For patients with mental health problems, de-institutionalization has meant a shift from institutional care to living in the community. However, several studies show that problems of stigmatization, loneliness and negative attitudes devalue the dignity and autonomy of these patients. The aim of this study was to gain a deeper understanding of how people with mental health problems experience living in an apartment of their own. The data collection method was focus group interviews. The constant comparative method revealed the (...) main category ‘preserving integrity’. The subcategories were: the need for control over information, similar relationships with both friends and neighbours (symmetrical contact), and ‘My home is my castle’. Participants who lived in a group home had little or no contact with their neighbours. The participants experienced lack of acceptance and loss of autonomy when meeting people. Integrity was a necessary condition in order for them to become equal citizens, experience autonomy and dignity, and have the opportunity to develop social contacts. (shrink)

A major issue facing the health of young adults in the United States is the often unintentional lack of confidentiality maintained in the provision of sensitive health services. Of primary concern is that young adults who remain on their parents' health insurance plans forgo Sexually Transmitted Infection screening and treatment, as well as other sensitive services such as family planning services and mental health treatment out of a concern that explanation of benefit forms from such services (...) will inform their parents, the policyholders. The challenges of providing confidential health care to young adults have become more prominent and concerning following the passage of the Affordable Care Act, as adult children can now remain on their parents' plans until the age of 26. While this change will grant more young adults access to health care services, ensuring confidential care remains a challenge whenever the parent and not the patient is the policyholder. This article discusses these serious challenges and offers potential solutions to ensuring confidentiality for specific services for young adults. (shrink)

A major issue facing the health of both minors and young adults in the United States is the often unintentional lack of confidentiality maintained in the provision of sensitive health services. Studies have shown that access to confidential care is crucial for minors seeking preventive care and treatment for sensitive services. Evidence demonstrates that many minors will not seek health care if confidentiality cannot be ensured, which can have significant negative health implications; this finding can be (...) extended to young adults covered under their parents health plans. Young adults, not just minors, also often forgo important sensitive services when they face a breach of confidentiality, which most likely occurs when their parents have access to the adult child's health information.Currently, private insurance companies generally send the policyholder an explanation of benefits whenever a service is provided under a plan. EOBs generally include information identifying the patient, provider, type of care received, total charge for services, amount paid by the insurance company, and any financial obligation of the policyholder. (shrink)

Those whom the gods wish to destroy, they first make mad, says a Nigerian proverb. These words of wisdom re-echo in traditional approaches to mental health ethics in sub-Saharan Africa. Among many cultures in Nigeria, it is customary to subject persons with mental health illness, especially those who present with violent behavior, to physical restraint and beatings. The belief is that such subjugation could restore mental health in the early stages of madness. Physical restraint and beatings only (...) form a part of the healing process, as it also has communitarian cum spiritual aspects. The healing process is carried out by family members or community, who share in the life of the mentally ill person. Their... (shrink)

The article by Jessica Pierce and Christina Kerby, raises some important but seldom asked questions about the use of natural resources in healthcare. They take for their example latex gloves, which are in wide everyday use, especially since the establishment of principles of universal precautions in infection control as a reaction to the spread of HIV. They trace the production of latex gloves back through rubber processing to their origins in Malaysian rubber plantations and elsewhere. They then ask, but do (...) not answer, some hard questions about the ethics of our relationship as patients to the impact of the materials we use on communities and the environment. To draw out their theme more starkly, consider the rumor widespread in South America that some babies purportedly adopted by Northerners are sold and cut up for their organs. Suppose this story were true; suppose your donated organ were obtained in this way. You would probably be so revolted by the immorality of its acquisition that you would refuse to accept it. But now take a morally more ambiguous case, as Pierce and Kerby intend. Suppose that the process of obtaining latex gloves is part of the gradual erosion of the Malaysian environment, and that workers in latex factories are poorly paid. Now, should or would you refuse to use latex gloves? Should or would you even be more selective in their use? The practice of universal precautions presumes a virtually unlimited supply of gloves; yet to react to resource scarcity with selective precautions hazards discrimination. Is there any way philosophically to balance the local justice issue of discrimination in comparison to injustice on a global scale and to future generations? (shrink)

