BackgroundHIV prevention research in resource-limited countries is associated with a variety of ethical dilemmas. Key amongst these is the question of what constitutes an appropriate standard of health care (SoC) for participants in HIV prevention trials. This paper describes a community-focused approach to develop a locally-appropriate SoC in the context of a phase III vaginal microbicide trial in Mwanza City, northwest Tanzania.MethodsA mobile community-based sexual and reproductive health service for women working as informal food vendors or in traditional (...) and modern bars, restaurants, hotels and guesthouses has been established in 10 city wards. Wards were divided into geographical clusters and community representatives elected at cluster and ward level. A city-level Community Advisory Committee (CAC) with representatives from each ward has been established. Workshops and community meetings at ward and city-level have explored project-related concerns using tools adapted from participatory learning and action techniques e.g. chapati diagrams, pair-wise ranking. Secondary stakeholders representing local public-sector and non-governmental health and social care providers have formed a trial Stakeholders' Advisory Group (SAG), which includes two CAC representatives.ResultsKey recommendations from participatory community workshops, CAC and SAG meetings conducted in the first year of the trial relate to the quality and range of clinic services provided at study clinics as well as broader standard of care issues. Recommendations have included streamlining clinic services to reduce waiting times, expanding services to include the children and spouses of participants and providing care for common local conditions such as malaria. Participants, community representatives and stakeholders felt there was an ethical obligation to ensure effective access to antiretroviral drugs and to provide supportive community-based care for women identified as HIV positive during the trial. This obligation includes ensuring sustainable, post-trial access to these services. Post-trial access to an effective vaginal microbicide was also felt to be a moral imperative.ConclusionParticipatory methodologies enabled effective partnerships between researchers, participant representatives and community stakeholders to be developed and facilitated local dialogue and consensus on what constitutes a locally-appropriate standard of care in the context of a vaginal microbicide trial in this setting.Trial registrationCurrent Controlled Trials ISRCTN64716212. (shrink)

Summary Recent research has highlighted the risk of HIV infection for married teenage women compared with their unmarried counterparts (Clark, 2004). This study assesses whether a relationship exists, for women who have completed their adolescence (age 20–29 years), between HIV status with age at first marriage and the length of time between first sex and first marriage. Multivariate analysis utilizing the nationally representative 2004 Cameroon Demographic and Health Survey shows that late-marrying women and those with a longer period of (...) pre-marital sex have the highest risk of HIV. Although women in urban areas overall marry later than their rural counterparts, the positive relationship between age at marriage and HIV risk is stronger in rural areas. The higher wealth status and greater number of lifetime sexual partners of late-marrying women contribute to their higher HIV risk. Given that the age at first marriage and the gap between first marriage and first sex have increased in recent years, focusing preventive efforts on late-marrying women will be of much importance in reducing HIV prevalence among females. (shrink)

Claims that there are good arguments for a public health service that do not amount to arguments for a national health service, but for something that looks far more like a transnational health service.

This study examines the use of a video news release in a specific story. Press coverage and editorial criticism in the case showed that journalists do not articulate sufficiently how the news owners' sway, through institutional controls, can lead to a hegemony of expedient action in the newsroom. Critical self-reflection by news workers will better enable journalists to ethically deliberate news choices that balance their responsibilities to owners, peers, and the public.

This study examines the use of a video news release in a specific story. Press coverage and editorial criticism in the case showed that journalists do not articulate sufficiently how the news owners' sway, through institutional controls, can lead to a hegemony of expedient action in the newsroom. Critical self-reflection by news workers will better enable journalists to ethically deliberate news choices that balance their responsibilities to owners, peers, and the public.

Few novel or emerging infectious diseases have posed such vital ethical challenges so quickly and dramatically as the novel coronavirus SARS‐CoV‐2. The World Health Organization declared a public health emergency of international concern and recently classified Covid‐19 as a worldwide pandemic. As of this writing, the epidemic has not yet peaked in the United States, but community transmission is widespread. President Trump declared a national emergency as fifty governors declared state emergencies. In the coming weeks, hospitals (...) will become overrun, stretched to their capacities. When the health system becomes stretched beyond capacity, how can we ethically allocate scarce health goods and services? How can we ensure that marginalized populations can access the care they need? What ethical duties do we owe to vulnerable people separated from their families and communities? And how do we ethically and legally balance public health with civil liberties? (shrink)

Reason and Rationality in Health and Human Services Delivery is the first book to discuss the topic of decisionmaking and services from a multidisciplinary approach. It uses theory and social considerations, not just technology, as a basis for improved services. Health and human service students and professionals will learn how to form rational and reasonable decisions that take their clients'cultural backgrounds into consideration when identifying an illness or appropriating any kind of intervention. With a particular (...) emphasis on theories, models, organizational settings, technologies, and practitioner training methods that lead to culturally sensitive decisions, Reason and Rationality will help you deliver efficient and improved medical and social services to clients from all ethnic backgrounds. Recognizing reason as the centerpiece of most of Western philosophy, this text reveals how our idea of truth, fact, and order are wrongly thought to be universal; yet, Western principles are continually used in the decision-making process for health and social services. Focusing on the policy implications of decisionmaking in medical and social service settings, this text works to incorporate a broad range of factors into the reasoning process, such as cultural traditions and beliefs, that will result in better treatment for patients. Giving you suggestions and strategies for upgrading reasoning and decision-making processes and applying them to every area of service, Reason and Rationality discusses different themes that will help you improve services to patients, such as: the rationale currently used to justify decision-making strategies concerning medical and human services using computer technology to make clinical assessments revising administrative structure, management theories, and organizational strategies so that decision-making processes enhance the overall quality of service delivery how the practitioner/patient relationship is important in choosing the proper treatment soliciting community-based input to assess the public's health and human service needs in order to lessen political involvement in decision-making stages In addition, Reason and Rationality provides information and examples that show why you should consider the "life-world"--the values, beliefs, and commitments of a culture's history-- as the key to understanding the powers of reasoning that specify parameters of health and illness. (shrink)

