In January 2023, the Science and Security Board of the Bulletin of the Atomic Scientists moved the hands of the Doomsday Clock forward to 90 s before midnight.

Ageism is the view that it is of greater moral value to allocate health care resources to younger people than to older people. In medical ethics, it is well-known that standard interpretations of distributive principles such as utilitarianism and egalitarianism imply some form of ageism. At times, ethicists argue as if practical complications are the only or main reason for not abiding to ageism. In this article, we argue that inferences to ageism from such distributive principles tend to commit what (...) we call the anticipation-blindness fallacy: A much too narrow focus on life quality benefits of health care treatments inclines us to overlook the importance of life quality benefits of health care safety, that is the mere trust in and expectation of being treated and cared for as one grows old. This is a key omission because health safety has value for a much larger population and for much longer time. Taking health safety into account therefore has important implications as for how ageist we ought to be. (shrink)

Throughout the COVID-19 pandemic, the concept of solidarity has been invoked frequently. Much interest has centred around how citizens and communities support one another during times of uncertainty. Yet, empirical research which accounts and understands citizen’s views on pandemic solidarity, or their actual practices has remained limited. Drawing upon the analysis of data from 35 qualitative interviews, this article investigates how residents in England and Scotland enacted, understood, or criticised (the lack of) solidarity during the first national lockdown in the (...) United Kingdom in April 2020—at a time when media celebrated solidarity as being at an all-time high. It finds that although solidarity was practiced by some people, the perceived lack of solidarity was just as pronounced. We conclude that despite frequent mobilisations of solidarity by policy makers and other public actors, actual practices of solidarity are poorly understood—despite the importance of solidarity for public health and policy. (shrink)

This paper argue that loneliness is a public health ethics issue and maps a research agenda for bioethicists.

The paper defends the World Health Organisation (WHO) definition of health against widespread criticism. The common objections are due to a possible misinterpretation of the word complete in the descriptor of health as ‘complete physical, mental and social well-being’. Complete here does not necessarily refer to perfect well-being but can alternatively mean exhaustive well-being, that is, containing all its constitutive features. In line with the alternative reading, I argue that the WHO definition puts forward a holistic account, not a notion (...) of perfect health. I use historical and analytical evidence to defend this interpretation. In the second part of the paper, I further investigate the two different notions of health (holistic health and perfect health). I argue that both ideas are relevant but that the holistic interpretation is more adept for political aims. (shrink)

Mobile health (mHealth) technologies for self-monitoring health-relevant parameters such as heart frequency, sleeping patterns or exercise regimes aim at fostering healthy behavior change and increasing the individual users to promote and maintain their health. We argue that this aspect of mHealth supports healthism, the increasing shift from institutional responsibility for public health toward individual engagement in maintaining health as well as mitigating health risks. Moreover, this healthist paradigm leads to a shift from understanding health as the absence of illness to (...) regarding health as the performance of certain rituals in order to project healthiness. By drawing from the analogy between healthiness and traditional virtues, we evaluate the promises made by proponents of mHealth technologies for self-monitoring. We argue that the implementation and use of mHealth risk entrenching existing inequalities and, more particularly, tend to exclude populations situated at the losing end of those inequalities from participating in the quasi-virtue of healthiness. Consequently, the implementation and use of mHealth technologies not only present challenges for social justice but also undermine their primary societal goal—to promote public health. Finally, we offer several suggestions on how to realize the potential benefit of mHealth. (shrink)

The article discusses the impact different concepts of solidarity can have on debates on models of consent for non-interventional research. It introduces three concepts of solidarity that have been referenced in bioethical debates: a purely descriptive concept, a concept that claims some derivative value for most but not all practices of solidarity, as well as a clearly normative concept where solidarity is tied to justice and taken to ground moral duties. It shows that regarding the rivalling models of study-specific consent, (...) tiered consent and broad consent, the first two concepts can be taken to favour tiered consent while only normative solidarity supports a model of broad consent—or an argument to allow non-interventional research without requiring consent at all. As normative solidarity is tied to considerations of justice, however, the argument appears less straightforward than one might expect: It presupposes that the research contributes to overcoming existing social injustices. (shrink)

