How far should we go in protecting and promoting public health? Can we force people to give up unhealthy habits and make healthier choices, or does everyone have the right to decide their own lifestyle? Should we stop treating smokers who refuse to give up smoking? Should we put a tax on fatty foods and ban vending machines in schools to address the obesity epidemic? Should parents be required to have their children vaccinated? Are some of our screening (...) programmes unethical Downs syndrome screening, for example or should we be screening people for more conditions, such as Huntington disease? Such questions are at the heart of public health ethics. Holland shows that to understand and debate these issues requires philosophy: moral philosophies, such as utilitarianism and deontology, as well as political philosophies such as liberalism and communitarianism. And philosophy informs other aspects of public health, such as epidemiology and health promotion. The aim of this book is to provide a lively, accessible and philosophically informed introduction to such issues. It is an ideal textbook for students taking courses in public health ethics. And since this book develops systematic discussions of issues in public health ethics, there is also much here to engage and challenge the more advanced reader. (shrink)

The psychosocial morbidity associated with HIV infection and responses to such infection may exceed morbidity associated with medical sequelae of such infection. This paper argues that negative judgements on those with HIV infection or in groups associated with such infection will cause avoidable psychological and social distress. Moral judgements made regarding HIV infection may also harm the common good by promoting conditions which may increase the spread of HIV infection. This paper examines these two lines of argument with regard (...) to the ethical aspects of psychological bases of health care, clinical contact, public perceptions of AIDS and the comparative perspective. It is concluded that the psychosocial aspects of HIV infection impose ethical psychological, as well as medical, obligations to reduce harm and prevent the spread of infection. (shrink)

“HTA is a multidisciplinary process that summarizes information about the medical, social, economic and ethical issues related to the use of a health technology in a systematic, transparent, unbiased, robust manner. Its aim is to inform the formulation of safe, effective, health policies that are patient focused, and seek to achieve best value” (EUnetHTA 2007). Even though the assessment of ethical aspects of a health technology is listed as one of the objectives of a HTA (...) process, in practice, the integration of these dimensions into reports remains limited. The article is focused on four points: 1. the HTA concept; 2. the difficult HTA-ethics relationship; 3. the ethical issues in HTA; 4. the methods for integrating ethical analysis into HTA. (shrink)

In recent years there has been increased recognition of the global burden of mental disorders, which in turn has led to the expansion of preventive initiatives at the community and population levels. The application of such public health approaches to mental health raises a number of important ethical questions. The aim of this collection is to address these newly emerging issues, with special attention to the principle of prevention and the distinctive ethical challenges in mental (...) health. The collection brings together an interdisciplinary group of experts in bioethics, mental health, public health, and global health. (shrink)

Despite progress, discrimination in public health remains a problem. A significant aspect of this problem relates to how medical resources are allocated. The paradigm of quality-adjusted-life-year (QALY) dictates that medical resources should be allocated on the basis of units measured as length of life and quality of life that are expected after the implementation of a treatment. In this article, I discuss some of the ethical shortcomings of QALY, by focusing on some of its flawed moral (...) aspects, as well as the way it relates to discrimination on the basis of age, race, and disability status. I argue that while this approach seeks to maximize efficiency, it does not place sufficient value on the preservation of life itself. Even more concerning is the fact that the use of QALY disproportionately harms minorities. While QALY is a well-intentioned approach to the allocation of scarce healthcare resources, new alternatives must be sought. (shrink)

Transparency has gained much attention in both public health and medical contexts. Alberto Giubilini, Rachel Gur-Arie and Euzebiusz Jamrozik make a valuable contribution to addressing the ethical question on the value and role of transparency by claiming that transparency is a necessary condition for the moral trustworthiness of experts. This comment is conceived as a follow-up on this issue. Usually, ethical discussions on transparency concern its consequentialist aspects such as the influence of disclosure on stakeholders’ (...) trust. However, as the author will claim, there is something morally significant and non-consequentialist at stake. The aim of the comment is to highlight two important aspects concerning transparency. Firstly, its role in public health ethics, and, secondly, the moral basis for this role. Regarding the former, the author will claim that transparency influences moral legitimacy of coercive public health policies. Regarding the latter, the author will claim that by being transparent, policymakers respect stakeholders as moral agents capable of reason. (shrink)

Given the need for organs, public organizations use social marketing strategies to increase the number of donors. Their campaigns employ a variety of moral appeals. However, their effects on audiences are unclear. We identified 14 campaigns in Germany from over the last 20 years. Our approach combined a multimodal analysis of categorized posters with a qualitative analysis of responses, collected in interviews or focus groups, of 53 persons who were either skeptical or undecided about organ donation. The combined (...) analyses revealed that the posters failed to motivate laypersons in general to donate, and were even less effective on skeptical or undecided individuals. We explain this in terms of the types of moral messages found on posters and the limits of such social marketing strategies. Furthermore, we discuss certain ethical aspects of organ donation campaigns pertaining to communicating norms and trust in public institutions. (shrink)

Should organ transplants be given to patients who have waited the longest, or need it most urgently, or those whose survival prospects are the best? The rationing of health care is universal and inevitable, taking place in poor and affluent countries, in publicly funded and private health care systems. Someone must budget for as well as dispense health care whilst aging populations severely stretch the availability of resources. The Ethics of Health Care Rationing is a clear (...) and much-needed introduction to this increasingly important topic, considering and assessing the major ethical problems and dilemmas about the allocation, scarcity and rationing of health care. Beginning with a helpful overview of why rationing is an ethical problem, the authors examine the following key topics: What is the value of health? How can it be measured? What does it mean that a treatment is "good value for money"? What sort of distributive principles - utilitarian, egalitarian or prioritarian - should we rely on when thinking about health care rationing? Does rationing health care unfairly discriminate against the elderly and people with disabilities? Should patients be held responsible for their health? Why does the debate on responsibility for health lead to issues about socioeconomic status and social inequality? Throughout the book, examples from the US, UK and other countries are used to illustrate the ethical issues at stake. Additional features such as chapter summaries, annotated further reading and discussion questions make this an ideal starting point for students new to the subject, not only in philosophy but also in closely related fields such as politics, health economics, public health, medicine, nursing and social work. (shrink)

