical climate to inform guidelines and improve ethical sensitivity. Research design This was a cross-sectional descriptive study. Participants and research context Data were collected from February 3 to 8 March 2021. Participants included 167 nurses caring for patients with COVID-19 in public health centres in South Korea. Ethical consideration This study was approved by the Institutional Review Board of the Chung-Ang University and followed the principles of research ethics. Results The factors influencing ethical sensitivity were working at a COVID-19 disease direct response department, nursing professionalism, and organisation’s ethical climate. The organisation’s ethical climate showed a partial mediating effect on the influence of nursing professionalism on ethical sensitivity. Conclusion Our findings show that nurses’ ethical sensitivity can be improved by refining the organisation’s ethical climate and nursing professionalism. (shrink)

Gene editing techniques, such as CRISPR, are being heralded as powerful new tools for delivering agricultural products and foods with a variety of beneficial traits quickly, easily, and cheaply. Proponents are concerned, however, about whether the public will accept the new technology and that excessive regulatory oversight could limit the technology’s potential. In this paper, we draw on the sociotechnical imaginaries literature to examine how proponents are imagining the potential benefits and risks of gene editing technologies within agriculture. We (...) derive our data from a content analysis of public comments submitted to the Food and Drug Administration’s 2017 docket titled “Genome Editing in New Plant Varieties Used for Food.” Our sample frame consists of 26 comments representing 30 agriculture and biotech companies, organizations, and trade associations. Our findings reveal three key sociotechnical imaginaries, including that gene editing technologies in agriculture: are not GMO but instead equivalent to traditional plant breeding; have the potential to usher in a new Green Revolution; and could facilitate the democratization of agricultural biotechnologies. We argue that forming and projecting these collective interpretations of the potential of gene editing technologies for crops and foods plays an important role in efforts by proponents to influence regulatory oversight, modes of governance, and build public acceptance. This research contributes to calls by science and technology studies scholars to investigate emergent concerns and imaginaries for novel technoscientific advances to help inform upstream models of public engagement and governance decisions. (shrink)

BackgroundEngagement of people with lived experience and members of the public is an ethically and scientifically essential component of health research. Authentic engagement means they are involved as full partners in research projects. Yet engagement as partnership is uncommon in practice, especially during priority-setting for research projects. What is needed for agenda-setting to be shared by researchers and people with lived experience and/or members of the public (or organisations representing them)? At present, little ethical guidance (...) exists on this matter, particularly that which has been informed by the perspectives of people with lived experience and members of the public. This article provides initial evidence about what they think are essential foundations and barriers to shared decision-making in health research priority-setting and health research more broadly.MethodsAn exploratory, qualitative study was conducted in 2019. 22 semi-structured interviews were performed with key informants from the UK and Australia.ResultsThree main types of foundations were thought to be essential to have in place before shared decision-making can occur in health research priority-setting: relational, environmental, and personal. Collectively, the three types of foundations addressed many (but not all) of the barriers to power sharing identified by interviewees.ConclusionsBased on study findings, suggestions are made for what researchers, engagement practitioners, research institutions, and funders should do in their policy and practice to support meaningful engagement. Finally, key international research ethics guidelines on community engagement are considered in light of study findings. (shrink)

Clinical decision-making in old-age care is a complex and ethically sensitive process. Despite its importance, research addressing the challenges of clinical decision-making in old-age care within this cultural context is limited. This study aimed to explore the challenges and ethical concerns in clinical decision-making in old-age care in Ethiopia. This qualitative study employed an inductive approach with data collected via semi-structured interviews with 20 older patients and 26 health professionals recruited from healthcare facilities in Ethiopia. Data (...) were analysed using reflexive thematic analysis. Our analysis identified three key themes. First, participants highlighted perceptions that older patients’ religious beliefs interfere with the clinical decisions both older patients and health professionals make. Second, older patients often receive limited information from health professionals about their diagnosis and treatment. Third, families of older patients appear to strongly influence clinical decisions made by older patients or health professionals. This research enhances the understanding of clinical decision-making in old-age care within Ethiopia, a context where such research is scarce. As a result, this study contributes towards advancing the deliberation of ethical dilemmas that health professionals who work with older patients in Ethiopia might face. A key implication of the study is that there is a need for more ethics and cultural competence training for health professionals working with older patients in Ethiopia. (shrink)