Alzheimer’s disease is an insidious onset neurodegenerative syndrome without effective treatment or cure. It is rapidly becoming a global health crisis that is overwhelming healthcare, society, and individuals. The clinical nature of neurocognitive decline creates significant challenges in bidirectional communication between caregivers and persons with Alzheimer’s disease that can negatively impact quality-of-life. This paper sought to understand how and to what extent would awareness training about the levels of consciousness in AD influence the quality-of-life interactions in the caregiver-patient dyad. (...) A literature review of multiple databases was conducted utilizing a transdisciplinary approach. The sum of findings indicates a positive relationship between enhanced caregiver awareness and training, positive interactions, and improved QOL measures among patients and caregivers. A multidirectional relationship was found among healthcare policies, training and education resources, caregivers, and persons with AD. Specifically, the current lack of policy and inadequate training and educational resources has various detrimental effects on patients and caregivers, while improvements in training and education of caregivers yields positive outcomes in communication and QOL. Furthermore, evidence of preserved consciousness in persons with AD was demonstrated from multiple disciplines, including neurobiological, psychological, and biopsychosocial models. The literature further revealed several methods to access the preserved consciousness in persons with AD and related dementias, including sensory, emotional, and cognitive stimulations. The evidence from the literature suggests a reframed approach to our understanding and treatment of persons with AD is not only warranted, but crucial to address the needs of those affected by AD. (shrink)

In this paper we address a frontier topic in the humanities, namely how the cultural and natural construction that we call landscape affects well-being and health. Following an updated review of evidence-based literature in the fields of medicine, psychology, and architecture, we propose a new theoretical framework called “processual landscape,” which is able to explain both the health-landscape and the medical agency-structure binomial pairs. We provide a twofold analysis of landscape, from both the cultural and naturalist points of (...) view: in order to take into account its relationship with health, the definition of landscape as a cultural product needs to be broadened through naturalization, grounding it in the scientific domain. Landscape cannot be distinguished from the ecological environment. For this reason, we naturalize the idea of landscape through the notion of affordance and Gibson’s ecological psychology. In doing so, we stress the role of agency in the theory of perception and the health-landscape relationship. Since it is the result of continuous and co-creational interaction between the cultural agent, the biological agent and the affordances offered to the landscape perceiver, the processual landscape is, in our opinion, the most comprehensive framework for explaining the health-landscape relationship. The consequences of our framework are not only theoretical, but ethical also: insofar as health is greatly affected by landscape, this construction represents something more than just part of our heritage or a place to be preserved for the aesthetic pleasure it provides. Rather, we can talk about the right to landscape as something intrinsically linked to the well-being of present and future generations. (shrink)

In this exploration of the mind-body connection, Ernst Feuchtersleben examines the role of suggestion in mental and physical health. This book is a must-read for psychologists, psychiatrists, and anyone interested in the intersection of mind and body. This work has been selected by scholars as being culturally important, and is part of the knowledge base of civilization as we know it. This work is in the "public domain in the United States of America, and possibly other nations. Within the (...) United States, you may freely copy and distribute this work, as no entity (individual or corporate) has a copyright on the body of the work. Scholars believe, and we concur, that this work is important enough to be preserved, reproduced, and made generally available to the public. We appreciate your support of the preservation process, and thank you for being an important part of keeping this knowledge alive and relevant. (shrink)

On July 2021, the UK High Court of Justice heard the Case CO/2066/2020 on the application of Heidi Crowter who lives with Down’s syndrome, and Máire Lea-Wilson whose son Aidan has Down’s syndrome. Crowter and Lea-Wilson, with the support of the disability rights campaign, ‘Don’t Screen Us Out’, have been taking legal action against the Secretary of State for Health and Social Care (the UK Government) for a review of the 1967 Abortion Act: the removal of section 1(1)(d) making (...) termination of pregnancy lawful for ‘severe’ fetal indications detected after 24 weeks' gestation. On 23 September 2021, the High Court dismissed the claim. This action came at a time when non-invasive prenatal testing (NIPT) was introduced into the NHS England Fetal Anomaly Screening Programme for the trisomies 21, 13 and 18. The implementation of NIPT has been heavily criticised, in particular by ‘Don’t Screen Us Out’ campaigners, for increasing fetal selection and discrimination of people living with disabilities. The case of Crowter and Lea-Wilson echoes debates in other European countries such as in France and Germany, where the introduction of NIPT in the public healthcare system has provoked equally vehement public reactions and discussions. The comparison between these three countries allows contextualising the public discourses around NIPT and the ground for termination of pregnancy in relation to different socio-cultural and political contexts. We examine how each country, and particularly England, deals with the conflict between the principles of promoting the rights of people living with disabilities and preserving women’s reproductive autonomy. (shrink)