Background: In Hospital Emergency Department and Emergency Medical Services professionals experience situations in which they face difficulties or barriers to know patient’s advance directives and implement them. Objectives: To analyse the barriers, facilitators, and ethical conflicts perceived by health professionals derived from the management of advance directives in emergency services. Research design, participants, and context: This is a qualitative phenomenological study conducted with purposive sampling including a population of nursing and medical professionals linked to Hospital Emergency Department and (...) Emergency Medical Services. Three focus groups were formed, totalling 24 participants. We performed an inductive-type thematic discourse analysis. Ethical considerations: This study was approved by ethical committees of Ethical Commitee of Clínic Hospital (Barcelona) and Comittee of Emergency Medical Services (Barcelona). The participants received information about the purpose of the study. Patients’ anonymity and willingness to participate in the study were guaranteed. Findings: There were four types of barriers that hindered the proper management of patients’ advance directives in Hospital Emergency Department and Emergency Medical Services: personal and professional, family members, organisational and structural, and those derived from the health system. These barriers caused ethical conflicts and hindered professionals’ decision-making. Discussion: These results are in line with those of previous studies and indicate that factors such as gender, professional category, and years of experience, in addition to professionals’ beliefs and the opinions of colleagues and family members, can also influence the professionals’ final decisions. Conclusion: The different strategies described in this study can contribute to the development of health policies and action protocols to help reduce both the barriers that hinder the correct management and implementation of advance directives and the ethical conflicts generated. (shrink)

Brain-Computer Interface is a set of technologies that are of increasing interest to researchers. BCI has been proposed as assistive technology for individuals who are non-communicative or paralyzed, such as those with amyotrophic lateral sclerosis or spinal cord injury. The technology has also been suggested for enhancement and entertainment uses, and there are companies currently marketing BCI devices for those purposes as well as health-related purposes. The unprecedented direct connection created by BCI between human brains and computer hardware raises (...) various ethical, social, and legal challenges that merit further examination and discussion. To identify and characterize the key issues associated with BCI use, we performed a scoping review of biomedical ethics literature, analyzing the ethics concerns cited across multiple disciplines, including philosophy and medicine. Based on this investigation, we report that BCI research and its potential translation to therapeutic intervention generate significant ethical, legal, and social concerns, notably with regards to personhood, stigma, autonomy, privacy, research ethics, safety, responsibility, and justice. Our review of the literature determined, furthermore, that while these issues have been enumerated extensively, few concrete recommendations have been expressed. We conclude that future research should focus on remedying a lack of practical solutions to the ethical challenges of BCI, alongside the collection of empirical data on the perspectives of the public, BCI users, and BCI researchers. (shrink)

Intrinsic value and animal integrity are two key concepts in the debate on the ethics of the genetic engineering of laboratory animals. These concepts have, on the one hand, a theoretical origin and are, on the other hand, based on the moral beliefs of people not directly involved in the genetic modification of animals. This ‘external’ origin raises the question whether these concepts need to be adjusted or extended when confronted with the moral experiences and opinions of people (...) directly involved in the creation or use of transgenic laboratory animals. To answer this question, 35 persons from the practice of biomedical research who are directly involved in genetic engineering (scientists, biotechnicians, animal caretakers and laboratory animal scientists) were interviewed. They were asked to give their moral opinion on different aspects of the genetic engineering of animals and to react to statements about the concepts of intrinsic value and animal integrity. Analysis of the interviews showed that, contrary to what is often assumed, the respondents embraced these concepts, even those senses that (more) specifically apply to genetic engineering. And although the respondents raised some objections that go beyond issues of animal welfare, these objections could quite well be expressed in terms of the concepts of intrinsic value and animal integrity. In short, the results of the present study strongly suggest that these concepts do not have to be adjusted or extended in the light of the moral experiences and opinions from practice. (shrink)

A lot of interest has been generated by the possibility of deriving gametes from embryonic stem cells and bone marrow stem cells. These stem cell derived gametes may become useful for research and for the treatment of infertility. In this article we consider prospectively the ethical issues that will arise if stem cell derived gametes are used in the clinic, making a distinction between concerns that only apply to embryonic stem cell derived gametes and concerns that are also relevant (...) for gametes derived from adult stem cells. At present, it appears preferable to use non-embryonic stem cells for the derivation of gametes. Adult stem cell derived gametes do not present any problems with regard to the moral status of the human embryo, bypass the safety risks linked to SCNT and do not present any ambiguity or novel problems with regard to informed consent, psychological consequences for the child or genetic parenthood. A remaining ethical concern, however, regards the safety of the procedure in terms of the welfare of the resulting children. This should spark a thorough reflection on how far one must go to accommodate a person’s wish to have a genetically related child. (shrink)

Tuberculosis is a major global public health challenge, and a majority of countries have adopted a version of the global strategy to fight Tuberculosis, Directly Observed Treatment, Short Course (DOTS). Drawing on results from research in Ethiopia and Norway, the aim of this paper is to highlight and discuss ethical aspects of the practice of Directly Observed Treatment (DOT) in a cross-cultural perspective.

Diminishing resources seem to be forcing rationing of medical services. Rationing the public health care system means that there needs to be ethical discussion on justice. Several years before resource allocation could impact on the levels of morbidity and mortality, economic problems created numerous methods of regulating medical and nursing services. In clinical practice, regularisation means a reduction of the possibility to decide autonomously and therefore requires specific ethical discussion. The different methods of regularisation from standards (...) and quality control to managed care are discussed with respect to their influence on medical thinking and decision making. Formalised decisions in severe disease can also be a field for regularisation, for example guidelines on the termination of life sustaining treatment (vs. Do-Not-Attempt-Resuscitation Orders). The debate on futility is discussed as a part of the economic discussion, with special regard to the impact of the macroeconomic situation on ”peripheral” medical decisions, which very often are made unconsciously, as shown by a new German study. It is impossible to discuss the influence of macroeconomy, different attempts at regularisation and the individual decision of the doctor without reflecting on their principle interdependency. Ethical reflection in this field cannot be sectioned into an economic, medical decision-making and futility sections. (shrink)