If ‘community’ is the answer, what is the problem? While questions undoubtedly arise in allocating resources to public health, such as ‘how much?’ and ‘to whom?’, we already have answers based on (i) the observation that disease and illness are bad, (ii) views of justice and fairness and (iii) an appreciation of market failure. What does the concept of community add to the existing answers? Not nothing, I shall argue, but not much either. In some cases, health (...) providers should take advantage of ties of community to deliver services more effectively. The desire to preserve communities may have some minor implications for devolved health care funding. The value of community may set some limits to inequalities in access to health care. That’s about it. I do consider some other claims of behalf of the concept, e.g. that people would not support justice in health care without a sense of community; but I don’t find these claims very plausible. Finally, I point out some ways in which communities can be damaged by the promotion of public health understood as population health. (shrink)

This paper explores an approach to the implementation and evaluation of integrated health service delivery. It identifies the key issues involved in integration evaluation, provides a framework for assessment and identifies areas for the development of new tools and measures. A proactive role for evaluators in responding to health service reform is advocated.

ABSTRACT Although considerable attention has been given to ethical issues related to clinical research in developing countries, in particular related to HIV therapy, there has been limited focus on health systems research, despite its increasing importance in the light of current trends in development assistance. This paper examines ethical issues related to health systems research in ‘post’‐conflict situations, addressing both generic issues for developing countries and those issues specific to ‘post’‐conflict societies, citing examples from the author’s Cambodian experience. (...) It argues that the destruction of health infrastructure results in a loss of structures and processes that would otherwise protect prospective research subjects who are part of vulnerable populations. It identifies the growth of health systems research as part of a trend towards sectoral and programmatic development assistance, the emergence of ‘knowledge generation’ as a form of research linked to development, and the potential for conflict where multilateral and bilateral donors are both primary funders and users of health systems research. It also examines the position of the health system researcher in relation to the sponsors of this research, and the health system being analysed. (shrink)

Using the infamous research studies in Tuskegee and Guatemala, the article examines the difference between victims and bystanders. The victims can include families, sexual partners, and children not just the participants. There are also the bystanders in the populations who are affected, even vaguely, decades after the initial studies took place. Differing reparations for victims and bystanders through lawsuits and historical acknowledgments has to be part of broader discussions of historical justice, and the weighing of the impact of racism and (...) imperial research endeavors. (shrink)

In 1997 President Clinton apologized to the survivors of the U.S. Public Health Service Syphilis Study. Since then, two of his recommendations have received little attention. First, he emphasized the need to remember the shameful past so we can build a better future for racial'ethnic minority populations. Second, he directed the creation in partnership with higher education to prepare training materials that would instruct biomedical researchers on the application of ethical principles to research with racial/ethnic minority populations. This (...) article proposes the inclusion of these issues in the implementation of the Affordable Care Act. It asks, What is the right or good thing to do? What are our obligations to one another? Two challenges are examined: (a) Conducting research with African Americans without knowledge of bioethics specific to this population, and (b) the ethical dilemma of conducting research that does not adequately take into account the diversity within the Black population that is a contributing factor in health disparities. Training and policy recommendations responsive to President Clinton's Apology are presented. (shrink)

Involuntary commitment links the healthcare, public health, and legislative systems to act as a “carceral health-service.” While masquerading as more humane and medicalized, such coercive modalities nevertheless further reinforce the systems, structures, practices, and policies of structural oppression and white supremacy. We argue that due to involuntary commitment’s inextricable connection to the carceral system, and a longer history of violent social control, this legal framework cannot and must not be held out as a viable alternative to the (...) criminal legal system responses to behavioral and mental health challenges. Instead, this article proposes true alternatives to incarceration that are centered on liberation that seeks to shrink the carceral system’s grasp on individuals’ and communities’ lives. In this, we draw inspiration from street-level praxis and action theory emanating from grassroots organizations and community organizers across the country under a Public Health Abolition framework. (shrink)

The generation of evidence is integral to the work of public health and health service providers. Traditionally, ethics has been addressed differently in research projects, compared with other forms of evidence generation, such as quality improvement, program evaluation, and surveillance, with review of non-research activities falling outside the purview of the research ethics board. However, the boundaries between research and these other evaluative activities are not distinct. Efforts to delineate a boundary – whether on grounds of primary (...) purpose, temporality, underlying legal authority, departure from usual practice, or direct benefits to participants – have been unsatisfactory. (shrink)