'Health promotion' has unfortunately come to mean different things to different people. Interpretations have frequently been left implicit and where spelt out have often been too diffuse or too limited to be useful. Nevertheless the term can be usefully employed to define a set of health-enhancing activities in which the focus is deflected from current disease- and cure-oriented power bases. Used in this way health promotion can come to include the best of the developing theory and practice (...) from a wide range of 'experts' but can also place due emphasis on community involvement. To reject health promotion on the basis of selected, inadequate interpretations is to discard past successes, current developments and future possibilities in important fields of activity and to preserve an inappropriate status quo. (shrink)

Eudaimonistic theorists of welfare have recently attacked conative accounts of welfare. Such accounts, it is claimed, are unable to classify states normally associated with physical and emotional health as non-instrumentally good and states associated with physical and psychological damage as non-instrumentally bad. However, leading eudaimonistic theories such as the self-fulfillment theory and developmentalism have problems of their own. Furthermore, conative theorists can respond to this challenge by dispositionalizing their theories, i.e., by saying that it is not merely the realization (...) of one’s values that is non-instrumentally good for one, but that the disposition to realize one’s values is also non-instrumentally good for one. This approach, properly elaborated, can accommodate the idea that, in many cases, states normally associated with physical and psychological health (or unhealth) are non-instrumentally good (or bad). It also preserves the many well-known advantages of conative theories. (shrink)

BackgroundWhile fertility preservation is recommended practice for paediatric oncology patients, it is increasingly being considered for transgender children and young people in paediatric care. This raises ethical issues for clinicians, particularly around consent and shared decision-making in this new area of healthcare.MethodsA systematic review of normative literature was conducted across four databases in June 2020 to capture ethical considerations related to fertility counselling and preservation in paediatric transgender healthcare. The text of included publications was analysed inductively, guided by (...) the Qualitative Analysis Guide of Leuven.ResultsTwenty-four publications were identified for inclusion. Four key ethical considerations emerged from this literature: access to fertility preservation, conscientious objection, decision-making capacity of children and young people, and shared decision-making.ConclusionIn the identified literature, there is consensus that transgender children and young people should not be refused access to fertility preservation services solely due to their gender identity, and that clinicians with conscientious objections to fertility preservation for this group have an obligation to refer on to willing providers. Factors that create ethical complexity in this area of paediatric care include the child’s age, mental health, and parents’ views. (shrink)

In the literature on health, naturalism and normativism are typically characterized as espousing and rejecting, respectively, the view that health is objective and value-free. This article points out that there are two distinct dimensions of disagreement, regarding objectivity and value-ladenness, and thus arranges naturalism and normativism as diagonal opposites on a two-by-two matrix of possible positions. One of the remaining quadrants is occupied by value-dependent realism, holding that health facts are value-laden and objective. The remaining quadrant, which (...) holds that they are non-objective but value-free, is unexplored. The article endorses a view in the latter quadrant, namely, the view that health is a secondary property. The article argues that a secondary property framework provides the resources to respond to the deepest objections to a broadly Boorsean account of natural function, and so preserves the spirit, though not the letter, of that account. Treating health as a secondary property permits a naturalistic explanation—specifically, an evolutionary explanation—of the health concept, in terms of the assistance such a concept might have provided to the survival and reproduction of those organisms that had it. This provides the explanation, missing from Boorse's account, for the fact that function is determined with reference to the contribution to the goals of survival and reproduction, relative to the age of the sex of the species, rather than some other equally natural goals or reference classes. _1_ Introduction _2_ Two Ways to Disagree about Health _3_ Secondary Properties _4_ Health as a Secondary Property _5_ Conclusion. (shrink)

The paper begins by tracing the historical development of American medicine as practice, profession, and industry from the eighteenth century to the present. This historical outline emphasizes shifting conceptions of physicians and physician ethics. It lays the basis for showing, in the second section, how contemporary controversies about the physician’s role in managed care take root in medicine’s past. In the final two sections, I revisit both the historical analysis and its application to contemporary debates. I argue that historical narratives (...) can function as “master narratives” that suppress or leave out historical facts. I bring to the surface what is covered up by the master narrative approach, and show its relevance to contemporary ethical debates. I conclude by proposing that preserving the integrity of medicine will require modifying the master narratives we tell about physicians. The integrity of medicine also offers new perspectives for thinking about managed care and the broader topic of health care reform. (shrink)