Photo ID 222412412 © US Navy Medicine | Dreamstime.com ABSTRACT In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. INTRODUCTION Medical resources in an austere environment without quick recourse for resupply or casualty evacuation are (...) often limited. The shortage extends not only to supplies like blood products and drugs, but physicians and other medical personnel. In the midst of a mass casualty scenario, such as a battle that includes intense ground fighting, the medical staff will stretch scarce resources and triage casualties according to specific criteria. Typically, they proceed by providing care for the most severely wounded first, referred to here as conventional triage. At times, though, the staff may reverse the triage so that soldiers with minor wounds can return to the fight. In a mass casualty situation, when medical personnel apply conventional triage and treat casualties from opposing forces, a dilemma may arise. We argue that it can be permissible for military physicians to prioritize their own soldiers over enemy combatants in a mass casualty triage, where reverse triage does not apply. The case we will focus on is as follows: Battlefield Triage: During combat operations on a remote island in the Pacific Ocean, a compatriot soldier and an enemy combatant arrive at the compatriot soldier country’s medical treatment facility. Both have similar gunshot wounds to the abdomen, and they arrive with similar conditions. Both have low oxygen saturation and excessive blood loss. The sole physician only has enough time to stabilize one person. The scenario is brief, and we are aware that medical rules of eligibility will most often dictate how the physician proceeds,[1] but this scenario is useful in setting up the question we focus on in this paper: would it be wrong to favor the stabilization of a soldier just because the soldier is the physician’s compatriot? In other words, can nationality serve as an ethically justified tiebreaker in a situation such as Battlefield Triage?[2] In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. The AMA’s Code of Medical Ethics asserts that physicians have “ethical obligations to place patients’ welfare above their self-interest and above obligations to other groups.”[3] The World Medical Association’s Declaration of Tokyo affirms that “no motive, whether personal, collective or political, shall prevail against this higher purpose” of alleviating distress.[4] Physicians are taught early on that triage decisions must be medically indicated and made without consideration of factors such as race, ethnicity, religion, social status, and nationality. They are taught that public trust and obligations of justice grounded in equality demand that only medical indications be considered. But military physicians in a military setting are beholden to obligations, duties, and responsibilities as members of the military, and when these obligations, duties, and responsibilities conflict, as they do in Battlefield Triage, which loyalties win out and why?[5] Critics of partiality on national grounds argue that partiality undermines public trust in medicine and justice because everyone should be treated equally regardless of nationality.[6] Proponents of partiality argue that military obligations supersede equality and that justice requires partiality in such cases.[7] Despite the critics’ disagreement, both agree that there is a morally right, perhaps even blameless, course of action. Drawing on insights from virtue ethics, we argue that Battlefield Triage is a moral tragedy in which justice is unattainable and there is no action without moral cost. The assumption that there is a morally right choice is flawed. We argue that while no decision in this scenario is free from moral blame, there are reasons to favor treating one’s soldiers over enemy combatants. I. The Case Against Partiality There is a common assumption that there is a morally right or just decision in Battlefield Triage. A number of organizations and scholars claim that it is wrong for military physicians to favor their own soldiers on the grounds of nationality or some form of ‘group membership.’ (In a conflict involving service members from multiple nations working as a coalition, a soldier from an allied country may receive the same priority as the US service member due to ‘group membership.’) The World Medical Association’s WMA Declaration of Lisbon on the Rights of the Patient, which was reaffirmed in 2015, posits that, “[i]n circumstances where a choice must be made between potential patients for a particular treatment that is in limited supply, all such patients are entitled to a fair selection procedure for that treatment. That choice must be based on medical criteria and made without discrimination.”[8] This echoes what was set forth in Article 12 of the Geneva Conventions, which states that “[o]nly urgent medical reasons will authorize priority in the order of treatment to be administered.”[9] The argument for impartiality in Battlefield Triage is that every person is morally equal, and equality entails that medical distribution is, “based on a combination of medical need and urgency.”[10] This is in keeping with the bioethical principles that are generally applied.[11] II. The Case for Partiality On the other side, there are arguments that favoritism is the ethically right decision in Battlefield Triage.[12] The argument asserts that members of the military form a morally significant community of friends and participation in these relationships demands partiality. Just as parents have strong ethical duties to their children and not just any children, military personnel have ethical duties to their group, a group that involves an affirmation of mutual aid and support. Some have termed these ‘associative duties. According to Michael Gross, obligations of friendship, care, and solidarity “leave very little room for generally applicable principles of justice that would obligate a medic to treat enemy or non-compatriot wounded ahead of their compatriots.”[13] This is true in Battlefield Triage, but it may also be true even if the enemy’s soldier were more seriously wounded: “the ethics of small group cohesion, largely an ethics of care, mostly replaces the demands of impartial justice.”[14] In a more recent article, Gross explains that preferential treatment is ethically justified based on fighting capability and “the special obligations people owe friends, family, and, no less, comrades-in-arms.”[15] To not show partiality to the US soldier would be morally wrong on the grounds of friendship and mutual care.[16] III. The Moral Tragedy of Battlefield Triage Defenders and critics of Battlefield Triage favoritism based on nationality both frame their position as just or fair. For example, Justin List argues that physicians are “bound to practice medical neutrality,”[17] Marcus Adams denies that physicians “possess special ethical obligations” to enemy combatants because of their profession.[18] These perspectives assume that there is a morally right decision and that justice is attainable. The assumption that there is or can be a morally right Battlefield Triage decision, and we need to put our heads together to figure it out, remains strongly entrenched. However, the facts of the situation should give us pause; there are too many people and too few resources, and this demands a decision-making process that determines who will receive scarce resources. By its very nature, a battlefield triage decision has to be made based on some characteristic or value, a characteristic or value that will inevitably favor some at the expense of others. This is precisely why competing analyses “in the military context struggle to resolve these conflicts satisfactorily.”[19] Drawing on the insights of virtue ethics, we suggest that Battlefield Triage is a moral tragedy. Virtue ethics suggests that morality is about acting virtuously, which is to say that we should do what a virtuous person would do in the situation. Ethics is about figuring out how a just, wise, compassionate, loving, and fair person would act, and then doing that, as one grows in virtue. But life is not always clear cut, and it is possible that virtuous people may find themselves in a moral tragedy, a situation in which, through no fault of one’s own, a person must make a morally objectionable decision. After the action the virtuous person “emerges having done a terrible thing, the very sort of thing that the callous, dishonest, unjust, or in general vicious agent would characteristically do.”[20] Stated differently, a moral tragedy presents a virtuous person with two or more courses of action, all of which have a moral cost.[21] In Battlefield Triage, no matter how the physician goes about deciding, there is going to be defensible concern from those not saved. The fact that there are more people than can be helped fosters competing values in battlefield triage: maximize lives saved, treat people equally, treat the worse off, and support the war effort. Treating people equally may create tension between treating the worse off, maximizing lives saved, and supporting the war effort. Reverse triage is a case in point, as supporting the war effort conflicts with treating the worse off first, as is a fair lottery system since deploying a lottery may not maximize lives saved or support the war effort. There can be reasons why one person is selected over another, to be sure. Yet, there are reasons for making a decision, and that the decision is subject to legitimate moral concern is another. To recognize the moral tragedy of Battlefield Triage is to recognize the impossibility of acting blamelessly in the situation. In this situation, the virtuous military physician is going to have to sacrifice important values such as justice, compassion, and respect for others, even with a defensible criterion in hand. The physician will grieve this sacrifice accordingly. The physician may find her decision difficult or stressful, and rightly so, because of what her circumstances require of her. This kind of moral tragedy results “in actions which betray and violate the rights of persons to whom there may be a strong duty of care. When this happens, it properly triggers an appropriate moral emotion since our moral integrity has been violated and this affects how we think of ourselves and what we have become.”[22] Rather than view her triage decision as the morally superior choice, the virtuous military physician will view her decisions in these circumstances in a different light: it is the least bad option in a terrible situation, and she did something ethically problematic, something that is contrary to her moral character. She deeply regrets the circumstances in which she had to act. IV. Virtue Ethics A virtue ethicist has insight into how one should go about deciding what to do in a moral tragedy, although virtue ethics may not be as helpful as one may hope. The goal of the virtuous military physician in Battlefield Triage is to adopt the best course of action or the action that she feels she ought to do, all things considered. This does not make her choice devoid of serious wrongdoing—a decision must be made, but that does not make it just. The virtuous military physician will approach the situation with courage, responsibility, and insight. She will think about the decision carefully, wisely, and conscientiously; she will weigh the goods and harms of the choices before her, in conjunction with a proper conception of the good life, human worth, and understanding of her obligations to others—including chain of command, fellow soldiers, and the medical community. She is attuned to the value of human life and has a reasonable idea of the various ways her decisions will affect others. She recognizes that she is in this non-ideal situation through no fault of her own: she is not the one fighting in battles; she is serving her country as a physician, whose job it is to save lives, treat everyone justly, and promote military objectives. She regrets the decision she is forced to make in battlefield triage, acting “with immense regret and pain,” Hursthouse explains, “instead of indifferently or gladly.”[23] This is because, no matter what decision is made, the virtuous military physician “does something terrible or horrible,” something she otherwise would not do and is contrary to her values.[24] V. A Resolvable Moral Tragedy Instead of asking whether there is a morally right decision, in which a decision is morally blameless and above reproach, the virtue ethicist asks whether there is a decision with a convincing rationale, knowing that a decision can have a clear rationale but still be morally tragic. It is perfectly reasonable to think that different virtuous persons will arrive at different courses of action: “two virtuous agents, in the same situation,” Hursthouse writes, “may act differently” in irresolvable moral tragedies, in cases in which there is no clear course of action.[25] Because a person must act in a moral tragedy, one goal is to identify reasons for choosing the chosen action. Some decisions are clearly indefensible—treating neither the compatriot soldier nor the enemy combatant in Battlefield Triage would be wrong—and some decisions are more problematic than others. If the military physician selects to treat the soldier because she does not like the enemy combatant’s skin color, such a reason would be deeply problematic. But much of the debate over how to act in a moral tragedy is not over clearly indefensible or problematic criteria. Instead, the literature is largely about different standards or implementations of justice. Some scholars defend nation-impartial triage as right, while others defend nation-aware triage as right, and each argues that the other side is promoting an unjust or otherwise wrong solution to Battlefield Triage. We suggest that Battlefield Triage is a resolvable moral tragedy and that virtue ethics offers convincing reasons to prefer the treatment of the compatriot soldier rather than the enemy combatant on the grounds of national identity. Virtues are integral to living a good life, a flourishing life, but as Aristotle observed long ago, human beings are inherently social, interdependent and interconnected in profound ways.[26] This goes beyond the obvious fact that we need each other to survive day to day (one person makes clothes, another farms, and another makes tools); the claim is that a good or flourishing life depends in large part on one’s social network or community. This is why many of Aristotle’s moral virtues are other facing: justice, friendship, generosity, and magnanimity, to name a few. Courage, a typically self-facing virtue, is understood by Aristotle to be the virtue that regards one’s fear of death in battle, a battle fought on behalf of one’s city.