The Patient Protection and Affordable Care Act (ACA) sets in motion a wide range of programs that substantially affected the health system in the United States and signify a moderate but important regulatory shift in the role of the federal government in public health. This article briefly addresses two interesting policy paradoxes about the ACA. First, while the legislation primarily addresses health care financing and insurance and establishes only a few initiatives directly targeting public (...) class='Hi'>health, the ACA nevertheless has the potential to produce extensive public health benefits across the United States population by improving access to health care and services and reducing cost. Essentially, the ACA does not take the explicit form of a public health law but instead strives to advance public health indirectly through its effects. Second, while the ACA does not establish a right to health — or even a right to health insurance — in the United States, it does set in motion a number of significant structural and normative changes to United States law that comport with the attainment of the right to health. Most significantly, key provisions of the bill are designed to improve availability, accessibility, acceptability, and quality of conditions necessary for health, and to prompt the government to respect, protect, and fulfill these conditions. These developments mean that, to a degree, the United States essentially has undertaken the same types of legal and policy steps that a country would be required to take to uphold the right to health without actually recognizing the right to health in any formal or legally binding way.Despite these dual paradoxes and the upside potential for public health improvements resulting from the ACA, the public health impact of the law remains uncertain and will be decided by numerous subsequent regulatory and implementation decisions. The ACA authorizes multiple federal agencies to engage in rulemaking, a process that will largely dictate the systemic and health impacts that will become its legacy. This reality opens up ample opportunity to bolster public health aspects and interpretations of the law, and to simultaneously augment the corresponding components of the right to health. (shrink)

Obesity is a particularly vexing public health challenge, since it not only underlies much disease and health spending but also largely stems from repeated personal behavioral choices. The newly enacted comprehensive health reform law contains a number of provisions to address obesity. For example, insurance companies are required to provide coverage for preventive-health services, which include obesity screening and nutritional counseling. In addition, employers will soon be able to offer premium discounts to workers who (...) participate in wellness programs that emphasize behavioral choices. These policies presume that government intervention to reduce obesity is necessary and justified. Some people, however, argue that individuals have a compelling interest to pursue their own health and happiness as they see fit, and therefore any government intervention in these areas is an unwarranted intrusion into privacy and one's freedom to eat, drink, and exercise as much or as little as one wants. This paper clarifies the overlapping individual, employer, and social interest in each person's health generally to avoid obesity and its myriad costs in particular. The paper also explores recent evidence on the impact of government interventions on obesity through case studies on food labeling and employer-based anti-obesity interventions. Our analysis suggests a positive role for government intervention to reduce and prevent obesity. At the same time, we discuss criteria that can be used to draw lines between government, employer, and individual responsibility for health, and to derive principles that should guide and limit government interventions on obesity as health reform's various elements (e.g., exchanges, insurance market reforms) are implemented in the coming years. (shrink)

Race and ethnicity are closely related, contentious concepts that have been abused and misinterpreted through history, but have a vast potential for good, at least in the health sciences. This article is not intending to elaborate on the conceptual foundations of race and ethnicity; I have addressed that elsewhere and summarized my stance in the glossary reprinted below in the Appendix. The terminology used here follows the glossary. Assuming that the conceptual foundations of my stance are reasonable, the (...) questions addressed here focus on public health and its primary health science, epidemiology, in a European context. The questions are simple ones:1.In epidemiology and public health what are we trying to achieve when we use the concepts of race and ethnicity?2.What would we lose by rejecting these concepts?3.If we do not reject them, how do we put the concepts into operation to help achieve our goals?4.What practical actions can result from the application of these concepts in order to improve the health and well-being of populations? (shrink)

The public health measures implemented in response to the COVID-19 pandemic have resulted in a substantially increased shared reliance on private infrastructure and digital services in areas such as healthcare, education, retail, and the workplace. This development has (i) granted a number of private actors significant (informational) power, and (ii) given rise to a range of digital surveillance practices incidental to the pandemic itself. In this paper, we reflect on these secondary consequences of the pandemic and observe (...) that, even though collateral data disclosure and additional activity monitoring appears to have been generally socially accepted as inevitable consequences of the pandemic, part and parcel of a larger conglomeration of emergency compromises, these increased surveillance practices were not directly justified by appeals to solidarity and public health in the same way that the instigating public health measures were. Based on this observation, and given the increased reliance on private actors for maintaining the digital space, we argue that governments have a duty to (i) seek and ensure that there are justifications for collateral data disclosure and activity monitoring by private actors in the context of (future) public health emergencies like the COVID-19 pandemic, and (ii) regulate and provide accountability mechanisms for and oversight over these private surveillance practices on par with governmental essential services that engage in surveillance activities. (shrink)

Academic publications of empirical public health research often entail recommendations for moral action that address practitioners and policy makers. These recommendations are regularly based on implicit moral judgments with the underlying reasons not explicitly stated. In this paper, we elaborate on the moral relevance of such judgments and the need to explain them in order to account for academic argumentation. We argue for an explicit reporting of bridge principles to increase the transparency of the reporting of public (...) health research. The reporting of bridge principles can inform readers, support them in understanding the relationship between empirical and normative claims in a specific paper, and may pave new ways for the rigorous reporting of empirical research that has moral implications. Furthermore, it can be used to classify studies to systematically address the justification for their argumentation. (shrink)

Within the field of medical ethics, discussions related to public health have mainly concentrated on issues that are closely tied to research and practice involving technologies and professional services, including vaccination, screening, and insurance coverage. Broader determinants of population health have received less attention, although this situation is rapidly changing. Against this backdrop, our specific contribution to the literature on ethics and law vis-à-vis promoting population health is to open up the ubiquitous presence of pets (...) within cities and towns for further discussion. An expanding body of research suggests that pet animals are deeply relevant to people’s health (negatively and positively). Pet bylaws adopted by town and city councils have largely escaped notice, yet they are meaningful to consider in relation to everyday practices, social norms, and cultural values, and thus in relation to population health. Nevertheless, not least because they pivot on defining pets as private property belonging to individual people, pet bylaws raise emotionally charged ethical issues that have yet to be tackled in any of the health research on pet ownership. The literature in moral philosophy on animals is vast, and we do not claim to advance this field here. Rather, we pragmatically seek to reconcile philosophical objections to pet ownership with both animal welfare and public health. In doing so, we foreground theorizations of personhood and property from sociocultural anthropology. (shrink)