Public health nursing is grounded in public health ideologies and fundamental nursing values. Researchers have argued that ethical responsibility from the perspective of the nurse is an understudied phenomenon. This meta-ethnography provides in-depth knowledge of how public health nurses (PHNs) experience ethical responsibility when working to prevent injury and disease, and promote health and well-being in children, young people and their families. There are reciprocal findings across the 10 included studies. The (...) findings reveal that these nurses often feel alone, have worries and uncertainties and are afraid of doing wrong. They describe unclear boundaries in their work, creating a heightened sense of responsibility. PHNs fight lonely battles. Yet they show courage and commitment and are ready to stand up and fight for children and families who do not receive adequate care. A line of argument is developed and the metaphorical phrase Chivalrous knights in moral armour is used to express the authors’ overall interpretations of the findings. Reflection on the findings shows how the different dimensions of ethical responsibility are interconnected. The nurses’ ethical sensitivity enables them to feel compassion for others and they show indignation when vulnerable others are not treated with dignity and respect. Indignation and compassion are interrelated, and when human life and dignity are threatened, the ethical demand to respond emerges. Indignation is a precursor to moral courage, and the nurses’ moral sensitivity and respect for their clients emboldens them to stand up for vulnerable others. The findings also illustrate the paradoxical nature of freedom. Freedom of choice due to unclear boundaries heightens the nurses' sense of responsibility. This research is an important step in theory development and has implications for further research, education and practice. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Public Health Ethics: Health by the NumbersMartina Darragh (bio) and Pat Milmoe McCarrick (bio)Hippocrates had nothing to say about public health. Rather, the idea that a government should protect its citizens from disease by maintaining sanitary conditions has its origin in Renaissance humanities texts, and the notion that physicians have public health responsibilities emerged in the works of such Enlightenment authors as (...) Johann Peter Frank, Benjamin Rush, and John Gregory (II, Coughlin and Beauchamp 1996). When the spread of infectious diseases such as typhoid and cholera accompanied the growth of the Industrial Revolution, England was the first to respond by passing the Public Health Act of 1848. The motivation for this reform was not based in humanitarian concerns but in the realization that unsanitary conditions were costly to industry. “... [The] founders of the public health movement were guided by nineteenth century utilitarian moral theories... the greatest good for the greatest number... accompanied by a growing appreciation for the innate value and dignity of mankind... however, the rights and autonomy of individuals have not always been respected in pursuing these important objectives” (I, Coughlin 1995, p. 1).Public health projects have dramatically improved global health status. One measure of their success is that “... most poor people now live longer, on average, than the wealthiest people a century ago” (I, Beaglehole and Bonita 1997, p. 13) These projects are not limited to such activities as disinfecting sewers. “Public health is what we, as a society, do to collectively assure the conditions in which people can be healthy. This requires that continuing and emerging threats to the health of the public be successfully countered. These threats include immediate crises, such as the AIDS epidemic; enduring problems, such as injuries and chronic illness; and impending crises foreshadowed by such developments as the toxic by-products of a modern economy” (I, Institute of Medicine (IOM) 1988, p. 1) The practice of public health has embraced this IOM challenge and includes the subspecialties of epidemiology, health promotion and education, public health administration, international health, maternal and child health, biostatistics, environmental health, and nutrition. This annotated bibliography focuses on epidemiology, [End Page 339] health promotion and education, and public health administration, and includes a wide variety of opinions on each topic.EpidemiologyAt first glance, it is hard to see what ethical issues could arise in population studies of the causes and control of illness. Disclosure of risk information in the clinical encounter is complicated by issues of uncertainty with regard to the data itself. Causation and causal inference may be affected by “wish bias,” leading to studies that use the same data but reach widely varying conclusions (II, Weed 1997). Given the complexity of the statistical calculations used to validate public health recommendations, and mass media’s portrayal of them, the public may be unintentionally deceived by population-based recommendations (V, Seedhouse 1997; II, Lupton 1995). With the addition of genetic screening, another layer of statistical complexity is added to this mix (VI, Stone and Steward 1996).Health Promotion and EducationIncreased life expectancy brought about by advances in public health has raised a new set of problems. With the realization that illness can be promoted in part by individual life-style choices, population-based recommendations about risk factors become important in the clinical encounter. This shift is not without difficulties; one author notes that he has yet to receive any risk information from his physicians, even when he asks “the experts” (V, Dugdale 1998). This may be due in part to the fact that “... public health lacks a vocabulary with which to speak about and identify commonalities among health problems experienced by very different populations” (IV, Mann 1997, p. 8). Furthermore, the mix of disciplines informing health promotion activities (sociology, psychology, recreation medicine, and the like) creates an illusion of shared ethics where none exists, which in turn leads to programs based on value systems that may not be meaningful for the populations they serve (V, Seedhouse 1997).Given these factors, a number of authors are skeptical of introducing public health measures into the clinical encounter. “We might do well to encourage people to live lives of modified hedonism so that they might... (shrink)

Background: A predictive genetic test for Huntington’s disease can be used before any symptoms are apparent, but there is only sparse knowledge about the long-term consequences of a positive test result. Such knowledge is important in order to gain a deeper understanding of families’ experiences. Objectives: The aim of the study was to describe a young couple’s long-term experiences and the consequences of a predictive test for Huntington’s disease. Research design: A descriptive case study design was used with a longitudinal (...) narrative life history approach. Participants and research context: The study was based on 18 interviews with a young couple, covering a period of 2.5 years; starting 6 months after the disclosure of the test results showing the woman to be a carrier of the gene causing Huntington’s disease. Ethical considerations: Even though the study was extremely sensitive, where potential harm constantly had to be balanced against the benefits, the couple had a strong wish to contribute to increased knowledge about people in their situation. The study was approved by the ethics committee. Findings: The results show that the long-term consequences were devastating for the family. This 3-year period was characterized by anxiety, repeated suicide attempts, financial difficulties and eventually divorce. Discussion: By offering a predictive test, the healthcare system has an ethical and moral responsibility. Once the test result is disclosed, the individual and the family cannot live without the knowledge it brings. Support is needed in a long-term perspective and should involve counselling concerning the families’ everyday life involving important decision-making, reorientation towards a new outlook of the future and the meaning of life. Conclusion: As health professionals, our ethical and moral responsibility thus embraces not only the phase in direct connection to the actual genetic test but also a commitment to provide support to help the family deal with the long-term consequences of the test. (shrink)