The practice of health-care professional involvement in capital punishment has come under scrutiny since the implementation of lethal injection as a method of execution, raising questions of the goals of medicine and the ethics of medicalized procedures. The American Medical Association and other professional associations have issued statements prohibiting physician involvement in capital punishment because medicine is dedicated to preserving life. I address the three primary arguments against health-care professionals being involved in lethal injection and argue that they (...) are not strong enough to prohibit physician involvement in the lethal injection process. (shrink)

Libertarian paternalism describes the idea of nudging—that is, steering individual decision-making while preserving freedom of choice. In medicine, libertarian paternalism has gained widespread attention, specifically with respect to interventions designed to promote healthy behaviours. Some scholars argue that nudges appropriately balance autonomy and paternalistic beneficence, while others argue that nudges inherently exploit cognitive weaknesses. This paper further explores the ethics of libertarian paternalism in public health. The use of nudges may infringe on an individual’s voluntary choice, autonomy and informed (...) consent, but they are ethically justified when there is a clear public health benefit to the manipulation of choice. (shrink)

This chapter contains sections titled: HIV Testing HIV Infection: Harm to Self or Harm to Others Access to Experimental Drugs and the Ethics of Research Clinical Trials Developing Preventive Vaccines Affordable Access to Life‐preserving Medication HIV Infection in Health‐care Professionals and Patients Final Remarks References Further reading.

Evaluating public health measures is one of the central tasks in public health ethics. Some public health measures incur the charge that they are paternalistic in an objectionable way. In a recent intriguing contribution to this journal, Thomas Nys responds to this complaint by setting out three challenges to be met if the charge is to be made good. The first challenge is that putatively objectionable public health measures in fact preserve autonomy; the second is that (...) autonomy is not undermined by measures that are the upshot of democratic processes; the third is that it is a mistake to charge measures intended to benefit others with being objectionably paternalistic. Nys's explicit aim in presenting these challenges is not to show that the charge of paternalism in public health is never sound, but to stimulate further discussion. My paper takes up this invitation by responding to each of the challenges Nys presents, including discussing where they fail and identifying which succeed. (shrink)

The sources, extent and margins of parental obligations in taking decisions regarding their children’s medical care are subjects of ongoing debates. Balancing children’s immediate welfare with keeping their future open is a delicate task. In this paper, we briefly present two examples of situations in which parents may be confronted with the choice of whether to authorise or demand non-therapeutic interventions on their children for the purpose of fertility preservation. The first example is that of children facing cancer treatment, (...) and the second of children with Klinefelter syndrome. We argue that, whereas decisions of whether to preserve fertility may be prima facie within the limits of parental discretion, the right to an open future does not straightforwardly put parents under an obligation to take actions that would detect or relieve future infertility in their children—and indeed in some cases taking such actions is problematic. (shrink)

Environmental sustainability is one of the contemporary discourses that has abundant values embedded in the Quran and Sunnah teachings. Islam gives great emphasis on environment as it is preserved and protected under the Maqasid al-Shariah. The general outlook of Quranic paradigm on utilizing natural environment is based on prohibition of aggression and misuse. It is likewise founded on the construction and sustainable use. Thus, this article attempts to elaborate key concepts of the Quran and Sunnah teachings that reveal imperative values (...) for environmental sustainability. Research method employs in this paper is an analytical study of Quranic verses with special highlights of tafsir bi al-ma’thur, tafsir bi al-ra’yi, and historical narrative. In short, this paper brings to light the relevance of classical and contemporary works of Quran and Sunnah studies that have meticulous values for shaping the better world of human–nature’s interaction. (shrink)

In this paper, the authors consider the idea of the public biobank governance framework with respect to the innovative paradigm of One Health. The One Health initiative has been defined as an integrative and interdisciplinary effort to improve the lives and well-being of human beings and non-human animals, as well as to preserve the environment. Here, we use this approach as a starting presumption with respect to institutional design. We examine the theoretical and legal framework underlying the concept (...) of biobanking that, being public orientated, is _for the public good_. We suggest that this account of research practice does not ethically correlate with One Health principles. Instead, we argue that One Health requires a model of biobanking that is based on universal goods, that is, goods that serve human beings as well as non-human animals and the environment, and which we define in detail. Our purpose is to begin a discussion on how One Health principles might be implemented in health initiatives. (shrink)