Solidarity is presumed to underpin the redistributive health and welfare systems in modern democracies; however, it is often considered a Western—or more specifically, European—concept. While health and welfare systems have been transplanted successfully to many non-Western developed countries, whether the solidarity necessary for such systems exists or is intellectually available remains under debate. Using an East Asian country with the Confucian tradition as an illustrative case, I first argue that the Confucian tradition has special theoretical and sociological importance for health (...) and welfare solidarity. Then, through investigating the classic Confucian writings, I propose transformed interpretations of the essential concepts of Confucian thought, namely filial piety, benevolent governance and the mandate of heaven. With these interpretations, the differentiated family-based solidarity and the people-rooted thought in Confucianism could be reimagined to fit with the modern liberal-democratic political regime and welfare arrangements. I call this model Confucian welfarism, which I argue could form the intellectual origins of solidarity for people who believe in or have an affinity to Confucian ethos. (shrink)

This article discusses the fairness of geographically targeted vaccinations (GTVs). During the initial period of local and global vaccine scarcity, health authorities had to enact priority-setting strategies for mass vaccination campaigns against COVID-19. These strategies have in common that priority setting was based on personal characteristics, such as age, health status or profession. However, in 2021, an alternative to this strategy was employed in some countries, particularly Norway. In these countries, vaccine allocation was also based on the epidemiological situations in (...) different regions, and vaccines were assigned based on local incidence rates. The aim of this article is to describe and examine how a geographical allocation mechanism may work by considering Norway as a case study and discuss what ethical issues may arise in this type of priority setting. We explain three core concepts: priority setting, geographical priority setting and GTVs. With a particular focus on Norway, we discuss the potential effects of GTV, the public perception of such a strategy, and if GTV can be considered a fair strategy. We conclude that the most reasonable defence of GTV seems to be through a consequentialist account that values both total health outcomes and more equal outcomes. (shrink)

Preventing sexual and gender-based violence—and mitigating its devastating impacts on individuals and societies—is a central challenge of public health. A Woman in Berlin is 34-year-old journalist Marta Hillers’s first-hand account of life during the 1945 Red Army occupation of Berlin at the conclusion of World War II, when Russian soldiers collectively raped 2 million German civilians. Reflecting upon Hillers’s testimony, I argue that historical narratives about large-scale acts of sexual and gender-based violence deserve a more central place in public health (...) discourse. I also question how the ethical challenges of memorializing and studying mass crimes might inform future public health efforts to advance gender equity and mitigate sexual violence globally. (shrink)

Femicide is an ongoing public health and human rights crisis of global proportions. Currently, however, there is a relative vacuum of ethics theory and discussion about femicide amongst the health professions. This article draws from three illustrative case examples along the continuum of femicide to explore contemporary ethical concerns relevant to addressing gender-based violence and death through clinical medicine and public health. Using an epistemic justice framework, we analyze the relative invisibility of femicide in public health discourse today, and renew (...) a conversation about ethical issues inherent to health interventions and policy-making around femicide. (shrink)

As we have now completed 15 years of journal content, it seems like a good time to take stock and reflect upon the development and nature of public health ethic.

Folkbiology refers to people’s everyday understanding of the biological world. The early twentieth-century pioneers of public health C.-E.A Winslow (1877–1957), and his mentor H. Biggs (1859–1923), conceptualized public health as the ‘purchasable’ science of preventing disease and death from unfavorable economic and living conditions. Their ideas were foundational in shaping public health’s strategy of a ‘war against disease’ (Winslow, 1903), a strategy that was very successful in preventing the early-life mortality risks from infectious diseases, and was eventually extended to combating (...) the chronic diseases of late life (like cancer). However, the initial framing of public health, through the lens of sanitation science, was predicated upon folkbiological premises that geroscience must abate in order to direct public health interventions toward the goal of improving the quality of life for older persons in the twenty-first century. Three folkbiological premises of sanitation science’s ‘war against disease’ are identified and critiqued: (i) the belief that health is the ‘normal’ condition of the human mechanism and disease ‘unnecessary’; (ii) the belief that the proximate causes of disease are the only modifiable risk factors public health interventions can alter; and (iii) the belief that the rate of biological aging is universal. (shrink)