LANGUAGE NOTE | Document text in English ; abstract also in Chinese. 本文介紹生物倫理學與公共健康倫理學領域，並描述兩者之間的關係；文章尾聲將展望公共健康倫理學論未來既廣泛又多變的方向。本文首先簡介公共健康倫理學的本質，以及如何把其與比之更廣闊的生物倫理學作出區分，因此 需要提出公共健康倫理學的定義，以助釐清公共健康倫理的重點。隨後，本文簡述公共健康倫理學文獻的一些最新進展，包括圍繞新冠病毒、大流行病、抗菌素抗藥性、「生活方式」疾病及正義等道德問題。本文同時論及就干預 公共健康的「合法範圍」所提出的觀點之間於政治及形而上學的角力。其後本文探討公共健康倫理學所面臨的挑戰，包括其複雜又多元的性質。而且公共健康實踐高度政治化，其政治化的原因是因為公共健康影響整個人口及社區 ，而很多關於公共健康的決策由政治人物而非公共健康專家所作出。此外，公共健康倫理也因為公共健康的範圍擴展至納入非政府公共健康行動者而面臨進一步的挑戰。本文最後闡述有關公共健康的一些未來方向，包括「公共健 康觀」的出現，以作為為人熟知的健康與社會問題的形而上學框架、把該領域的認知和道德基礎去殖民化以涵蓋更廣泛的知識，以及一些包括美德在内的公共健康倫理學的理論發展。筆者建議讀者把文章視為對公共健康倫理學領 域的一部分介紹，並鼓勵他們閲讀本文所引用的論文，並以這些論文作為進入所涵蓋主題的大量文獻之門徑。公共健康倫理學是一個相對年輕的領域，而該領域有著巨大的成長及發掘更多新概念的潛力。 This essay begins by introducing the fields of bioethics and public health ethics and describing the relationship between them. It ends with some glimpses into the wide-ranging and discourse-changing directions of the literature on public health ethics. To open, the paper describes the field of public health ethics and how it is differentiated from the wider field of bioethics. This requires a (...) brief description of public health to clarify the nature of public health ethics. The essay then provides a brief overview of a few recent developments in the public health ethics literature, including the moral issues raised by COVID-19 and pandemics, anti-microbial resistance, ‘lifestyle’ diseases and justice. The paper also touches on the political and metaphysical tensions in views on what counts as a ‘legitimate area’ of intervention for public health. The essay then turns to a couple of challenges in the field of public health ethics, specifically the complex and multi-disciplinary nature of the field and the fact that public health practice is a highly political area. Public health is political both in the sense that it affects entire populations or communities and in the sense that many decisions about public health are made by politicians rather than public health experts. A further challenge to public health ethics is the question of what counts as ‘public health’, as the scope has been broadened to include non-governmental public health actors. Finally, the essay describes some future directions for research in public health ethics, including ‘public health view’ becoming a metaphysical framing for familiar health and social issues and decolonising the epistemic and moral foundations of the field to include a wider set of knowledge sources and values. There are also some theoretical developments that integrate virtue into public health ethics. The reader should take this essay as a partial introduction to the field, and they are highly encouraged to read the papers that are cited here and to use those papers as a gateway into the large literature on the topics covered. Public health ethics is a relatively young field, with an enormous potential for growth and new ideas. (shrink)

The vision of legendary criminologist Cesare Lombroso to use scientific theories of individual causes of crime as a basis for screening and prevention programmes targeting individuals at risk for future criminal behaviour has resurfaced, following advances in genetics, neuroscience and psychiatric epidemiology. This article analyses this idea and maps its ethical implications from a public health ethical standpoint. Twenty-seven variants of the new Lombrosian vision of forensic screening and prevention are distinguished, and some scientific and technical (...) limitations are noted. Some lures, biases and structural factors, making the application of the Lombrosian idea likely in spite of weak evidence are pointed out and noted as a specific type of ethical aspect. Many classic and complex ethical challenges for health screening programmes are shown to apply to the identified variants and the choice between them, albeit with peculiar and often provoking variations. These variations are shown to actualize an underlying theoretical conundrum in need of further study, pertaining to the relationship between public health ethics and the ethics and values of criminal law policy. (shrink)

This paper proposes that public health is the sort of institution that has a role in producing structures of virtue in society. This proposal builds upon work that describes how virtues are structured by the practices of institutions, at the collective or whole-of-society level. This work seeks to fill a gap in public health ethics when it comes to virtues. Mainstay moral theories tend to incorporate some role for virtues, but within public health (...) ethics this role has not been fully articulated. Two recent papers have proposed ways in which the virtues might be incorporated: working from a structural account, Rozier suggests that public health could work to instil virtues, like temperance, in the public in order to achieve its health-related goals; Nihlén Fahlquist suggests that compassion is among three virtues that practitioners of public health should cultivate in order to do their work well. In the end, both accounts recommend incorporating virtues at the level of individuals, among the public and among practitioners. I propose a third kind of role for virtue in public health that focuses on structures. Public health activities take place at the population level, and a public health virtue ethics must also be suitably population-focussed. (shrink)

This article argues that governments in countries that currently permit intensive animal agriculture - especially but not exclusively high-income countries - are, in principle, morally justified in taking steps to restrict or even eliminate intensive animal agriculture to protect public health from the risk of zoonotic pandemics. Unlike many extant arguments for restricting, curtailing, or even eliminating intensive animal agriculture which focus on environmental harms, animal welfare, or the link between animal source food (ASF) consumption and noncommunicable disease, (...) the argument in this article appeals to the value of protecting populations from future global health emergencies and their broad social, economic, and health impacts, taking the SARS-CoV-2 virus as a particularly salient example. The article begins by identifying how intensive animal agriculture contributes to the outbreak (and risk of future outbreaks) of zoonotic diseases. Next, we explore three specific policy options: 1. Incentivizing plant-based and cell-based ASF alternatives through government subsidies; 2. Disincentivizing intensive ASF production through the adoption of a “zoonotic tax”; and 3. Eliminating intensive ASF production through a total ban. We argue that all three of these measures are permissible, although we remain agnostic as to whether these measures are obligatory. We argue for this conclusion on the grounds that each measure is justified by the same sorts of considerations that justify other widely accepted public health interventions, and each is compatible with a variety of theories of justice. We then address potential objections. Finally, we discuss how our novel argument relates to extant ethical arguments in favor or curtailing ASF production and consumption. (shrink)