[27] All of this remains true today. Namely, there is an important sense in which our community matters to our lives: it is easier to live a good, flourishing life if one is part of a good, flourishing community. Our community is made up of smaller groups, and it is more accurate to say that we are simultaneous members of different groups within a broader community. A person may be part of a family, friend group, research team, large state university, city, state, and nation. Groups can function well or not, as we all have experienced, and this suggests that there are virtues or excellences that groups can instantiate. Good groups are unified in purpose, with each member doing their duty alongside others for the attainment of that purpose. Good groups manifest solidarity among their members. Although Aristotle does not list solidarity as a virtue, a number of modern-day virtue ethicists have begun examining how group solidarity can be a virtue that contributes to a good or flourishing life.[28] Solidarity is not conceptualized as an individual virtue, a virtue possessed by a person in isolation of others; instead, it is a collective virtue, a virtue that is shared among members of a defined group with particular ends.[29] “A group has solidarity to the extent that its members are disposed to: (1) share values, aims, or goals; (2) care about those values, aims, or goals; (3) act in accordance with those values, aims, or goals; (4) trust the testimony of other group members with respect to those values, aims, and goals; and (5) feel a sense of belonging to the group.”[30] The virtue of collective or group solidarity involves individuals having special concern for each other, shared aims and values, trust, loyalty, and a sense of belonging with these specific others. There is a oneness to the group in the pursuit of a definite goal or purpose, involving mutual support and affirmation of each member. As such, the group has ends and goods above and beyond the good of each individual person. Sometimes solidarity requires personal sacrifice for the collective (for example, a father sacrificing food so his child can eat). The virtue of collective or group solidarity is important to the military and medical community at every level, and for clear reasons. In the military, there is a clear hierarchy of command, unity of purpose and end, mutual trust and support in complex settings, and so on. Soldiers need to know they can count on one another, and solidarity grounds a soldier’s ability to trust others and be assured of mutual aid. In medicine, solidarity maintains self-regulation of the profession, shared values and goals, as well as public support, not to mention that day-to-day operations require physician trust, engagement, and effort toward the ends of clinical care. Physicians need to work together, along with others, in pursuit of health, and disunity is sowed when there is mistrust, selfishness, or disengagement among the healthcare team and organization. Importantly, just as we are all members of various groups and hence may manifest group solidarity in different settings, the virtuous military physician instantiates collective solidarity with both the medical profession and the military. Her dual loyalty contributes to the moral difficulty of acting in Battlefield Triage. The military physician has competing obligations to distinct groups and cannot satisfy all obligations in Battlefield Triage. Solidarity with the military supports the consideration of favoring the soldier for reasons of national identity, whereas solidarity with the medical community does not. Something has to give, which is why it is a moral tragedy. The virtuous military physician, therefore, must weigh the costs of each course of action. To fulfill her obligations to the medical community would require that she does not use nationality and other non-medical considerations in Battlefield Triage. Since the soldier and enemy combatant are equally injured, justice would demand a random process, perhaps a flip of the coin. Although this may satisfy obligations the military physician has to the medical community, this would be costly to the physician’s military group. If word gets out that the physician decides who to treat based on a coin toss, soldiers, families, and citizens may become frustrated and angry. Soldier morale may go down if it becomes known that a coin flip led to the preventable death of a soldier and the saving of an enemy combatant who had killed (or attempted to kill) other soldiers. As Gross highlights, military solidarity involves a mutual aid promise that military personnel promise to help one another.[31] A military physician is part of the military and, as such, is part of the mutual aid promise, which would appear to be violated if the physician flips a coin. Treating a member of one’s own team may be psychologically more beneficial than treating an enemy combatant and may lead to less moral distress.[32] Finally, treating soldiers rather than enemy combatants promotes broader military and social aims, including returning soldiers to health, maintaining unity of purpose, and minimizing community suffering from a soldier’s death. Favoring members of one’s group, that is, triage based on nationality in Battlefield Triage, would fulfill obligations of military group loyalty, which is contrary to the values and duties of medicine. It does not seem as though showing favoritism in this particular situation is very costly to the medical community or general public, but this is because there is recognition that the physician is in the military. Medicine is impartial to non-medical indications partly because of fairness and to promote public trust in medicine. However, Battlefield Triage is unique, as medicine is being practiced in a non-public, wartime setting. In ordinary circumstances, a patient’s identity is irrelevant, and physicians ought not play favorites. Since Battlefield Triage is not an ordinary circumstance, decisions based on patient identity may not undermine public trust in medicine. In addition, it is contestable that fairness in Battlefield Triage requires that no consideration be paid to one’s nationality. Fairness is about giving each person their due, what is owed to them, and the case can be made that soldiers who place themselves in danger for the sake of the common good or a just cause are owed special attention when they suffer harm in the line of duty. In other words, soldiers voluntarily undergo risk to themselves for the greater good, and society owes them for this sacrifice. This plausibly includes preferential treatment in a situation such as Battlefield Triage. So, while the medical community affirms justice demands non-preferential treatment, the military community can affirm the opposite. The demands of fairness are unclear at best or in conflict in this situation: demands of physician justice decry favoritism, while demands of military justice support favoritism. Triage not based on nationality is arguably unfair and triage based on nationality may not undermine public trust, after all. All things considered, there is a clear rationale for favoring nationality-based preferential treatment in Battlefield Triage. Adopting a nationality-based preference in this situation is more defensible than not. This does not make such a decision ethically right or just. Preference based on nationality is the least bad decision, but it is not morally blameless. It involves one in a serious moral wrong, a wrong otherwise avoided and contrary to one’s character. The virtuous military physician is in a situation in which obligations conflict, and we disagree with Gross, who posits that care of fellow soldiers “is important to the near exclusion of all else.”[33] Gross fails to appreciate the collective virtue of solidarity as applied to those in medicine. The military physician has duties to fellow soldiers but also to fellow physicians, to the medical community, and humanity. To favor a soldier on grounds of nationality violates her duties and responsibilities to this latter group. She is involved in a moral tragedy and can only seek the most just action given the circumstances, yet, at least in virtue ethics, the action remains far from blameless. CONCLUSION We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. As such, the virtuous military physician incurs a moral cost to acting as she does—there is a moral residue. However, despite being a moral tragedy, there are clear reasons to act in favor of treating one’s own, considering group solidarity. As such, these kinds of tragedies are resolvable: virtuous military physicians should favor treatment of their own, although they would do so with sorrow. - [1] Militaries set forth medical rules of eligibility or guidelines used to determine whether a person qualifies for specific medical interventions or treatments in certain circumstances, and these guidelines are binding for a military physician. For example, despite opposition from medical organizations, militaries have adopted reverse triage guidelines for military physicians to follow. For ethical discussion, see Falzone, Elisabeth, P. Pasquier, C. Hoffmann, O. Barbier, M. Boutonnet, A. Salvadori, A. Jarrassier, J. Renner, B. Malgras, and S. Mérat. "Triage in military settings." Anaesthesia Critical Care & Pain Medicine 36, no. 1 (2017): 43-51. https://doi.org/10.1016/j.accpm.2016.05.004 [2] There are issues that are related to this, including the triage of civilians and allied soldiers. We set related issues aside for purposes of this paper [3] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [4] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [5] This is termed the “dual loyalty” dilemma in military medicine and has been described at length elsewhere: Institute of Medicine (US) Board on Health Sciences Policy. Military Medical Ethics: Issues regarding Dual Loyalties: Workshop Summary. Washington (DC): National Academies Press (US); 2008. Toward a Framework for Resolving Dual Loyalties. Available from: https://www.ncbi.nlm.nih.gov/books/NBK214853/ [6] See Kenneth G. Swan and K.G. Swan, Jr., “Triage: The Past Revisited,” Military Medicine 161:8 (1996): 448–452. https://doi.org/10.1093/milmed/161.8.448; Jerome A. Singh, “American Physicians and dual loyalty obligations in the ‘war on terror,’” BMC Medical Ethics 4.4 (2003): 1–10. https://doi.org/10.1186/1472-6939-4-4; Beam, Thomas E. "Medical Ethics on the Battlefield." Military Medical Ethics: Sect. IV. Medical ethics in the military. Medical ethics on the battlefield: the crucible of military medical ethics 2 (2003): 369-402; Hereth, Blake. "Health justice for unjust combatants." Journal of Military Ethics 20, no. 1 (2021): 67-81. https://doi.org/10.1080/15027570.2021.1949782. [7] See Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. Gross, Michael L. "Comradery, community, and care in military medical ethics." Theoretical medicine and bioethics 32 (2011): 337-350. https://doi.org/10.1007/s11017-011-9189-6. Gross, Michael L. "The limits of impartial medical treatment during armed conflict." In Military medical ethics for the 21st century, pp. 71-84. Routledge, 2016. [8] World Medical Association, WMA Declaration of Lisbon on the Rights of the Patient. 5 December 2022, https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/ [9] Geneva Convention for the Amelioration of the Condition of Wounded, Sick in Armed Forces in the Field. 12 August 1949. https://www.un.org/en/genocideprevention/documents/atrocity-crimes/Doc.30_GC-I-EN.pdf. [10] List, Justin M. "Medical neutrality and political activism: physicians' roles in conflict situations." In Physicians at war: The dual-loyalties challenge, pp. 237-253. Dordrecht: Springer Netherlands, 2008. 240 [11] Beauchamp, T., and J. Childress. 2013. Principles of Biomedical Ethics, 7th ed. Oxford, United Kingdom: Oxford University Press. [12] Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. [13] Gross, "Comradery, community, and care in military medical ethics," 347. [14] Gross, “Comradery, community, and care in military medical ethics,” 349. [15] Gross, Michael L. "When medical ethics and military ethics collide." Narrative inquiry in bioethics 13, no. 3 (2023): 199-204. 202 https://dx.doi.org/10.1353/nib.2023.a924191 [16] Our argument draws on virtue ethics, from which care ethics derives, and it is worth clarifying how our argument relates to Gross’s. We do not think that the virtue of friendship grounds triage decisions, for we think it is unlikely that the physician and wounded soldier are friends. Instead, as explained below, we think the collective virtue of group solidarity better captures the moral significance of group loyalty and that Gross would agree with us. But since military physicians are part of distinct groups, with competing obligations, the military physician will be forced to sacrifice a value in battlefield triage cases. In other words, we think Gross downplays the dual group membership of a military physician. [17] List,”Medical neutrality and political activism,” 250. [18] Adams,”Triage priorities and military physicians,” 235. [19] London, Leslie, Leonard S. Rubenstein, Laurel Baldwin-Ragaven, and Adriaan Van Es. "Dual loyalty among military health professionals: human rights and ethics in times of armed conflict." Cambridge Quarterly of Healthcare Ethics 15, no. 4 (2006): 381-391. 383. [20] Hursthouse, R. On Virtue Ethics. OUP 1999. 74 [21] Nussbaum, Martha C. "The costs of tragedy: Some moral limits of cost-benefit analysis." The Journal of Legal Studies 29, no. S2 (2000): 1005-1036, 1007. [22] De Wijze, S. (2005). Tragic-remorse–the anguish of dirty hands. Ethical theory and moral practice, 7(5), 453-471, 457. https://doi.org/10.1007/s10677-005-6836-x [23] Hursthouse, 73 [24] Hursthouse, 81 [25] Hursthouse, 72 [26] Aristotle, Politics 1253a8. Reeve, C. D. C., Indianapolis: Hackett Publishing Co., 2017 [27] Aristotle, Nicomachean Ethics. III.6.114a, 34-35. 2002, Nicomachean Ethics, Christopher Rowe (trans.), Oxford: Oxford University Press [28] Byerly, T. Ryan, and Meghan Byerly. "Collective virtue." The Journal of Value Inquiry 50, no. 1 (2016): 33-50. https://doi.org/10.1007/s10790-015-9484-y; Federico, Veronica. "Conclusion: solidarity as a public virtue." Solidarity as a Public Virtue (2018): 495-542. https://doi.org/10.5771/9783845290058. Rehg, William. "Solidarity and the common good: An analytic framework." Journal of Social Philosophy 38, no. 1 (2007): 7-21. https://doi.org/10.1111/j.1467-9833.2007.00363.x [29] Byerly and Byerly. "Collective virtue." 43 [30] Battaly, Heather. "Solidarity: Virtue or vice?." In Social virtue epistemology, pp. 303-324. Routledge, 2022. 304 [31] Ibid., 2011: 341 [32] It might be thought that displaying altruism by helping an enemy combatant at the expense of one’s fellow soldier may be psychologically satisfiying. For evidence that military physicians find it difficult to treat enemy combatants, see Lundberg, Kristina, Sofia Kjellström, Anders Jonsson, and Lars Sandman. "Experiences of Swedish military medical personnel in combat zones: adapting to competing loyalties." Military medicine 179, no. 8 (2014): 821-826. https://doi.org/10.7205/MILMED-D-14-00038. Lamblin, Antoine, Clément Derkenne, Marion Trousselard, and Marie-Ange Einaudi. "Ethical challenges faced by French military doctors deployed in the Sahel (Operation Barkhane): a qualitative study." BMC Medical Ethics 22 (2021): 1-13. https://doi.org/10.1186/s12910-021-00723-2 [33] Ibid., 2011: 344. (shrink)

