In The Community of Advantage, Robert Sugden advocates an opportunity-oriented framework for normative analysis, positions it a substitute for behavioral welfare economics, and criticizes the latte...

This article analyses domestic and foreign reactions to a 2008 report in the British Medical Journal on the complementary and, as argued, synergistic relationship between palliative care and euthanasia in Belgium. The earliest initiators of palliative care in Belgium in the late 1970s held the view that access to proper palliative care was a precondition for euthanasia to be acceptable and that euthanasia and palliative care could, and should, develop together. Advocates of euthanasia including author Jan Bernheim, independent from but (...) together with British expatriates, were among the founders of what was probably the first palliative care service in Europe outside of the United Kingdom. In what has become known as the Belgian model of integral end-of-life care, euthanasia is an available option, also at the end of a palliative care pathway. This approach became the majority view among the wider Belgian public, palliative care workers, other health professionals, and legislators. The legal regulation of euthanasia in 2002 was preceded and followed by a considerable expansion of palliative care services. It is argued that this synergistic development was made possible by public confidence in the health care system and widespread progressive social attitudes that gave rise to a high level of community support for both palliative care and euthanasia. The Belgian model of so-called integral end-of-life care is continuing to evolve, with constant scrutiny of practice and improvements to procedures. It still exhibits several imperfections, for which some solutions are being developed. This article analyses this model by way of answers to a series of questions posed by Journal of Bioethical Inquiry consulting editor Michael Ashby to the Belgian authors. (shrink)

To date, we know very little about the effects of the differences in attachment classifications on the physiological correlates of stress regulation in adolescent age groups. The present study examined for the first time heart rate and heart rate variability during an attachment interview in adolescents. HR and HRV data were collected during a baseline assessment as well as during the administration of the Adult Attachment Projective Picture System in a community-based sample of 56 adolescents. We additionally used the Adult (...) Attachment Interview in 50% of our sample to test the convergent validity. Adolescents with a secure attachment representation showed a higher HRV from baseline to the AAP interview compared to those with an insecure-dismissing and the unresolved group. A comparison between the two insecure attachment groups showed no significant difference related to HR and HRV. Cohen’s Kappa revealed an almost perfect agreement between the AAP and the AAI for the four-group classification. Our results indicate that adolescents with a secure attachment representation are more capable of dealing with attachment-related distress which is represented in higher HRV during an attachment interview. (shrink)

Public health ethics is emerging as a new field of inquiry, distinct not only from public health law, but also from traditional medical ethics and research ethics. Public health professional and scholarly attention is focusing on ways that ethical analysis and a new public health code of ethics can be a resource for health professionals working in the field. This article provides a preliminary exploration of the ethical issues faced by public health professionals in day-to-day practice and of the type (...) of ethics education and support they believe may be helpful. (shrink)

Public health ethics is emerging as a new field of inquiry, distinct not only from public health law, but also from traditional medical ethics and research ethics. Public health professional and scholarly attention is focusing on ways that ethical analysis and a new public health code of ethics can be a resource for health professionals working in the field. This article provides a preliminary exploration of the ethical issues faced by public health professionals in day-to-day practice and of the type (...) of ethics education and support they believe may be helpful. (shrink)

This paper explores the use of an ethics framework based on the Public Health Code of Ethics to guide rationing decisions during a pandemic flu crisis involving a shortage of ventilators. While the law provides public health officials with authority to act, public health officials, as community leaders and health department managers, must address complex questions about how they should use their legal authority, how they can ethically justify a particular action, how they should engage community stakeholders in decision making, (...) and how the process of public justification should take place. Recognising the need for a tool that could help public health officials manage ethical tensions in practice, such as allocation of scarce resources, the Public Health Leadership Society led efforts to develop a Public Health Code of Ethics. The 12 Principles in the Code were written to express the general norms implicit in the practice of public health professionals. The Code offers no hierarchical weighting of the different principles and anticipates that weights and specification of the principles would take place in the context of each community through a process of engagement between public health officials and community stakeholders about specific cases. We describe how public health officials can use the Code to guide deliberation in helping communities prepare to address the tragic choices when allocating scarce ventilators in an influenza pandemic. (shrink)

The use of quality of life (QOL) outcomes in clinical trials is increasing as a number of practical, ethical, methodological, and regulatory reasons for their use have become apparent. It is important, then, that QOL measurements and differences between QOL scores be readily interpretable. We study interpretation in two contexts: when determining QOL and when basing decisions on QOL differences. We consider both clinical situations involving individual patients and research contexts, e.g., randomized clinical trials, involving groups of patients. We note (...) the ethical importance of such understanding: proper interpretation and communication facilitate health care decision making. Communication that facilitates interpretation is of moral significance since better communication can attenuate ethical problems and inform choices. Much of what is communication worthy about QOL assessments is determined by the particular QOL instrument used in the assessment and how it is administered. In practice, these choices will be driven by the purpose of the assessment, but, it is argued, to maximize understanding, we should combine the information garnered from traditional standardized QOL instruments, from individualized QOL assessments, and from a recently proposed dialogic paradigm, where QOL is determined by shared conversation regarding the interpretation of texts. And, while some studies can surely succeed using abbreviated methods of administration (e.g., postal surveys may suffice for certain purposes), we will focus on methods of administration involving interviewer–respondent interaction. We suggest that during the QOL elicitation process, interviewer and respondent should engage in a two-way conversation in order to achieve a shared understanding of the “answers” to QOL “questions” and, finally, to reach a shared interpretation of the individual’s QOL. (shrink)