Human consumption of pharmaceuticals often leads to environmental release of residues via urine and faeces, creating environmental and public health risks. Policy responses must consider the normative question how responsibilities for managing such risks, and costs and burdens associated with that management, should be distributed between actors. Recently, the Polluter Pays Principle (PPP) has been advanced as rationale for such distribution. While recognizing some advantages of PPP, we highlight important ethical and practical limitations with applying it in this context: PPP (...) gives ambiguous and arbitrary guidance due to difficulties in identifying the salient polluter. Moreover, when PPP does identify responsible actors, these may be unable to avoid or mitigate their contribution to the pollution, only able to avoid/mitigate it at excessive cost to themselves or others, or excusably ignorant of contributing. These limitations motivate a hybrid framework where PPP, which emphasizes holding those causing large-scale problems accountable, is balanced by the Ability to Pay Principle (APP), which emphasizes efficiently managing such problems. In this framework, improving wastewater treatment and distributing associated financial costs across water consumers or taxpayers stand out as promising responses to pharmaceutical pollution from human use. However, sound policy depends on empirical considerations requiring further study. (shrink)

The COVID-19 pandemic during 2020–2022 raised ethical questions concerning the balance between individual autonomy and the protection of the population, vulnerable individuals and the healthcare system. Pediatric COVID-19 vaccination differs from, for example, measles vaccination in that children were not as severely affected. The main question concerning pediatric vaccination has been whether the autonomy of parents outweighs the protection of the population. When children are seen as mature enough to be granted autonomy, questions arise about whether they have the right (...) to decline vaccination and who should make the decision when parents disagree with each other and/or the child. In this paper, I argue that children should be encouraged to not only take responsibility for themselves, but for others. The discussion of pediatric vaccination in cases where this kind of risk–benefit ratio exists extends beyond the 2020–2022 pandemic. The pandemic entailed a question that is crucial for the future of public health as a global problem, that is, to what extent children should be seen as responsible decision-makers who are capable of contributing to its management and potential solution. I conclude that society should encourage children to cultivate such responsibility, conceived as a virtue, in the context of public health. (shrink)

The legalization of cannabis in Canada instantiates principles of harm-reduction and safe supply. However, in-depth understanding of values at stake and attitudes toward legalization were not part of extensive democratic deliberation. Through a qualitative exploratory study, we undertook 48 semi-structured interviews with three Canadian stakeholder groups to explore opinions and values with respect to the legalization of cannabis: (1) members of the general public, (2) people with lived experience of addiction and (3) clinicians with experience treating patients with addiction. Across (...) all groups, participants tended to be in favor of legalization, but particular opinions rested on their viewpoint as stakeholders. Clinicians considered the way legalization would affect an individual’s health and its potential for increasing rates of addiction on a larger scale. People with lived experience of addiction cited personal autonomy more than other groups and stressed the need to have access to quality information to make truly informed decisions. Alternatively, members of the public considered legalization positive or negative in light of whether one’s addiction affected others. We elaborate on and discuss how scientific evidence about drug use impact values relates and how can different arguments play in democratic debates about legalization. (shrink)

Public healthcare systems are increasingly refusing (temporarily) to reimburse newly approved medical treatments of insufficient or uncertain cost-effectiveness. As both patient demand for these treatments and their list prices increase, a market might arise for voluntary additional health insurance (VHI) that covers effective but (very) expensive medical treatments. In this paper, we evaluate such potential future practices of VHI in public healthcare systems from a justice perspective. We find that direct (telic) egalitarian objections to unequal access to expensive treatments based (...) on different ability to afford VHI do not stand up to scrutiny. However, such unequal access might lead to loss of self-respect among individuals, or loss of fraternity within society, rendering it more difficult for citizens to interact on equal moral footing. This would be problematic from a relational egalitarian perspective. Moreover, the introduction of VHI might turn out to have negative consequences for the comprehensiveness and/or the quality of the public healthcare services that are offered to all patients equally through basic health insurance. These consequences must be weighed against potential health gains and the value of liberty. We conclude that governments should be careful when considering the introduction of VHI in public healthcare systems. (shrink)