This qualitative study was designed to explore ethical issues in public health nursing in the Canadian context, and to begin to identify strategies to support ethical practice. Twenty-two public health nurses, 11 in rural and 11 in urban settings, were asked to describe ethical problems they had experienced in the course of their work. These participants most often described situations that required a relational response rather than an active choice between options. Their goal (...) was to optimize the good, while at the same time maintaining a supportive relationship. Analysis revealed five interrelated themes, each with several subthemes: relationships with health care professionals; systems issues; character of relationships; respect for persons; and putting self at risk. It was clear that all aspects of public health nursing have ethical components. (shrink)

Consulting the public about the ethical approaches underlying health policies can seem an appealing means of addressing concerns about limited public participation in development of health policy. However ambiguity surrounds questions of whether, or how consultation can really contribute to more defensible decisions about ethical aspects of policy. This paper clarifies the role and limits of public consultation on ethics, beginning by separating different senses of defensibility in decisions on ethics. Defensibility of (...) class='Hi'>ethical decisions could be understood either in the sense of legitimacy in virtue of reflecting the opinions of the public whose interests are affected, or in the sense of being able to withstand and respond to challenges presented in ethical debate. The question then is whether there are forms of consultation which have the potential to realise more defensible decisions in either of these senses. Problems of adequately accounting for the views of those affected by policy decisions casts doubt on the plausibility of using consultation as a means of determining the opinions of the public. Consultation can have a role by bringing new ideas and challenges to debate, although it is uncertain whether this will increase the defensibility of any decision on ethics. (shrink)

Ethical guidelines for conducting clinical trials have historically been based on a perceived therapeutic obligation to treat and benefit the patient-participants. The origins of this ethical framework can be traced to the Hippocratic oath originally written to guide doctors in caring for their patients, where the overriding moral obligation of doctors is strictly to do what is best for the individual patient, irrespective of other social considerations. In contrast, although medicine focuses on the health of the (...) person, public health is concerned with the health of the entire population, and thus, public health ethics is founded on the societal responsibility to protect and promote the health of the population as a whole. From a public health perspective, research ethics should be guided by giving due consideration to the risks and benefits to society in addition to the individual research participants. On the basis of a duty to protect the population as a whole, a fiduciary obligation to realise the social value of the research and the moral responsibility to distribute the benefits and burdens of research fairly across society, how a public health perspective on research ethics results in fundamental re-assessments of the proper course of action for two salient topical issues in research ethics is shown: stopping trials early for reasons of efficacy and the conduct of research on less expensive yet less effective interventions. (shrink)

The purpose of this study was to describe the extent to which nurses perceive the ethical dimensions of clinical practice situations involving patients, families and health care professionals. Using the composite theory of basic moral principles and the professional standard of care established by legal custom as a framework, situations involving ethical dilemmas were gleaned from the nursing literature. They were reviewed for content validity, clarity and representativeness in a two-stage process by expert panels. The situations (...) were presented in a written format to a convenience sample of nurses (n = 125), who were primarily staff nurses (65.6%). Respondents' judgements about whether the main issue of each situation concerned ethics ranged from a low of 0.8% to a high of 40%. From analyses of the categories into which the majority of subjects placed each situation, it was concluded that these nurses generally perceived ethics as the main issue in situations that directly involve patients' autonomy. Analysis yielded unanticipated findings about the themes in ethical situations to which nurses in practice may respond. (shrink)

Over the last decade, successive New Zealand governments have instituted social, political and economic changes that have fundamentally challenged nurses’ sense of themselves and their position in society. Major upheavals in the health service have occurred as a result of reforms promoting competition and contestability. This paper deals with the impact of one aspect of the reforms, that of the deregulation of the labour market through the Employment Contracts Act 1991. More specifically, the way in which discussions and decisions (...) regarding the withdrawal of nursing labour are shaped by the language available to those involved are considered. The intersection of ethics and union discourses may exacerbate feelings of ambiguity and confusion in nurses facing strike action. The result can be unnecessary and unproductive division and conflict: among nurses, between employers and employees, between unions, between nurses and the public, and between nursing organizations and the Government. An examination of some of the discourses of strike action may serve as a tool to elucidate the way nurses see themselves and their clients in the context of social change and social action. (shrink)

Obesity has been described as pandemic and a public health crisis. It has been argued that concerted research efforts are needed to enhance our understanding and develop effective interventions for the complex and multiple dimensions of the health challenges posed by obesity. This would provide a secure evidence base in order to justify clinical interventions and public policy. This paper critically examines these claims through the examination of models of public health and public (...) health ethics. I argue that the concept of an effective public health intervention is unclear and underdeveloped and, as a consequence, normative frameworks reliant on meeting the effectiveness criterion may miss morally salient dimensions of the problems. I conclude by arguing for the need to consider both an ecological model of public health and inclusion of a critical public health ethics perspective for an adequate account of the public health challenges posed by obesity. (shrink)

Introduction : a framework for public health ethics -- Moral considerations : bases and limits for public health -- The political and legal context of public health ethics -- Public health perspectives -- Surveillance and public health data : the foundation and eyes of public health -- Case finding : screening, testing, and tracing -- Immunization : protection through vaccination -- Containing communicable diseases : personal control measures (...) -- Health communication -- Public health and the environment. (shrink)

ABSTRACT As bioethics emerged in the 1960s and 1970s and began to have enormous impacts on the practice of medicine and research – fuelled, by broad socio‐political changes that gave rise to the struggle of women, African Americans, gay men and lesbians, and the antiauthoritarian impulse that characterised the New Left in democratic capitalist societies – little attention was given to the question of the ethics of public health. This was all the more striking since the core values (...) and practices of public health, often entailing the subordination of the individual for the common good, seemed opposed to the ideological impulses of bioethics. Of what relevance is autonomy‐focused bioethics for public health, with its mix of justifications including those that are either implicitly or explicitly paternalistic or that seek to impose strictures on individuals and communities in the name of collective welfare? To examine the deep divide between the central commitments of bioethics and the values that animate the practice of public health, we focus on a series of controversies implicating the concepts of privacy, liberty, and paternalism. Recognising the role of moral values in decision‐making was a signal contribution of bioethics in its formative period. Over the past three decades a broad array of perspectives emerged under the rubric of bioethics but individualism remains central. As we commence the process of shaping an ethics of public health, it is clear that bioethics is the wrong place to start when thinking about the balances required in defence of the public's health. (shrink)