BackgroundGenetic/genomic testing (GGT) are useful tools for improving health and preventing diseases. Still, since GGT deals with sensitive personal information that could significantly impact a patient’s life or that of their family, it becomes imperative to consider Ethical, Legal and Social Implications (ELSI). Thus, ELSI studies aim to identify and address concerns raised by genomic research that could affect individuals, their family, and society. However, there are quantitative and qualitative discrepancies in the literature to describe the elements (...) that provide content to the ELSI studies and such problems may result in patient misinformation and harmful choices.MethodsWe analyzed the major international documents published by international organizations to specify the parameters that define ELSI and the recognized criteria for GGT, which may prove useful for researchers, health professionals and policymakers. First, we defined the parameters of the ethical, legal and social fields in GGT to avoid ambiguities when using the acronym ELSI. Then, we selected nine documents from 44 relevant publications by international organizations related to genomic medicine.ResultsWe identified 29 ELSI sub-criteria concerning to GGT, which were organized and grouped within 10 minimum criteria: two from the ethical field, four from the legal field and four from the social field. An additional analysis of the number of appearances of these 29 sub-criteria in the analyzed documents allowed us to order them and to determine 7 priority criteria for starting to evaluate and propose national regulations for GGT.ConclusionsWe propose that the ELSI criteria identified herein could serve as a starting point to formulate national regulation on personalized genomic medicine, ensuring consistency with international bioethical requirements. (shrink)