This paper discusses the ethics of public health communication. We argue that a number of commonplace tools of public health communication risk qualifying as non-honest and question whether or not using such tools is ethically justified. First, we introduce the concept of honesty and suggest some reasons for thinking it is morally desirable. We then describe a number of common ways in which public health communication presents information about health-promoting interventions. These include the omission of information about the magnitude of (...) benefits people can expect from health-promoting interventions, and failure to report uncertainty associated with the outcomes of interventions. Next we outline some forms of behaviour which are generally recognised by philosophers as being non-honest, including deception, manipulation, and so on. Finally, we suggest that many of the public health communicative practices identified earlier share features with the non-honest behaviours described and suggest this warrants reflection upon whether such non-honesty is justified by the goals of public health communication. (shrink)

After the discovery of the origins of the new coronavirus disease 2019 (COVID-19) to be possibly wet markets in Wuhan, China, the normative questions of what ought to be the ethical relations between human beings and non-human animals have started to attract renewed interest among environmentalists. Although these are not new questions in environmental philosophy, the impact of COVID-19 across the world is challenging human beings to seriously reconsider some of these often-neglected questions. In this article, I examine COVID-19 as (...) essentially an environmental ethical challenge. Specifically, I consider the extent to which the relationships between human and non-human animals can effectively impact the health and lives of humanity and the environment at large. I then provide some alternative ways by which human beings ought to re-think their relationships with non-human animals to avoid future catastrophes like COVID-19. I argue that the African view of animal ethics could at least provide a valuable lens through which to view correct relations between human beings and non-human animals. Ultimately, I set forth and defend an African environmental ethic for the right relations between human beings and animals and to show how such an ethic better places humanity in confronting future zoonoses. (shrink)

Despite extensive stigma mitigation efforts, infectious disease stigma remains common. So far, little attention has been paid to the moral psychology of stigmatizing practices (i.e. beliefs, attitudes, actions) rather than the experience of being stigmatized. Addressing the moral psychology behind stigmatizing practices seems necessary to explain the persistence of infectious disease stigma and to develop effective mitigation strategies. Our article proposes building on Jonathan Haidt’s moral foundations theory, which states that moral judgements follow from intuitions rather than conscious reasoning. Conceptual (...) analysis was conducted to show how Haidt’s five moral foundations can be connected to (i) moral judgements about stigmatizing practices and (ii) stigmatizing practices themselves. We found that care/harm, fairness/cheating, loyalty/betrayal and sanctity/degradation intuitions can inform moral judgements about stigmatizing practices. Loyalty/betrayal and sanctity/degradation intuitions can sometimes also feed stigmatizing practices. Authority/subversion intuitions can inform moral judgements and stigmatizing practices towards people who disrespect authoritative rules meant to protect public health. Moral dumbfounding and posthoc reasoning might explain the persistence of stigmatizing practices. In conclusion, this study demonstrates the relevance of Haidt’s approach to infectious disease stigma research and mitigation strategies. We hope that this study motivates researchers to further test and assess this approach. (shrink)

The One Health approach to antimicrobial resistance (AMR) requires stakeholders to contribute to cross-sectoral efforts to improve antimicrobial stewardship (AMS). One Health AMR policy implementation is challenging in livestock farming because of the infrastructural role of antibiotics in production systems. Mitigating AMR may require the development of more stringent stewardship obligations and the future limitation of established entitlements. Drawing on Amatai Etzioni’s compliance theory, regulatory analyses and qualitative studies with stakeholder groups we examine the structural and socio-cultural dimension of antibiotic (...) use and AMS compliance in Australian beef and dairy production. We found a disconnect between how antibiotic use is conceptualised by farmers and the way in which AMS policies construe agricultural AMR risks. Under the umbrella of food safety standards and national-level prescribing restrictions, farmers and veterinarians interact around antibiotic use with different operating logics and compliance mechanisms. These parallel regimes service distinct and sometimes competing common goods of food security and antibiotic preservation. Further reforms to mitigate AMR need to account for the value orientations of different groups and the embeddedness of the constraints imposed by existing systems. Advocacy for greater AMR precaution in agriculture should acknowledge and compensate for erosions in competing common goods and the cost of proposed interventions. (shrink)