Introduction -- 1. General obligations. Conflicts of interest -- Uncompensated work -- Community service -- Pro bono work -- Living conditions -- Working conditions -- Layoffs -- Unequal pay -- 2. Obligations to the public. Repressive governments -- Corrupt politicians -- Public officials -- Public opinion -- Public bailouts -- Public reviews -- Public health -- Cultural differences -- 3. Obligations to the client. Self-destructive behavior -- Distrustful behavior -- Dishonest behavior -- Deceptive (...) behavior -- Spendthrift behavior -- Solicitous behavior -- Unrealistic expectations -- Manipulative situations -- 4. Obligations to the profession. Greed -- Insensitivity -- Jealousy -- Betrayal -- Treachery -- Unfairness -- Uncertainty -- Cheating -- 5. Obligations to colleagues. Office affairs -- Working hours -- Labor law violations -- Crediting coworkers -- Accommodating disabilities -- Firm bankruptcy -- Firm loyalties -- Untrustworthy colleagues -- 6. Obligations to the environment. Environmental hypocrisy -- Environmental conflicts -- Contextual conflicts -- Social justice -- Future generations -- Other species -- Reducing waste -- Reducing consumption -- Why ethics matters now. (shrink)

Many ethical issues are posed by public health interventions. Although abstract theorizing about these issues can be useful, it is the application of ethical theory to real cases which will ultimately be of benefit in decision-making. To this end, this paper will analyse the ethical issues involved in Childsmile, a national oral health demonstration programme in Scotland that aims to improve the oral health of the nation's children and reduce dental inequalities through a (...) combination of targeted and universal interventions. With Scotland's level of dental caries among the worst in Europe, Childsmile represents one of the largest programmes of work aimed at combating oral health inequalities in the UK. The areas of ethical interest include several contrasting themes: reducing health inequalities and improving health; universal and targeted interventions; political values and evidence base; prevention and treatment; and underlying all of these, justice and utility. (shrink)

The least infringement principle has been widely endorsed by public health scholars. According to this principle, public health policies may infringe upon “general moral considerations” in order to achieve a public health goal, but if two policies provide the same public health benefit, then policymakers should choose the one that infringes least upon “general moral considerations.” General moral considerations can encompass a wide variety of goals, including fair distribution of (...) burdens and benefits, protection of privacy and confidentiality, and respect for autonomy.In this article, we argue that the Center for Disease Control and Prevention's 2006 HIV screening recommendations may violate the least infringement principle. This is a concern because, although not legally binding, the Recommendations appear to have already influenced state laws and will likely continue to do so as legislative proposals continue to be passed. At a minimum, therefore, the Recommendations have important implications for HIV screening within the United States. (shrink)

The recent Covid-19 pandemic has brought a broad range of ethical problems to the forefront, raising fundamental questions about the role of government in response to such outbreaks, the scarcity and allocation of health care resources, the unequal distribution of health risks and economic impacts, and the extent to which individual freedom can be restricted. In this clear introduction to the topic Iwao Hirose explores these ethical questions and analyzes the central issues in the ethics of (...) pandemic response and preparedness such as: The general nature of pandemics and the ethics of preparedness Ethical questions about general goals of pandemic response and preparedness The distribution of scarce resources, e.g., ventilators, hospital beds, antiviral drugs and vaccines Restrictions on individual freedom Ethical questions in the wake of pandemics, including contact-tracing, vaccine passports and socioeconomic inequalities. With the use of real-life examples and a clear philosophical approach, The Ethics of Pandemics is a much-needed introduction to some of the most important ethical issues surrounding pandemics. It is essential reading for students of ethics, bioethics, and political philosophy and will also be of interest to those working in related areas such as public policy, public health, health law, nursing and life sciences. (shrink)

The health care systems are fairly similar in theScandinavian countries. The exact details vary, but inall three countries the system is almost exclusivelypublicly funded through taxation, and most (or all)hospitals are also publicly owned and managed. Thecountries also have a fairly strong primary caresector (even though it varies between the countries),with family physicians to various degrees acting asgatekeepers to specialist services. In Denmark most ofthe GP services are free. For the patient in Norwayand Sweden there are out-of-pocket co-payments for (...) GPconsultations, with upper limits, but consultations forchildren are free. Hospital treatment is free inDenmark while the other countries use a system without-of-pocket co-payment. There is a very strongpublic commitment to access to high quality healthcare for all. Solidarity and equality form theideological basis for the Scandinavian welfare state.Means testing, for instance, has been widely rejectedin the Scandinavian countries on the grounds thatpublic services should not stigmatise any particulargroup. Solidarity also means devoting specialconsideration to the needs of those who have lesschance than others of making their voices heard orexercising their rights. Issues of limited access arenow, however, challenging the thinking about a healthcare system based on solidarity. (shrink)

There is growing interest in using non-coercive interventions to promote and protect public health, in particular "health nudges." Behavioral economist Richard Thaler and law scholar Cass Sunstein coined the term nudge to designate influences that steer individuals in a predetermined direction by activating their automatic cognitive processes, while preserving their freedom of choice. Proponents of nudges argue that public and private institutions are entitled to use health-promoting nudges because nudges do not close off any options. (...) Opponents reply that the nudgee has no opportunity to deliberate over her choice. The nudger controls the nudgee, who has no real freedom of choice. -/- In my dissertation, I salvage the concept of nudge from the charge that it merely pays lip service to freedom of choice, offer an alternative account of the moral import of nudges for the evaluation of public health policies, and provide an ethical framework for their justified use. -/- My argument proceeds in four steps. First, I argue that nudging mechanisms often involve some form of incomplete deliberation, and do not always bypass deliberation. Second, I maintain that nudges preserve freedom of choice because they preserve the choice-set and are substantially noncontrolling. I show that the debate over nudges is plagued by confusion between real nudges, which are easily resistible and therefore substantially noncontrolling, and influences that are not easily resistible yet activate the same cognitive mechanisms as nudges. Third, I reject the view that nudges are systematically preferable to more controlling influences, even when they interfere with non-consequential liberties. I show that the principle of the least restrictive alternative often invoked in public health ethics is applied with too wide a scope. Fourth, I argue that paternalism is not central to the ethics of public health nudges. Rather, the substantive problem with nudges is that their overall cumulative effect might weaken our decisional capacities or undermine their proper exercise. This is a reason to limit recourse to certain nudges. I finally show, contra certain Kantians and Millians, that we have no perfect duty to engage or enhance decisional capacities. (shrink)