This book represents the fourth volume in the series Collected Papers on Advancing Uncertain Combinatorics through Graphization, Hyperization, and Uncertainization: Fuzzy, Neutrosophic, Soft, Rough, and Beyond. This volume specifically delves into the concept of the HyperUncertain Set, building on the foundational advancements introduced in previous volumes. The series aims to explore the ongoing evolution of uncertain combinatorics through innovative methodologies such as graphization, hyperization, and uncertainization. These approaches integrate and extend core concepts from fuzzy, neutrosophic, soft, and rough set theories, (...) providing robust frameworks to model and analyze the inherent complexity of real-world uncertainties. At the heart of this series lies combinatorics and set theory—cornerstones of mathematics that address the study of counting, arrangements, and the relationships between collections under defined rules. Traditionally, combinatorics has excelled in solving problems involving uncertainty, while advancements in set theory have expanded its scope to include powerful constructs like fuzzy and neutrosophic sets. These advanced sets bring new dimensions to uncertainty modeling by capturing not just binary truth but also indeterminacy and falsity. In this fourth volume, the integration of set theory with graph theory takes center stage, culminating in "graphized" structures such as hypergraphs and superhypergraphs. These structures, paired with innovations like Neutrosophic Oversets, Undersets, Offsets, and the Nonstandard Real Set, extend the boundaries of mathematical abstraction. This fusion of combinatorics, graph theory, and uncertain set theory creates a rich foundation for addressing the multidimensional and hierarchical uncertainties prevalent in both theoretical and applied domains. The book is structured into thirteen chapters, each contributing unique perspectives and advancements in the realm of HyperUncertain Sets and their related frameworks. -/- The first chapter (Advancing Traditional Set Theory with Hyperfuzzy, Hyperneutrosophic, and Hyperplithogenic Sets) explores the evolution of classical set theory to better address the complexity and ambiguity of real-world phenomena. By introducing hierarchical structures like hyperstructures and superhyperstructures—created through iterative applications of power sets—it lays the groundwork for more abstract and adaptable mathematical tools. The focus is on extending three foundational frameworks: Fuzzy Sets, Neutrosophic Sets, and Plithogenic Sets into their hyperforms: Hyperfuzzy Sets, Hyperneutrosophic Sets, and Hyperplithogenic Sets. These advanced concepts are applied across diverse fields such as statistics, clustering, evolutionary theory, topology, decision-making, probability, and language theory. The goal is to provide a robust platform for future research in this expanding area of study. The second chapter (Applications and Mathematical Properties of Hyperneutrosophic and SuperHyperneutrosophic Sets) extends the work on Hyperfuzzy, Hyperneutrosophic, and Hyperplithogenic Sets by delving into their advanced applications and mathematical foundations. Building on prior research, it specifically examines Hyperneutrosophic and SuperHyperneutrosophic Sets, exploring their integration into: Neutrosophic Logic, Cognitive Maps,Graph Neural Networks, Classifiers, and Triplet Groups. The chapter also investigates their mathematical properties and applicability in addressing uncertainties and complexities inherent in various domains. These insights aim to inspire innovative uses of hypergeneralized sets in modern theoretical and applied research. The third chapter (New Extensions of Hyperneutrosophic Sets – Bipolar, Pythagorean, Double-Valued, and Interval-Valued Sets) studies advanced variations of Neutrosophic Sets, a mathematical framework defined by three membership functions: truth (T), indeterminacy (I), and falsity (F). By leveraging the concepts of Hyperneutrosophic and SuperHyperneutrosophic Sets, the study extends: Bipolar Neutrosophic Sets, Interval-Valued Neutrosophic Sets, Pythagorean Neutrosophic Sets, and Double-Valued Neutrosophic Sets. These extensions address increasingly complex scenarios, and a brief analysis is provided to explore their potential applications and mathematical underpinnings. Building on prior research, the fourth chapter (Hyperneutrosophic Extensions of Complex, Single-Valued Triangular, Fermatean, and Linguistic Sets) expands on Neutrosophic Set theory by incorporating recent advancements in Hyperneutrosophic and SuperHyperneutrosophic Sets. The study focuses on extending: Complex Neutrosophic Sets, Single-Valued Triangular Neutrosophic Sets, Fermatean Neutrosophic Sets, and Linguistic Neutrosophic Sets. The analysis highlights the mathematical structures of these hyperextensions and explores their connections with existing set-theoretic concepts, offering new insights into managing uncertainty in multidimensional challenges. The fifth chapter (Advanced Extensions of Hyperneutrosophic Sets – Dynamic, Quadripartitioned, Pentapartitioned, Heptapartitioned, and m-Polar) delves deeper into the evolution of Neutrosophic Sets by exploring advanced frameworks designed for even more intricate applications. New extensions include: Dynamic Neutrosophic Sets, Quadripartitioned Neutrosophic Sets, Pentapartitioned Neutrosophic Sets, Heptapartitioned Neutrosophic Sets, and m-Polar Neutrosophic Sets. These developments build upon foundational research and aim to provide robust tools for addressing multidimensional and highly nuanced problems. The sixth chapter (Advanced Extensions of Hyperneutrosophic Sets – Cubic, Trapezoidal, q-Rung Orthopair, Overset, Underset, and Offset) builds upon the Neutrosophic framework, which employs truth (T), indeterminacy (I), and falsity (F) to address uncertainty. Leveraging advancements in Hyperneutrosophic and SuperHyperneutrosophic Sets, the study extends: Cubic Neutrosophic Sets, Trapezoidal Neutrosophic Sets, q-Rung Orthopair Neutrosophic Sets, Neutrosophic Oversets, Neutrosophic Undersets, and Neutrosophic Offsets. The chapter provides a brief analysis of these new set types, exploring their properties and potential applications in solving multidimensional problems. The seventh chapter (Specialized Classes of Hyperneutrosophic Sets – Support, Paraconsistent, and Faillibilist Sets) delves into unique classes of Neutrosophic Sets extended through Hyperneutrosophic and SuperHyperneutrosophic frameworks to tackle advanced theoretical challenges. The study introduces and extends: Support Neutrosophic Sets, Neutrosophic Intuitionistic Sets, Neutrosophic Paraconsistent Sets, Neutrosophic Faillibilist Sets, Neutrosophic Paradoxist and Pseudo-Paradoxist Sets, Neutrosophic Tautological and Nihilist Sets, Neutrosophic Dialetheist Sets, and Neutrosophic Trivialist Sets. These extensions address highly nuanced aspects of uncertainty, further advancing the theoretical foundation of Neutrosophic mathematics. The eight chapter (MultiNeutrosophic Sets and Refined Neutrosophic Sets) focuses on two advanced Neutrosophic frameworks: MultiNeutrosophic Sets, and Refined Neutrosophic Sets. Using Hyperneutrosophic and nn-SuperHyperneutrosophic Sets, these extensions are analyzed in detail, highlighting their adaptability to multidimensional and complex scenarios. Examples and mathematical properties are provided to showcase their practical relevance and theoretical depth. The ninth chapter (Advanced Hyperneutrosophic Set Types – Type-m, Nonstationary, Subset-Valued, and Complex Refined) explores extensions of the Neutrosophic framework, focusing on: Type-m Neutrosophic Sets, Nonstationary Neutrosophic Sets, Subset-Valued Neutrosophic Sets, and Complex Refined Neutrosophic Sets. These extensions utilize the Hyperneutrosophic and SuperHyperneutrosophic frameworks to address advanced challenges in uncertainty management, expanding their mathematical scope and practical applications. The tenth chapter (Hyperfuzzy Hypersoft Sets and Hyperneutrosophic Hypersoft Sets) integrates the principles of Fuzzy, Neutrosophic, and Soft Sets with hyperstructures to introduce: Hyperfuzzy Hypersoft Sets, and Hyperneutrosophic Hypersoft Sets. These frameworks are designed to manage complex uncertainty through hierarchical structures based on power sets, with detailed analysis of their properties and theoretical potential. The eleventh chapter (A Review of SuperFuzzy, SuperNeutrosophic, and SuperPlithogenic Sets) revisits and extends the study of advanced set concepts such as: SuperFuzzy Sets, Super-Intuitionistic Fuzzy Sets,Super-Neutrosophic Sets, and SuperPlithogenic Sets, including their specialized variants like quadripartitioned, pentapartitioned, and heptapartitioned forms. The work serves as a consolidation of existing studies while highlighting potential directions for future research in hierarchical uncertainty modeling. Focusing on decision-making under uncertainty, the tweve chapter (Advanced SuperHypersoft and TreeSoft Sets) introduces six novel concepts: SuperHypersoft Rough Sets,SuperHypersoft Expert Sets, Bipolar SuperHypersoft Sets, TreeSoft Rough Sets, TreeSoft Expert Sets, and Bipolar TreeSoft Sets. Definitions, properties, and potential applications of these frameworks are explored to enhance the flexibility of soft set-based models. The final chapter (Hierarchical Uncertainty in Fuzzy, Neutrosophic, and Plithogenic Sets) provides a comprehensive survey of hierarchical uncertainty frameworks, with a focus on Plithogenic Sets and their advanced extensions: Hyperplithogenic Sets, SuperHyperplithogenic Sets. It examines relationships with other major concepts such as Intuitionistic Fuzzy Sets, Vague Sets, Picture Fuzzy Sets, Hesitant Fuzzy Sets, and multi-partitioned Neutrosophic Sets, consolidating their theoretical interconnections for modeling complex systems. This volume not only reflects the dynamic interplay between theoretical rigor and practical application but also serves as a beacon for future research in uncertainty modeling, offering advanced tools to tackle the intricacies of modern challenges. (shrink)