Improving the evidence in public health is an important goal for the health promotion community. With better evidence, health professionals can make better decisions to achieve effectiveness in their interventions. The relative failure of such evidence in public health is well-known, and it is due to several factors. Briefly, from an epistemological point of view, it is not easy to develop evidence-based public health because public health interventions are highly complex (...) and indeterminate. This paper proposes an analytical explanation of the complexity and indeterminacy of public health interventions in terms of 12 points. Public health interventions are considered as a causal chain constituted by three elements and two levels of evaluation. Public health interventions thus differ from clinical interventions, which comprise two causal elements and one level of evaluation. From the two levels of evaluation, we suggest a classification of evidence into four typologies: evidence of both relations; evidence of the second but not of the first relation; evidence of the first but not of the second relation; and no evidence of either relation. In addition, a grading of indeterminacy of public health interventions is introduced. This theoretical point of view could be useful for public health professionals to better define and classify the public health interventions before acting. (shrink)

One of the most frequently voiced criticisms of free will skepticism is that it is unable to adequately deal with criminal behavior and that the responses it would permit as justified are insufficient for acceptable social policy. This concern is fueled by two factors. The first is that one of the most prominent justifications for punishing criminals, retributivism, is incompatible with free will skepticism. The second concern is that alternative justifications that are not ruled out by the skeptical view per (...) se face significant independent moral objections (Pereboom 2014: 153). Despite these concerns, I maintain that free will skepticism leaves intact other ways to respond to criminal behavior—in particular incapacitation, rehabilitation, and alteration of relevant social conditions—and that these methods are both morally justifiable and sufficient for good social policy. The position I defend is similar to Derk Pereboom’s (2001, 2013, 2014), taking as its starting point his quarantine analogy, but it sets out to develop the quarantine model within a broader justificatory framework drawn from public health ethics. The resulting model—which I call the public health-quarantine model (Caruso 2016, 2017a)—provides a framework for justifying quarantine and criminal sanctions that is more humane than retributivism and preferable to other non-retributive alternatives. It also provides a broader approach to criminal behavior than Pereboom’s quarantine analogy does on its own since it prioritizes prevention and social justice. -/- In Section 1, I begin by (very) briefly summarizing my arguments against free will and basic desert moral responsibility. In Section 2, I then introduce and defend my public health-quarantine model, which is a non-retributive alternative to criminal punishment that prioritizes prevention and social justice. In Sections 3 and 4, I take up and respond to two general objections to the public health-quarantine model. Since objections by Michael Corrado (2016), John Lemos (2016), Saul Smilanksy (2011, 2017), and Victor Tadros (2017) have been addressed in detail elsewhere (see Pereboom 2017a; Pereboom and Caruso 2018), I will here focus on objections that have not yet been addressed. In particular, I will respond to concerns about proportionality, human dignity, and victims’ rights. I will argue that each of these concerns can be met and that in the end the public health-quarantine model offers a superior alternative to retributive punishment and other non-retributive accounts. (shrink)

This paper is sadly opportune. The general public is angry and bewildered if not hurt by the variety of strikes which are brought more or less forcibly to their attention. People used to understand what lay behind a strike - a demand for more pay, better conditions - but today a political element often intrudes, and it is this that worries those who ask themselves whether this or that dispute is either lawful or morally acceptable. Professor Dworkin, a lawyer, (...) first sets out the legal issues surrounding strikes and then advances the ethical arguments, closely relating them to the legal framework. The most interesting part of the paper, however, may well be that devoted to the moral obligation of example, in particular the example to be set by members of the medical profession and by all those caring for the sick. As public attitudes to industrial disputes `become dulled and quiescent' it is absolutely necessary that there should be a reappraisal of the moral standards of the past which coincide with a respect for the law. In the last century the term `anomie' was used to describe a `society which has shaken off its former restraints such as religion, respect for law and order and a definite moral code as to what is right and wrong'. We are living in that sort of society today, and one need not be a professional `ethicist' to recognize the signs, and hopefully, to work for the return of `ethical' values. (shrink)

Public health preparedness must use a comprehensive approach that includes both communities and public health systems. There are three basic questions that should be asked when evaluating public health preparedness in communities of color: 1) Is the community basically healthy?; 2) Does the community have access, to necessary information, resources and services?; and 3) Are the information, resources and services available and provided to the community in a nondiscriminatory manner?Racial-based health disparities (...) is a well documented fact for many communities of color. Individuals from these communities tend to have more morbidity and higher mortality. This health disparity is race based and not just a function of social class. Similarly, access to basic goods and health care is racialized and class based. (shrink)

Public health preparedness must use a comprehensive approach that includes both communities and public health systems. There are three basic questions that should be asked when evaluating public health preparedness in communities of color: 1) Is the community basically healthy?; 2) Does the community have access, to necessary information, resources and services?; and 3) Are the information, resources and services available and provided to the community in a nondiscriminatory manner?Racial-based health disparities (...) is a well documented fact for many communities of color. Individuals from these communities tend to have more morbidity and higher mortality. This health disparity is race based and not just a function of social class. Similarly, access to basic goods and health care is racialized and class based. (shrink)