In Brazil, the epicenter of the Zika crisis, brown, black, and indigenous poor women living in municipalities with scarce resources were disproportionally affected. The gendered consequences of the epidemic exposed how intersectional lenses are central to understand the impact of public health emergencies in the lives of women and girls. The demand for Zika-affected children and women to be research participants is relevant for an ethical analysis of participant protection procedures during a crisis. We investigated how women (...) experienced research participation by analyzing their narratives. Two-year-long longitudinal qualitative study in Brazilian sites located in the epidemic's epicenter was performed using mixed methods: ethnography with women from two distinct states and individual semi-structured interviews with five women in different Zika-affected states, four of which were community leaders. All women in the study were mothers or grandmothers of Zika-affected children. Thematic analysis was used for data evaluation. Women perceived being pressured to participate in research and a lack of benefit sharing. Structural determinants of gender inequality, such as its effect on power distribution, were found to impact research participant protection. Formal procedures for research protocols approvals were insufficient in protecting participants because these instruments were unable to account for structural aspects. Communitarian mobilization, through WhatsApp groups, was found to be an important mechanism to create conditions to challenge oppressive structures. Strengthening public health, effective community-based participation in research planning and implantation of ethical strategies that promotes gender equality can have transformative effect on unequal power structures and promote participant protection. (shrink)

This paper aims to search the question ‘whether the ethical issues of infectious disease, which has been so long considered as a problem in the discipline of bioethics, can be brought under the purview of public health ethics’. To explore the problem I begin with a brief description of the evolution of bioethics. I elaborate the six reasons of neglecting the discussion of infectious diseases in early bioethics as highlighted by Selgelid (2005). Then I analyse the view (...) of Bayer and Fairchild (2004) that how infectious diseases by its own ethical questions, make the shift from the autonomy-centred bioethics to common welfare focused public health ethics. However, I would like to conclude that although the ethical discussion of infectious diseases makes a moral shift from the discipline of bioethics to public health ethics, the latter should not always be solely guided by the principle of beneficence to avoid harm for the sake of community welfare. Public health ethics needs to be guided by the balance of the four biomedical principals, such as beneficence, nonmaleficence, autonomy, and justice. (shrink)

This book explores the ethical implications of managing uncertainty in clinical decision-making during the COVID-19 pandemic. It develops an ethics of clinical uncertainty that brings together insights from the clinical and biomedical ethical literatures. The book sets out to recognize the central role uncertainty plays in clinical decision-making and to acknowledge the different levels, kinds, and dimensions of clinical uncertainty. It also aims to aid clinicians and patients in managing clinical uncertainty, and to recognize the ethical duty (...) they have to manage clinical uncertainty. The book addresses four ethical duties related to clinical uncertainty: (1) the duty to advance the welfare of those in clinical medicine, (2) to respect the rights of those in clinical medicine, (3) to promote just access to health care, and (4) to care for one another in clinical medicine. These duties took on select urgency during the COVID-19 pandemic because clinical risk assessments about COVID-19 were limited, we were asked to give informed consent in the context of limited and changing knowledge, the pandemic unearthed myriad problems about the distribution of health care, and the pandemic raised questions about how we care for each other in medicine. An Ethics of Clinical Uncertainty will appeal to scholars, advanced students, and medical professionals working in philosophy of medicine, biomedical ethics, clinical medicine, nursing, public health care, and gerontology. (shrink)

This study aimed to examine the thoughts and expectations of patients receiving healthcare from their physicians and evaluate the ethical aspects of these thoughts and expectations. To determine the ethical aspects of the thoughts and expectations of patients, an open-ended question was asked on the web page of the Turkish Armed Forces (TAF) Health Care Command, which is accessible to the users of the TAF intranet system (the internet system used within TAF institutions). The participants were asked (...) to express their thoughts in their own words. A total of 804 participants answered the question by providing their input. The statements of the participants were classified separately by two public health specialists. The classification was made in accordance with the basic principles of patient rights, and they were collected under various headings including expectations about respect and care, good communication, informed consent, and fair and non-privileged distribution of healthcare services. The results show that patients tend to consider the physicians they see as solely responsible for all the negative issues that they encounter during their healthcare. This indicates that there is a need for extensive research on the underlying factors involved in the negative thoughts and feelings toward healthcare professionals in both TAF and Turkey in general. (shrink)

Currently whole world is facing immense crisis caused by the unprecedented pandemic coronavirus disease 2019 (COVID-19). This pandemic with its unique features has raised distinct ethical issues and the whole scenario has altered according to its pressing novel features. This paper aims to analyze the emerging ethical issues raised by the recent worldwide pandemic outbreak of SARS-COV-2. I have differentiated and analyzed the unprecedented emerging ethical issues from three aspects. First, there are ethical issues which arise (...) due to the sudden imposition of preventive measures such as isolation, quarantine, and social distancing by public health authorities. It is indeed problematic to suddenly adopt the ‘new normal’ in our usual social life. Secondly, there are moral dilemmas which occur when physicians and health care workers try to maintain just allocation of the limited medications to treat large number of patients. Finally, the challenge of policy makers on the effective implementation of the policies that gain trust from people. Here, the role of administrative policy makers is to recognize the moral values in decision-making within the ethically challenging situations when the usual approved behaviors are dangerous to others. I analyze the importance of the virtue of solidarity, benevolence, honesty, and equity to deal with this crisis. (shrink)

A number of recent publications by the philosopher David Seedhouse are discussed. Although medicine is an eminently ethical enterprise, the technical and ethical aspects of health care practices can be distinguished, therefore justifying the existence of medical ethics and its teaching as a specific part of every medical curriculum. The goal of teaching medical ethics is to make health care practitioners aware of the essential ethical aspects of their work. Furthermore, the contention that rational bioethics (...) is a fruitless enterprise because it analyses non-rational social events seems neither theoretically tenable nor to be borne out by actual practice. Medical ethics in particular and bioethics in general, constitute a field of expertise that must make itself understandable and convincing to relevant audiences in health care. (shrink)

Technology has a pervasive and profound effect on the contemporary world, and engineers play a central role in all aspects of technological development. In order to hold paramount the safety, health, and welfare of the public, engineers must be morally committed and equipped to grapple with ethical dilemmas they confront.