A large body of information and opinion related to COVID-19 is being shared via social media platforms. Recent reports have raised concerns about the reliability and verifiability of said information being disseminated and the way systems, processes and design of the platforms facilitates such spread. This, alongside other areas of concern, has resulted in several social media platforms taking steps towards tackling the spread of mis- and dis-information. Here we discuss approaches to online public health messaging from (...) a range of sources during COVID-19, with a focus on official and non-official sources in the United Kingdom. We highlight issues for ongoing public health decisions, and the potential impact for the future course of the pandemic. (shrink)

The precautionary principle brings a special challenge to the practice of evidence-based public health decision-making, suggesting changes in the interpretative methods of public health used to identify causes of disease. In this paper, precautionary changes to these methods are examined: including discounting contrary evidence, reducing the number of causal criteria, weakening the rules of evidence assigned to the criteria, and altering thresholds for statistical significance. All such changes reflect the precautionary goal of earlier primary preventive intervention, i.e. (...) acting on insufficient evidence, the least amount, or minimum level, of evidence for causation. Evaluating the impact of these changes will be difficult without a careful study of how well the current methods of causal inference work, their theoretical foundations, and the ethical implications of their applications. That research program will be most productive if it is jointly developed by public health professionals trained in the ethics and philosophy and by bioethicists and philosophers trained in the theories, methods, and practice of public health. (shrink)