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

Amyotrophic lateral sclerosis (ALS; also called motor neuron disease) is a devastating medical condition that progressively robs patients of their ability to move, speak and eventually breathe. At present, many physicians are hesitant to propose tracheostomy and respiratory support in the terminal phase of ALS. In accordance with the principle of patient autonomy, physicians should respect the right of the ALS patient to accept or refuse any treatment, including mechanical ventilation. Also, in environments where euthanasia or physician-assisted death is legal, (...) such requests can be acceptable. At least two conditions are necessary for full autonomy. To have a claim on full autonomy, people need to have intact cognitive abilities, and to exercise this right they must be able to communicate. In the past, the first condition was in doubt (indeed, overlap with other neurodegenerative diseases is sometimes suspected and some patients with ALS are thought to have associated frontotemporal dementia) and the second was severely compromised in patients with devastating motor impairment (communication being limited to the twitch of a finger or the blink of an eye). In this issue of J Neurol Neurosurg Psychiatry, Lakerveld and colleagues1 investigated cognition in 11 patients with late stage ALS (see page 25). They showed preserved cognitive functioning (ie, language, executive function, intelligence, learning and long term memory) compared with healthy controls. Assessments were exclusively based on a ‘‘yes–no’’ response mode. Because of the absence of verbal and motor communication, the neuropsychological assessment of these patients is complicated, and adapted testing is needed. By using a ‘‘yes–no’’ response mode based on the remaining motor abilities of the patient, this study proves the possibility of assessing patients with minimal motor capacities. (shrink)

BackgroundFear of abandonment and aloneness play a key role in the clinical understanding interpersonal and attachment-specific problems in patients with borderline personality disorder and has been investigated in previous functional Magnet Resonance Imaging studies. The aim of the present study was to examine how different aspects of attachment representations are processed in BPD, by using for the first time an fMRI attachment paradigm including personalized core sentences from the participants’ own attachment stories. We hypothesized that BPD patients would show increased (...) functional involvement of limbic brain regions associated with fear and pain when presented personalized attachment relevant stimuli representing loneliness compared to healthy controls.MethodsWe examined the attachment classifications of 26 female BPD patients and 26 female HC using the Adult Attachment Projective Picture System. We used an fMRI-adapted attachment paradigm to investigate the neural correlates of attachment. All participants were presented three personalized sentences extracted from their AAP attachment narrative, combined with standardized AAP pictures representing being alone or in interactive attachment situations.ResultsAs expected, the classification of unresolved attachment was significantly greater in BPD compared to HC. BPD patients showed increased fMRI-activation in brain areas associated with fear, pain, and hyperarousal than HC when presented with personalized attachment-relevant alone stimuli. In particular, pictures with monadic attachment situations induced greater anterior medial cingulate cortex, anterior insula, amygdala, thalamus and superior temporal gyrus activation in the patient group.ConclusionThe results point to increased fMRI-activation in areas processing emotional distress and painful experiences in BPD patients. In particular, the emotional cascade reflecting attachment distress was evoked by combining monadic pictures, representing abandonment and aloneness, with the patients’ personalized narrative material. Our results confirmed and replicated previous results that illustrate once again the high relevance of aloneness and feelings of abandonment for BPD in the context of attachment trauma. Moreover, our results support the hypothesis of hypermentalization in response to attachment distress as a core feature of social-cognitive impairment in BPD associated with common treatment implications across different therapeutic orientations. (shrink)

Public health ethics is emerging as a new field of inquiry, distinct not only from public health law, but also from traditional medical ethics and research ethics. Public health professional and scholarly attention is focusing on ways that ethical analysis and a new public health code of ethics can be a resource for health professionals working in the field. This article provides a preliminary exploration of the ethical issues faced by public health professionals in day-to-day practice and of the type (...) of ethics education and support they believe may be helpful. (shrink)

Public health ethics is emerging as a new field of inquiry, distinct not only from public health law, but also from traditional medical ethics and research ethics. Public health professional and scholarly attention is focusing on ways that ethical analysis and a new public health code of ethics can be a resource for health professionals working in the field. This article provides a preliminary exploration of the ethical issues faced by public health professionals in day-to-day practice and of the type (...) of ethics education and support they believe may be helpful. (shrink)

The issue of public health ethics has received much attention in recent years and is seen as a new field, distinct from medical ethics. Faculty from the University of Virginia, Johns Hopkins School of Public Health, Georgetown University, the University of Minnesota, and others received a grant from the Greenwall Foundation to examine this new field of public health ethics and identify the unique principles that distinguish it from the study of medical ethics. In the course of that study, which (...) included exploring the field with public health practitioners, a number of distinguishing ethical principles emerged. The moral principles appropriate for public health officials included producing benefits; avoiding, preventing and removing harms; producing a maximum balance of benefits over harms; and distributing benefits and burdens fairly. (shrink)