Background: Textbooks are central for the education of professionals in the health field and a resource for practitioners already in the field. Objectives: This article focuses on how 12 textbooks in psychiatric nursing and psychiatry, published in Norway between 1877 and 2012, describe and present people with psychosis. Research design: We used qualitative content analysis. Ethical considerations: The topic is published textbooks, made available to be read by students, teachers and professionals, and no ethical approval was required. (...) Findings: The analysis shows that all 12 textbooks describe and present people who are considered as psychotic from a ‘perspective from above’. In this perspective, the readers are learning about psychosis in the professional’s language and from the author’s viewpoint. Most often the textbooks communicate a universal image of people with psychosis, a description that fits with the diagnostic criteria. The analysis also shows that two textbooks in psychiatric nursing combined this perspective with a ‘perspective from within’. Here, the readers are learning about psychosis from the patients’ own viewpoint. The authors communicate a personal, psychotic universe that differs from various people, even if they have the same diagnosis, and the descriptions are focusing on the patient as a whole person. Discussion and conclusion: Drawing partly on Rita Charon’s writings about narrative knowledge in the health field, and partly on insights from Martha Nussbaum and her concept of narrative imagination, we argue that mental health professionals need to learn about, understand and fathom what patients go through by reading, listening to and acknowledging the patients’ own stories and experiences. Cultivating the capacity for empathy and compassion are at the very heart of moral performance in the mental health field. A valuable moral resource in that regard is leading textbooks and how they describe and present people with severe mental illness. (shrink)

AimIn case of extremely rare diseases, case reports are often the only experience to draw from for evidence-based management. Carmi syndrome is a rare, mostly lethal combination of junctional epidermolysis bullosa and pyloric atresia. During an ethical board, there were differences in perception of mortality rate. We tested the hypothesis that the cumulative mortality of single case reports is lower than that of multiple case series.CaseA baby girl was born at 33 weeks gestation with Carmi syndrome. The treatment options (...) discussed in an interdisciplinary ethics board were a palliative approach versus surgical gastrojejunostomy. Because about one third of operated children described in case reports survived, we opted for surgical treatment. The patient died a painful death 4 weeks later.MethodsThe PubMed database was systematically searched for reports of Carmi syndrome. Single case reports were compared to case series in terms of outcome.ResultsA total of 102 cases of Carmi syndrome were identified in the literature. Mortality of single case reports was 17 out of 27 patients (63%), while that of case series was higher at 62 out of 74 patients (84%,p = 0.036).ConclusionsSelection and publication bias may lead to inflation of survival rates in single case reports because successful cases are more likely to be published in the literature. These biases may lead to inappropriately aggressive treatment in futile cases. Clinicians should be cautious when discussing prognosis and making decisions based on the cumulative experience of case reports of extremely rare or novel diseases. (shrink)

This article describes and rejects three standard views of reason in secular clinical ethics. The first, instrumental reason view, affirms that reason may be used to draw conceptual distinctions, map moral geography, and identify invalid forms of argumentation, but prohibits recommendations because reason cannot justify any content-full moral or metaphysical commitments. The second, public reason view, affirms instrumental reason, and claims ethicists may make recommendations grounded in the moral and metaphysical commitments of bioethical consensus. The third, (...) comprehensive reason view, also affirms instrumental reason, but encourages ethicists to make recommendations grounded in the moral and metaphysical commitments of their private worldviews. A compatibilist view of public reason is then defended, which holds that each standard view captures an important role for reason in different aspects of secular clinical ethics. The article ends by identifying three implications for enduring theoretical debates in clinical ethics. (shrink)

Sunnybrook Health Sciences Centre, Toronto and University of Toronto Ross E. G. Upshur * Sunnybrook Health Sciences Centre, Joint Centre for Bioethics University of Toronto, Toronto * Corresponding author: Ross E. G. Upshur, Primary Care Research Unit, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, #E-349, Toronto, Ontario, Canada M4N 3M5. Tel.: 416-480-4753; Fax: 416-480-4536; Email: ross.upshur{at}sunnybrook.ca ' + u + '@' + d + ' '//--> Abstract Are restrictive measures and duties to care ethically reasonably acceptable to (...) faith-based organizations? This study describes the perceptions of individually interviewed spiritual leaders of the disease control measures used during the recent SARS outbreak in Toronto. Four central themes were identified: the relationship between religious obligation and civic responsibilities; the role of faith-based organizations in supporting public health restrictive measures; the reciprocal obligations of public health and religious communities during restrictions; and justifiable limits to duties to care. We conclude that, within certain constraints, spiritual leaders find restrictive measures ethically reasonable and that spiritual leaders can play an important role during pandemic and epidemic control planning. Public health officials should therefore include them in the early and ongoing deliberations of the criteria and logistics for implementation during public health emergencies. CiteULike Connotea Del.icio.us What's this? (shrink)

Writing reflects some of the different characteristics of the language being used and of the people who are communicating. The present paper focusses on the internal written communication in international and inter-disciplinary research projects. Using a case study of an international public health research project, it argues that the authorship and the languages used in internal project communication are not neutral but help to generate or reinforce power hierarchies. Within research partnerships, language thus raises ethical issues that (...) have so far been neglected. Current ethics guidelines often focus on interactions between scientists and participants of social research and clinical trials, with less attention paid to the interactions among the scientists themselves. Describing all the different project phases based on writing within a research project, the paper distinguishes different influences on the distribution of power that emerge through a focus on written communication. The focus of the present paper is to illuminate the issues of ethics, power and the dimensions of hierarchy, physical location and native versus non-native English speakers that arise from paying attention to such communications. (shrink)