Undertaking engagement in public health research is ethically essential. There is a growing emphasis on practicing engagement as the co‐construction of knowledge, which goes beyond other common forms of engagement in health research practice: consulting and informing. Taking such an approach means researchers jointly construct knowledge with research users and beneficiaries; all parties design and conduct research together and share decision‐making power. This article makes the normative argument that such engagement is necessary to achieve (...) the foundational moral aims of public health research—building relations of equality and addressing the health needs of those considered disadvantaged—which reflect the field's underlying commitment to social justice. It next identifies and discusses three ways in which co‐constructing knowledge advances those moral aims: by facilitating self‐determination, supporting individuals’ right to research, and maximizing social knowledge to address cognitive and epistemic injustice. Objections to the arguments presented in the article are then articulated and defended against. (shrink)

Biobanks’ activity is based not only on securing the technology of collecting and storing human biospecimen, but also on preparing formal documentation that will enable its safe use for scientific research. In that context, the issue of informed consent, the reporting of incidental findings and the use of Transfer Agreements remain a vast challenge. This paper aims to offer first–hand tangible solutions on those issues in the context of collaborative and transnational biobanking research. It presents a four‐step checklist (...) aiming to facilitate researchers on their compliance with applicable legal and ethical guidelines, when designing their studies, when recruiting participants, when handling samples and data, and when communicating research results and incidental findings. Although the paper reflects the outcomes of the H2020 B3Africa project and examines the transfers from and to the EU as a case study, it presents a global checklist that can be used beyond the EU. (shrink)

Background:The decision-making process should be done according to a set of rules and principles so as to be fairly understood.Objectives:The aim of this study was to identify the basic principles and rules used by nurses to understand justice in nurse managers’ decision-making processes based on a procedural justice model.Research design and participants:This research was a qualitative study based on directed content analysis, which was performed on a group of 15 nurses working in different hospitals in Tehran, (...) Iran. An in-depth semi-structured interview was used as the method of data collection for this study.Ethical consideration:This research has been approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences. The respondents were informed about the aim of the study, about voluntary participation, anonymity and confidentiality.Findings:The results of this study showed that in order to understand procedural justice, nurses use several rules, including: duties organization, managerial support, consistency, bias-suppression, accuracy, correctability, representativeness, and ethicality.Conclusion:Nursing leaders must consider the importance of justice rules as one of many strategies to ensure the nurses’ perception of fairness in decision-making processes. (shrink)

Intergenerational Relations - Contemporary Theories, Studies, and Policies, concentrates on actual discussions around various aspects of interactions that occur between people from different age groups and generations. The authors present studies related to four sets of challenges crucial for relationships between children, young adults, middle-aged adults, and older adults. These challenges include social and cultural challenges, economic and technological challenges, environmental challenges, and political and legal challenges. The volume also addresses issues important for the global, national, regional, and local (...) application and performance of intergenerational solutions, projects, and programs focused on achieving the United Nations Sustainable Development Goals (SDGs). The collection includes chapters encompassing research and practical recommendations from various disciplines such as demography, economics, ethics, management, gerontology, public health, pedagogy, social work, political science, and sociology. This book is an asset to academic and professional communities interested in theories of intergenerational relationships as well as public services and age-related policies. Moreover, the volume is a useful resource to help students, practitioners, and people working in government, business, and nonprofit organizations build positive and harmonious interactions between generations. (shrink)

Within the context of structural theories this paper examines what health professionals say about their clinical service structures. We firstly trace various conceptual perspectives on clinical service structures, discussing multiple theoretical axes. These theories question whether clinical service structures represent either superficial or more profound changes in hospitals. We secondly explore which view is supported though a content analysis of the free text responses of 111 health professionals (44 doctors, 45 nurses and 22 allied health practitioners) about their clinical service (...) structures in a questionnaire survey in two large hospitals that had implemented clinical service structures three years previously. Commentaries unfavourable toward clinical service structures were made by 47.7% of staff, favourable by 24.3%, mixed (both favourable and unfavourable) by 17.1% and non-evaluative statements were made by 10.8%. The most frequent criticisms were inefficient organisation of change (27%), poor management (24.3%), lack of cooperation between staff (15.9%) and failure to empower health practitioners (13.5%). All professions made more negative than positive evaluations of their clinical service structures but the ratio was highest for doctors and lowest for allied health. Ranking of nurses' and allied health staffs' specific evaluations were similar but both differed significantly from doctors.' Unfavourable or negative comments predominated, and change appears more superficial and less profound than advocates of structural contributions hope. Four types of belief systems about clinical service structures are apparent. Some study participants are disposed toward the status quo; others toward restructuring; yet others are team oriented; and a final group is tribally oriented. The implication of this paper for managers is that more work is needed if clinical service structures are to realise the promise of more multi-disciplinarity and less fragmentation across professional groups. For scholars, the implication is that marrying different theoretical frames with empirical data can serve to produce fresh perspectives and perhaps new insights. (shrink)

Uncertainty is a necessary condition for the sound moral and scientific conduct of research involving human subjects. If the expert scientific communities, medical or otherwise, lacked uncertainty about the interventions under investigation, it would be unethical to knowingly subject individuals to inferior or harmful treatment. Moreover, if the relative merits of the interventions were previously established, as indicated by the lack of uncertainty within the relevant expert community, the results of the trial would be of little, if (...) any, scientific value. Despite the important role that uncertainty plays in the formulation and conduct of research involving human subjects, the concept has received inadequate treatment in the research ethics literature. To the limited extent that uncertainty is addressed, much of the emphasis remains on the ethical, not epistemic, aspects of uncertainty. What is left insufficiently examined is the nature and scope of the uncertainty. Often, uncertainty is glossed as agnosticism, indifference, and conflict. Yet these terms represent distinct types of uncertainty, and the type that obtains impacts the epistemic and ethical justifications for a proposed trial. A failure to recognize and clearly articulate the parameters of uncertainty in particular situations compromises our ability to respond to important moral and scientific concerns in the development and conduct of research. This problem is particularly pronounced in public health research that investigates problems resulting not only from uncertainties in scientific knowledge but from institutional failures, economic and social constraints, and lack of political will. Indeed, the role of research in public health is tied to its capacities to successfully navigate such complex questions. The way in which a study is designed and carried out, as well as ethically and scientifically justified, must reflect a robust and systematic characterization of the uncertainties present. Using an example from a study examining the efficacy of using treated sewage sludgeto remediate lead-contaminated soil, I explore and analyze the aforementioned deficiencies in understanding uncertainty among researchers and ethicists. The case study serves as a vehicle through which to illustrate (1) important considerations in characterizing and addressing uncertainty; (2) the influence of the uncertainty characterization on the formulation of parameters used to evaluate the ethical permissibility of the research; and (3) ways in which these parameters might be operationalized in the context of a particular study. (shrink)