The recent confirmation of the constitutionality of the Obama administration’s Patient Protection and Affordable Care Act (PPACA) by the US Supreme Court has brought to the fore long-standing debates over individual liberty and religious freedom. Advocates of personal liberty are often critical, particularly in the USA, of public health measures which they deem to be overly restrictive of personal choice. In addition to the alleged restrictions of individual freedom of choice when it comes to the question of whether (...) or not to purchase health insurance, opponents to the PPACA also argue that certain requirements of the Act violate the right to freedom of conscience by mandating support for services deemed immoral by religious groups. These issues continue the long running debate surrounding the demands of religious groups for special consideration in the realm of health care provision. In this paper I examine the requirements of the PPACA, and the impacts that religious, and other ideological, exemptions can have on public health, and argue that the exemptions provided for by the PPACA do not in fact impose unreasonable restrictions on religious freedom, but rather concede too much and in so doing endanger public health and some important individual liberties. (shrink)

BackgroundThe Public Health Service Increased Risk designation identified organ donors at increased risk of transmitting hepatitis B, hepatitis C, and human immunodeficiency virus. Despite clear data demonstrating a low absolute risk of disease transmission from these donors, patients are hesitant to consent to receiving organs from these donors. We hypothesize that patients who consent to receiving offers from these donors have decreased time to transplant and decreased waitlist mortality.MethodsWe performed a single-center retrospective review of all-comers waitlisted for liver (...) transplant from 2013 to 2019. The three competing risk events (transplant, death, and removal from transplant list) were analyzed. 1603 patients were included, of which 1244 (77.6%) consented to offers from increased risk donors.ResultsCompared to those who did not consent, those who did had 2.3 times the rate of transplant (SHR 2.29, 95% CI 1.88–2.79, p < 0.0001), with a median time to transplant of 11 months versus 14 months (p < 0.0001), as well as a 44% decrease in the rate of death on the waitlist (SHR 0.56, 95% CI 0.42–0.74, p < 0.0001). All findings remained significant after controlling for the recipient age, race, gender, blood type, and MELD. Of those who did not consent, 63/359 (17.5%) received a transplant, all of which were from standard criteria donors, and of those who did consent, 615/1244 (49.4%) received a transplant, of which 183/615 (29.8%) were from increased risk donors.ConclusionsThe findings of decreased rates of transplantation and increased risk of death on the waiting list by patients who were unwilling to accept risks of viral transmission of 1/300–1/1000 in the worst case scenarios suggests that this consent process may be harmful especially when involving “trigger” words such as HIV. The rigor of the consent process for the use of these organs was recently changed but a broader discussion about informed consent in similar situations is important. (shrink)

While industrial wind turbines (IWTs) clearly raise issues concerning threats to the health of a few in contrast to claimed health benefits to many, the trade-off has not been fully considered in a public health framework. This article reviews public health ethics justifications for the licensing and installation of IWTs. It concludes that the current methods used by government to evaluate licensing applications for IWTs do not meet most public health ethical criteria. (...) Furthermore, these methods are contrary to widely held fundamental principles of administrative law and governmental legitimacy. A set of decision-making principles are suggested to address this situation that are derived from existing and emerging legal principles in Canada and elsewhere. These include the Precautionary Principle, the Least Impactful Means (Proportionality) Test, and the Neighbor Principle. (shrink)

Fragile states and developing countries increasingly contract out health services to non-state providers (NSPs) (such as non-governmental organisations, voluntary sector and private sector). The paper identifies ethical issues when contracts involve devolution of health services to NSPs and proposes procedures to prevent or resolve these ethical dilemmas. Ethical issues were identified by examining processes of contracting out. Health needs could be used to select areas to be contracted out and to identify service needs. Health (...) needs comprise “disease-burden-related needs”, “health-service needs”, and “urgency of health-service needs”. The mix of services should include an analysis of cost-effectiveness. NSPs should be selected fairly, without bias, and conflicts of interest during their work must be avoided. The population’s views must be respected and accountability structures established. Devolved health services should ensure equity of access to healthcare. The services ought to be sustainable and evaluated objectively. Of these issues, conflicts of interest among NSPs and sustainability of health services have not attracted attention in the literature on ethics of health policy. Fair procedures could address these ethical issues—for example, public consultation on issues; decisions based on the public consultation and made on evidence; principles of decisions stated and reasonable; decisions given adequate publicity; a mechanism established to challenge decisions; assurance that mechanisms meet the above conditions; and regular review of the policies. These procedures are complemented by improving self-governance of NSPs, countries’ development of guidelines for devolving health services, and measures to educate the public of the client countries on these issues. (shrink)

BackgroundDignity 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.PurposeThis study aimed to describe the perceptions of nursing's professional dignity of public health nurses in primary care in Finland.Research designAn (...) inductive qualitative descriptive approach with semi-structured focus group interviews was utilised.Participants and research contextTwenty-seven Finnish public health nurses were interviewed via eight semi-structured focus group interviews in primary health care settings.Ethical considerationsBefore 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.FindingsBased 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 conclusionProfessional 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)