Climate change continues to have profound impacts on people’s health, lives and life prospects. For the most part, people who are at highest risk from the impacts of climate change have contributed very little to the problem. This is the crux of the injustice. After I discuss the risks and contributions associated with the injustice of climate change, I turn to the issue of responsiveness: of why and how people should respond to this injustice. I avoid discussions of legal liability (...) and focus more attention on the need to take political action to change social structures and habits. However, I realize how political engagement can prove to be ineffective, burdensome and dangerous. So in the last section, I say more about the reasons and changes that limit the effectiveness of political engagement. I suggest how we might change both the perception and practice of politics. At the end, I note two issues that I have not addressed in this limited article. (shrink)

Despite the important role of physical activity in population health and well-being, it has received less focus in public health ethics as compared to other modifiable lifestyle factors such as smoking and diet. However, when considering the current and potential role of physical activity within public health—including interventions and policies to encourage physical activity in schools and workplaces, changes to the built environment and the equity issues associated with access to physical activity—it is a ripe territory for ethical analysis. This (...) paper makes a case for a more sustained focus on physical activity within public health ethics by reviewing two ethical issues within physical activity and public health: physical activity inequity as a structural injustice issue, and stigma in physical activity promotion. While the benefits of physical activity for every age group and demographic are numerous, ethics oversight is encouraged to ensure that these efforts do not impose unnecessary risks or stigmatize marginalized populations. (shrink)

Global consumption of antibiotics has accelerated the evolution of bacterial antimicrobial resistance. Yet, the risks from increasing bacterial antimicrobial resistance are not restricted to human populations: transmission of antimicrobial resistant bacteria occurs between humans, farms, the environment and other reservoirs. Policies that take a ‘One Health’ approach deal with this cross-reservoir spread, but are often more restrictive concerning human actions than policies that focus on a single reservoir. As such, the burden of justification lies with these more restrictive policies. We (...) argue that an ethical justification for preferring One Health policies over less restrictive alternatives relies on empirical evidence as well as theory. The ethical justification for these policies is based on two arguments: (i) comparatively greater effectiveness, and (ii) comparatively better tracking of moral responsibility. Yet the empirical assumptions on which these claims rest are limited by existing empirical knowledge. Using livestock farming as an example, we suggest that scientific research into characterising antimicrobial resistance and linking practices to outcomes ought to be guided (at least in part) by the imperative to supply the context-specific data needed to ethically justify preferring a One Health policy over less restrictive alternatives. (shrink)

Paternalism is a frequent source of anxiety and scholarly enquiry within public health. This article examines debate in the UK from the 1950s to the early 1980s about two quintessentially paternalistic laws: those making it compulsory to use a motorcycle helmet, and a car seatbelt. This kind of historical analysis, looking at change over time and the circumstances that prevent or enable such change, draws attention to two significant features: the contingent nature of that which is perceived as paternalistic and (...) therefore objectionable, and the wide range of arguments that can be marshalled for and against. It suggests that paternalism became a particularly disruptive accusation in the UK of the 1970s in relation to seatbelts, thanks to the population that would be affected and the wider socio-political context. It also suggests that arguments about the social cost of death and injury on the roads, along with overt acceptance that some element of paternalism could be acceptable, proved influential—as was the sense of inevitability that 10 years of regular debate helped to create. (shrink)

Through users’ cross-system comparative experience engaging with the health systems in Taiwan and other countries, this article probes into their understandings and value judgments and specifically their reasonings for the ‘solidarity with whom?’ question in the health sector solidarity. With the cross-system comparison approach, the study adopted semi-structured interviews with 30 Taiwanese participants who have studied, lived or worked abroad and engaged with the health system in Canada, the USA or the UK. This approach offers the opportunity for one to (...) evaluate the health system in the home country from a relative viewpoint from the host country. The participants suggested that the boundary of Taiwan’s National Health Insurance (NHI) should be as inclusive as possible, covering all legal residents in Taiwan regardless of their status, and that the citizens should share more financial responsibility. The ethical reasons for supporting the NHI include recognizing health sector solidarity among people, considering the coverage as a protection of the human right to health, humanitarian reasons and self-interest. Three archetypes of users emerged from the synthesis: Universalists, Rationalists and Republicans. The cross-system comparative experience makes the participants have more supportive attitudes toward the ideals of health sector solidarity. (shrink)