Psychiatry is rapidly adopting digital phenotyping and artificial intelligence/machine learning tools to study mental illness based on tracking participants’ locations, online activity, phone and text message usage, heart rate, sleep, physical activity, and more. Existing ethical frameworks for return of individual research results (IRRs) are inadequate to guide researchers for when, if, and how to return this unprecedented number of potentially sensitive results about each participant’s real-world behavior. To address this gap, we convened an interdisciplinary expert working group, (...) supported by a National Institute of Mental Health grant. Building on established guidelines and the emerging norm of returning results in participant-centered research, we present a novel framework specific to the ethical, legal, and social implications of returning IRRs in digital phenotyping research. Our framework offers researchers, clinicians, and Institutional Review Boards (IRBs) urgently needed guidance, and the principles developed here in the context of psychiatry will be readily adaptable to other therapeutic areas. (shrink)

Purpose This research aims to study the coping experience of visually impaired bankers in India after they have received reasonable accommodation from their employers, that is, the work process or environment has been suitably modified to ensure a barrier-free environment for them. Design/methodology/approach Data were collected through semi-structured interviews with 12 VI bankers working with public sector banks in India. A phenomenological approach was adopted during data analysis. Findings Despite the provision of reasonable accommodations, VI employees often find (...) it difficult to fulfill their job responsibilities. This is on account of extensive paperwork required for completion of their jobs and the partially accessible information systems available to them. As a result, these VI employees are found resorting to workarounds to carry out their jobs, with the nature of workarounds adopted varying with the type and extent of visual impairment. Furthermore, it is observed that VI employees require social support not only from their superiors and peers but also from their subordinates and customers to carry out their tasks. Research limitations/implications Data collection was done through snowball sampling which could have resulted in sampling bias. Due to confidentiality issues, observation of workarounds in practice by VI employees could not be carried out as part of the study. Originality/value The study contributes to the literature on integration of persons with disabilities by examining their coping experience after provision of reasonable accommodations. It emphasizes the role of workarounds, an under-studied area in PwD integration, as well as support of other stakeholders in the experience. (shrink)

This study investigated the beliefs that formed teachers’ intentions to integrate STEM content into their social studies instruction. Participants were 60 elementary, middle, and high school in-service teachers who attended a summer history workshop on Abraham Lincoln. Data were collected by qualitative and quantitative instruments. Beliefs about likely outcomes of integrating STEM, and beliefs about persons who would approve, or disapprove, of STEM integration were elicited from teachers, and content analyzed. The resulting outcome and normative beliefs were used as (...) stems for items in the quantitative instrument. Quantitative data were analyzed primarily by correlation and multiple regression. This study found that attitude toward the behavior, integrating STEM, was formed by 15 outcome beliefs, subjective norm was formed by five normative beliefs, and that attitude and norm predicted behavioral intention. The theory we used enabled us to calculate the numerical contribution of each of the beliefs that were important in forming teachers’ intentions. The results have implications for theory, research, and practice in social studies education. In the realm of practice, these implications are for the initial preparation of, and the subsequent professional development of social studies teachers, both at the elementary and secondary levels. (shrink)

Background Despite news reports of morally distressing situations resulting from complex and demanding community-care delivery in Canada, there has been little research on the topic of ethical conflicts experienced by community-based health care professionals. Research aim To identify ethical conflicts experienced by community nurses. Research design Data were collected using semi-structured interviews and then relevant text was extracted and condensed using qualitative content analysis. This research was part of a larger grounded theory project examining how community (...) nurses manage ethical conflict. Research context and participants Community nurses, including 13 public health nurses and 11 home care nurses from two Canadian provinces, were interviewed. Ethical considerations Study approval was granted by the Health Research Ethics Authority of Newfoundland and Labrador and by provincial health authorities. Findings Seven ethical conflicts were identified and assigned to one of two groups. In the grouping categorized as challenges with obligations or risks, the ethical conflicts were: (1) screening for child developmental issues knowing there is a lack of timely early intervention services; (2) encountering inequities in the health care system; (3) not fulfilling principles, goals, and initiatives of primary and secondary prevention; and (4) feeling powerless to advocate for clients. The remaining ethical conflicts were categorized as challenges with process, risks, and consequences, and were: (5) jeopardizing therapeutic relationships while reporting signs of a child at risk; (6) managing confidentiality when neighbors are clients; and (7) supporting client autonomy and decision-making but uncertain of the consequences. Conclusions Research investigation will continue to be important to raise awareness and mobilize ethics supports as health care services are steadily shifted from institutional to community settings. Moreover, with heightened potential for communicable disease outbreaks across international borders from global warming, community nurses around the world will continue to be required to address ethically-difficult care situations with competence and compassion. (shrink)

Background: Information sharing is one of the most important means of public health nurses collaborating with other healthcare professionals and community members. There are complicated ethical issues in the process. Research objectives: To describe the ethical dilemmas associated with client information sharing that Japanese public health nurses experience in daily practice and to clarify their decision-making process to resolve these dilemmas. Research design: Data were collected using a three-phase consensus method consisting of semi-structured interviews, self-administered (...) questionnaires and a group interview. Participants and research context: We surveyed administrative public health nurses in Shizuoka Prefecture, Japan. The semi-structured interviews were carried out with 12 administrative public health nurses, and the self-administered questionnaires were sent to all 899 administrative public health nurses. The group interview was carried out with eight administrative public health nurses. Ethical considerations: Ethical approval was granted by the ethics committee of the School of Health Sciences, Nagoya University, Japan (8-158, 9-130). Findings: Information-sharing ethical dilemmas occurred most often when clients’ decisions did not coincide with the nurses’ own professional assessments, particularly when they faced clinical issues that were inherently ambiguous. In their decision-making processes, nurses prioritised ‘protection of health and life’. Discussion: These findings suggest that, above all, they sought to address urgent risks to clients’ lives while upholding the principle of client autonomy as much as possible. In such cases, the nurses made decisions regarding whether to share information about the client depending on the individual situation. Conclusion: Public health nurses should protect the client’s health while taking into consideration their relationship with the client. (shrink)

Stem cell tourism is a small but growing part of the thriving global medical tourism marketplace. Much stem cell research remains at the experimental stage, with clinical trials still uncommon. However, there are over 700 clinics estimated to be operating in mostly developing countries – from Costa Rica and Argentina to China, India and Russia – that have lured many patients, mostly from industrialized countries, driven by desperation and hope, which in turn continue to fuel the growth of such (...) tourism.While much research has focused on such dimensions as the promotions that allow such businesses to make their services known, media coverage, some patient research, and regulatory conditions for developing country clinics, little attention has been paid to the non-affected members of the general population, the future potential users of such services. This empirical study based on five focus group discussions with a diverse group of healthy adults in a Canadian city, explored participant views of patients who use stem cell tourism services, the likelihood they would avail themselves of such services if they were to suffer similar illnesses, and the conditions under which they might do so, and the impact that admonitions and advice from international expert bodies might have on their decisions. Our findings suggest that these healthy adults are sympathetic to the drivers of hope and desperation, and, despite cautions about research limitations, may seek such treatments themselves under similar conditions. These findings are discussed in the context of the policy and ethical issues raised by this form of medical tourism. (shrink)