Rationale, aims and objectives This randomized controlled trial was designed to evaluate the 2-year costs and effects of a proactive, public health nursing case management approach compared with a self-directed approach for 129 single parents (98% were mothers) on social assistance in a Canadian setting. A total of 43% of these parents had a major depressive disorder and 38% had two or three other health conditions at baseline. Methods Study participants were recruited over a 12 month period (...) and randomized into two groups: one receiving proactive public health nursing and one which did not. Results At 2 years, 69 single parents with 123 children receiving proactive public health nursing (compared with 60 parents with 91 children who did not receive public health nursing services) showed a slightly greater reduction in dysthymia and slightly higher social adjustment. There was no difference between the public health and control groups in total per parent annual cost of health and support services. However, costs were averted due to a 12% difference in non-use of social assistance in the previous 12 months for parents in the public health nursing group. This translates into an annual cost saving of $240 000 (Canadian) of costs averted within 1 year for every 100 parents. Conclusions In the context of a system of national health and social insurance, this study supports the fact that it is no more costly to proactively service this population of parents on social assistance. (shrink)

The medicalization of risk rests on foundational assumptions shared by economics and public health. Economists, however, think in terms of pursuing an array of goods, and hence, they offer useful critiques of the irrationality involved in trying to subordinate all goods to one narrow good, like avoiding death from a particular disease. Many of our approaches to health do not appear to be fully rational, suggesting that the deeper motivation lying behind our concerns about health are (...) to be found in something other than the impulse to extend human lives as much as possible. This paper draws on the theology of St. Thomas Aquinas to sketch a richer way of thinking about the goods we pursue in health care that can help us to avoid the pitfalls associated with the medicalization of risk. (shrink)

We examine stigma and how it operates, then develop a novel framework to classify the range of positions that are conceptually possible regarding how stigma ought to be handled from a public health perspective. In the case of weight stigma, the possible positions range from encouraging the intentional use of weight stigma as an obesity prevention and reduction strategy to arguing not only that this is harmful but that weight stigma, independent of obesity, needs to be actively challenged (...) and reduced. Using weight stigma as an illustrative example, we draw on prior theoretical work on stigma mechanisms and intervention strategies to develop a framework for improving the understanding, evaluation, and planning of anti-stigma interventions. This framework has the potential to help public health actors to map out how protest, contact, education, and regulation strategies can be used to reduce direct discrimination, structural discrimination, and internalized stigma. (shrink)

This article reflects on the increasing roles of faith-based organisations (FBOs) and individual followers in the provision of health services in Zimbabwe within the context of declining capabilities of state-funded and state-owned health facilities. In colonial and post-colonial Africa in general and Zimbabwe in particular, FBOs have consistently contributed to the provision of public services and social security. We contend that state fragilities in the Zimbabwean political landscape result in severe public service delivery deficits (...) that are often filled by FBOs and individual followers. The implications for FBOs and individual followers are twofold. Firstly, the increased involvement of FBOs in the production and provision of public services such as education and health services afford FBOs with opportunities and spaces to evangelise. Secondly, and on the downward side, the provision of health services can often be expensive and diverts attention from the core business of these religious organisations. The article reveals that in the context of economic and governance crises, FBOs play an increasingly momentous role in providing health care services in Zimbabwe. The article focuses on Zimbabwe during the crisis periods of 2007–2009 and 2018 up to the current (2022) socio-economic and political declines, poor governance, and the subsequent fragilities in the state.Contribution: Faith-based organisations assume increasing roles in the provision of health services in place of failing states. Those increased roles provide FBOs opportunities to evangelise. However, FBOs are not a sustainable replacement because they become afflicted with the same financial challenges that bedevil the state. (shrink)

This article focuses on key roles that the ill-defined concept of ‘public benefit’ plays in accessing the public health data held by the UK’s National Health Service. Using the concept of the ‘trade-off fallacy’, this article argues that current data access and governance structures, based on particular construals of public benefit in the context of public health data, largely negate the possibility of effective control by individuals over future uses of personal health (...) data. This generates a health data version of the trade-off fallacy that enables widespread involvement of commercial actors in personal data, despite public concerns over commercial involvement in, and potential exploitation of, public health data. The article suggests that, despite ostensibly robust regulatory and governance structures, this publicly held data is potentially subject to similar logics of accumulation as seen elsewhere in the digital economy, highlighting the inadequacies of current data regulatory frameworks in the digital era. (shrink)

Ethical challenges surrounding the implementation of male circumcision as an HIV prevention strategyResearchers have been exploring the possibility of a correlation between male circumcision and lowered risk of HIV infection almost since the beginning of the HIV/AIDS epidemic.1 Results from a randomised controlled trial in South Africa in 2005 indicate that male circumcision protects men against the acquisition of HIV through heterosexual intercourse,2 confirming the findings from 20 years of observational studies.3 Circumcised men in the South African trial were 60% (...) less likely to acquire HIV than their uncircumcised counterparts. A mathematical modelling study, based on the South African trial, estimates that the practice of male circumcision could avert two million new HIV infections and 300 000 HIV-related deaths over the next 10 years in sub-Saharan Africa.4 More recently, two randomised controlled trials in Kisumu, Kenya and Rakai, Uganda showed, respectively, 53% and 48% reductions in HIV acquisition among circumcised men than uncircumcised men in the trial.5 These results strongly suggest that male circumcision could play an important role in the struggle against the continued rise in new HIV infections. However, as observers noted at the 2006 XVI International AIDS Conference in Toronto, Canada, excitement about the potential epidemiological impact has overshadowed the debate over the difficult translation of research on male circumcision, into policy and practice.6 Similar calls for caution have been raised before and elsewhere.7,8The topic of male circumcision carries an enormous amount of ethical baggage. Male infants, worldwide, are circumcised for various medical, social and/or religious reasons. Circumcision is a cultural act and a surgical procedure; medical reasons are not the only reasons to circumcise that people have found and continue to find as compelling. Benatar and Benatar9 have argued that—when …. (shrink)

The potential power of predictive genetic testing as a risk regulator is impressive. By identifying asymptomatic individuals who are at risk of becoming ill, predictive genetic testing may enable those individuals to take prophylactic measures. As new therapies become available, the usefulness of genetic testing undoubtedly will increase. Further, when a person's family medical history indicates a propensity towards a particular genetic disease, a negative test result may open up otherwise denied opportunities by showing that this person has not inherited (...) suspect genes. In the latter type of case, a negative test result may reassure the individual that pursuing a particular course of action is worthwhile, or may convince prospective employers that the individual will be a serviceable employee. (shrink)

The potential power of predictive genetic testing as a risk regulator is impressive. By identifying asymptomatic individuals who are at risk of becoming ill, predictive genetic testing may enable those individuals to take prophylactic measures. As new therapies become available, the usefulness of genetic testing undoubtedly will increase. Further, when a person's family medical history indicates a propensity towards a particular genetic disease, a negative test result may open up otherwise denied opportunities by showing that this person has not inherited (...) suspect genes. In the latter type of case, a negative test result may reassure the individual that pursuing a particular course of action is worthwhile, or may convince prospective employers that the individual will be a serviceable employee. (shrink)

The article examines the issue of public health and medical services in Algeria and analyses the role of the public and private sectors in supporting and promoting public health. Our study is based on an analysis of legal texts that highlight Algeria’s health policies. Some significant aspects of the article are: the Algerian policy of opening health services up to private investment; the lack of contribution of private health institutions in (...) the field of medical education; and issues surrounding the organisation of blood donation. The article also notes the absence of foreign investment in Algerian hospitals. (shrink)

Many observers have argued that the US health care system could be more efficient, and achieve better outcomes if providers focused more on improving the community's health, not just the welfare of individual patients. The passage of the Affordable Care Act in 2010 seemed to herald the promise of such reforms, and greater integration of the health care and public systems. In this article, we reassess the quest for integration, a quest we call the “integration project.” (...) After examining the modest steps taken so far toward integration, we consider some conceptual barriers to integration as well as some of the risks it might portend for the public health system. Our assessment contributes to wide-ranging debates among public health advocates, practitioners, and policymakers as to the health care system's role in protecting public health, and how the public health system can best be organized to meet expected population health challenges. (shrink)

Local health officials are called upon every day to implement the programs, enforce the regulations, and take the actions that protect the health of the citizens in their districts. These responsibilities and duties are created and regulated by a complex interplay of federal, state, and local law. Not only is an understanding of these laws necessary to carry out public health activities on a daily basis, but many public health scholars and practitioners also believe (...) that the law can be used as a tool to take proactive steps to improve public health. Unfortunately, many local public health officials do not have access to the legal assistance they need to address the various legal questions that confront them. This deficit makes it harder for them to meet their day-to-day responsibilities and makes it much more difficult for them to use the law proactively as a method to improve public health in their communities. In addition, many of the attorneys who provide legal support to public health departments do not have the time or resources to develop a thorough and up-to-date understanding of public health law. This paper examines the experience of a number of local health offices in obtaining legal advice and of attorneys who provide legal advice and assistance to local health departments and assesses different models for organizing and financing the provision of legal services to local public health officials. (shrink)

Objective Our study sought to (1) describe the practices and preferences of Colombian adolescents in accessing sexual and reproductive health services: accompanied versus alone; (2) compare actual practices with stated preferences; and (3) determine age and gender differences regarding the practice and these stated preferences. -/- Methods 812 participants aged 11–24 years old answered a survey in two Profamilia clinics in the cities of Medellin and Cali in Colombia. A cross-sectional analysis was performed to compare participants’ answers based (...) on the variables of gender and age. -/- Results A quarter of participants visited the clinic alone (25.4%). Females were more likely to go alone in comparison to males (26.3% vs 14.1%; p = 0.031), and older participants went alone more often than younger participants (p < 0.001). Most participants – 72.7% (95 %CI: 69.3–75.9) – expressed a preference in being accompanied to the clinic, and more than 90% had their preferences met. The preferences of older participants were, however, less likely to be met than those of younger participants (p < 0.001), notably, because they predominantly wanted to be accompanied. -/- Conclusion Contemporary public health and bioethics literature advocates in favor of developing health services that better meet the preferences of adolescents. The present research highlights an apparent blind spot related to the role that others (e.g., parents, friends, partners) can or should play in accompanying adolescent patients when they access sexual and reproductive health services. Respecting adolescents’ preferences, and hence their autonomy, is not simply a matter of ensuring freedom from constraints (e.g., their right and ability to go alone). Rather, it should also consider the liberty to choose whether to be accompanied when accessing SHRS and by whom. (shrink)

BackgroundSolitary death (kodokushi) has recently become recognized as a social issue in Japan. The social isolation of older people leads to death without dignity. With the outbreak of COVID-19, efforts to eliminate solitary death need to be adjusted in line with changes in lifestyle and accompanying changes in social structure. Health monitoring services that utilize wearable devices may contribute to this end. Our goals are to outline how wearable devices might be used to (1) detect emergency situations involving (...) solitary older people and swiftly connect them with medical treatment, to (2) reduce the frequency of deaths that remain undiscovered and (3) to reduce social isolation by promoting social interaction. MethodsTheoretical and philosophical approaches were adopted to examine ethical issues surrounding the application of wearable devices and cloud-based information processing systems to prevent solitary death in the world with/after COVID-19.Main body(1) Technology cannot replace social connections; without social support necessary to foster understanding of the benefits of health management through wearable devices among older adults, such devices may remain unused, or not used properly. (2) Maturity of the technology; systems face the difficult task of detecting and responding to a wide range of health conditions and life-threatening events in time to avert avoidable morbidity and mortality. (3) Autonomy and personhood; promoting the voluntary use of wearable devices that are a part of larger efforts to connect isolated individuals to a community or social services might be effective. Legal force should be avoided if possible. There is some concern that landlords may require an older person to sign a contract agreeing to wear a device. The autonomy of solitary older people should be respected. (4) Governance: policies must be developed to limit access to data from wearables and the purposes for which data can be used.ConclusionIf thoughtfully deployed under proper policy constraints, wearable devices offer a way to connect solitary older people to health services and could reduce cases of solitary death while respecting the personhood of the user. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.4 (2003) 373-378 [Access article in PDF] The Forgotten Self:Training Mental Health and Social Care Workers to Work With Service Users Kim Woodbridge Keywords self, workers perspective, them and us, win-win situation The three main papers and the case studies presented in this issue of Philosophy, Psychiatry, & Psychology all focus on the service user perspective in relation to the self as illustrated by (...) different aspects of philosophy. This is also in the context of the service user looking for help during a time when they are experiencing levels of distress and difficulty.Important as this is, evident by the substantial clinical and philosophical literature in this area, what has been overlooked is the perspective of the mental health and social care worker responsible for the care of individuals whose sense of self is disturbed. The significance of this omission has been brought home to me through my experiences in running training workshops for workers working with service users with a diagnosis of personality disorder. (From here on, in this paper, the terms worker and trainee are used interchangeably to refer to the mental health and social care worker).During these workshops challenges to the worker's sense of self have been revealed emotionally ("this doesn't feel like me"), ideologically ("I am not a bad person"), and/or practically ("I don't usually behave like this") when discussing their work with service users. This paper draws from the workshop experiences to explore and consider the workers perspective in relation to the self in more detail.There follows a descriptive account of three workshop sessions which include the trainees responses. With each activity the responses are considered within the context of the self, particularly from the worker's perspective. In the conclusion the argument is made, as evidenced by these illustrations, for the importance of including the workers' perspective when attempting to understand the self. The Trainees and Service Users Workers from various professional and nonprofessional backgrounds attend the workshops. They include psychiatrists, nurses, social workers, support workers, and occupational therapists who work in both in-patient and community settings. They usually have several years of clinical experience working with people with a [End Page 373] diagnosis of personality disorder, but rarely have they had any formal education or training in the area. Discussing their experiences of working with this service user group generates strong and highly emotionally charged personal responses during training.It is their experiences of the relationships with service users whose sense of self is absent, inconsistent, or unstable, that make a substantial contribution to the content of the workshops.Often service users are struggling with fragmented, distorted, or threatening perceptions of the world, themselves, and others. The worker, while embedded within their own sense of self, is engaged in a relationship with the service user. The issues that arise as a part of this relationship can be challenging and distressing for the workers. There are two main areas:The impact the service user's chaotic, fragmented, and unstable sense of self has on the worker's own sense of self.The response of the workers when their sense of self is challenged, and the impact that response has on the service user. These can be seen in more detail in the examples taken from the training sessions presented later in this paper. The Training Sessions The training sessions are either run alone or form part of a 1- or 2-day workshop. As mentioned, the groups are composed of a variety of professionally and nonprofessionally qualified staff. The experiences they share mainly relate to people with a diagnosis of Borderline Personality Disorder, although other subcategories are mentioned occasionally. Information regarding these and other related sessions can be found in two recent publications: Making positive connections (Duff, Meredith, & Woodbridge,2003) and "Whose good practice?" (Woodbridge & Fulford, 2003). The First Activity: Revealing Internal Models Given the lack of available evidence, even the best-informed trainees are likely to have to fill in the knowledge gaps with their own interpretations of... (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)

A typical discussion around health reform in the U.S. focuses on how the nation can most effectively and efficiently extend insurance coverage to the rising number of people who have none. Furthermore, discussions about health care reform typically are centered on times of normalcy, when the health care system is not overly taxed and there is the luxury of time to think about everyday matters of health and health care, including health care services (...) needed to prevent illness, treat conditions, and address individual emergencies. But in light of the lessons learned over the past decade, it is also essential to consider how any reformed health care system will react to and mitigate the consequences of a public health emergency. (shrink)

Chloroquine-resistant plasmodium falciparum malaria is a serious public health threat that is spreading rapidly across Sub-Saharan Africa. It affects over three quarters (80%) of malarial endemic countries. Of the estimated 300-500 million cases of malaria reported annually, the vast majority of malarial-related morbidities occur among young children in Africa, especially those concentrated in the remote rural areas with inadequate access to appropriate health care services. In Liberia, in vivo studies conducted between 1993 and 2000 observed varying (...) degrees of plasmodium falciparum malaria infections that were resistant to chloroquine, including sulfadiazine-pyrimethamine. As the country emerges from a prolonged civil war, the health care delivery system may not be adequately prepared to implement an effective nation-wide malarial control strategy. As a result, the management of uncomplicated malaria in Liberia poses a significant public health challenge for the government-financed health care delivery system. Therefore, based on extensive literature review, we report the failure of chloroquine as an effective first-line drug for the treatment of uncomplicated plasmodium falciparum malaria in Liberia and recommend that national health efforts be directed at identifying alternative drug(s) to replace it. (shrink)