In Dobbs v. Jackson Women's Health Organization, the Supreme Court eliminated the long‐standing federal constitutional right to abortion. Discussions of Dobbs tend to emphasize the loss of protection for reproductive choice. But Dobbs also eroded protection for a related yet distinctly important interest that served under Roe v. Wade as a check on government regulation of reproduction: the preservation of health. This erasure has opened the door to increasingly restrictive and punitive abortion bans, which are causing providers (...) to deny or delay care that is necessary to prevent harm to both pregnant and nonpregnant patients. Federal regulatory attempts to prevent these harms will have limited impact, partially due to Congress's own history of exceptionalizing abortion in ways that devalue health. Only federal legislation can ensure adequate and enduring protection for the health of women, trans men, and other patients targeted for reproductive control because of their capacity for pregnancy. (shrink)

This paper aims at explicating the role of the connections and interactions between health, well being and beauty. The primary goal of all medical approaches, including the classic biomedical and humanistic or humane approaches, is to restore or create health, whereby medical approaches that include prevention go beyond the mere restoration of health to include the preservation of health. Equating well-being and thus health with a largely self-determined and joyful life, then not only does (...) a healthy life become a beautiful life, a beautiful life also becomes a healthy life! By bringing Beauty into the health discourse, we are entering the field of aesthetics in general and social aesthetics in particular. As the beautiful is not just a decorative element of life but a genuine source of human strength, it gives us the strength and power we need to implement and achieve all that we then experience as “well-being” and that is called a healthy life. Therefore a further development of a human-based medicine is needed, a medicine that focuses not on a disease construct but which places a human being as a whole, with all his potential and limitations at the heart of diagnostic and therapeutic efforts. The noblest therapeutic goal of this kind of medicine can only be the restoration or preservation of a comprehensive state of health in the sense of complete physical, mental and social well-being, in the sense of opening up the possibility for a mostly autonomous and joyful life. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Global Health Careers:Serving the Navajo CommunityMaricruz Merino, Jonathan Iralu, and Sonya ShinGallup Indian Medical Center (GIMC) sits on a hilltop in Gallup, New Mexico, a town of 20,000 in the four corners region of the Southwestern United States. From its third story windows one can see the red cliffs of the nearby Navajo Nation, a 27,000 square mile reservation that reaches into Arizona, northern New Mexico, and the (...) southern edges of Utah. It is a vast, rural landscape that houses more than 350,000 Navajos. For many on the reservation, healthcare is provided by Indian Health Service hospitals such as GIMC."Are you going to stay?" is a common question for new doctors at GIMC. The Navajo know that their geographic location, while beautiful and attractive to many young providers, will also be the reason they leave. It is hard for doctors to be away from their own homelands. Aging parents get sick, [End Page 86] educational opportunities arise, and children who need to be near extended family are born. But to the Navajo, the story of an individual provider is not so important or memorable. All they know is that providers come and go."Are you here to experiment on us?" is yet another question. Years of exploitation and efforts to destroy traditional ways and language have made many Navajo wary of healthcare providers, no matter how genuine their intentions. Many are so fearful of the hospital—they regard it as "the place to go die."Yet despite this initial suspicion, the Navajo are welcoming people at heart, and tend to develop relationships of trust with their providers. Parents will begin to talk about their grief over a son that has committed suicide or a daughter who died from alcoholic cirrhosis. The elderly will tell you how they care for their five orphaned grandchildren while they can barely take care of their own diabetes. A carpenter tells you he has not worked in a year and feels worthless. An HIV-positive woman will tell you she has been sleeping in a dry river bed because she has no place to go. It quickly becomes apparent that as a physician you will be treating patients with enormous social challenges in addition to complex medical conditions.The origins of the Federal Government's involvement in the healthcare of American Indians and Alaskan Natives (AI/ANs) in the 19th century arose out of both legal obligation and concern for self- preservation. Health services were promised to AI/ ANs in exchange for land, settlements, and agreements. In addition, infectious diseases endemic on reservations as a consequence of crowding and abject poverty, including smallpox and tuberculosis, were seen as a major public health concern. The responsibility of Native American health was first granted to the War Department, then to the Bureau of Indian Affairs, and finally to the Public Health Service in 1955 under the heading of the IHS, or Indian Health Service (U.S. Commission on Civil Rights, 2004; National Library of Medicine, 1994).Since then, the IHS has had many successes. Vaccination rates have gone up, and rates of pneumonia and tuberculosis have gone down significantly. Maternal and infant mortality have declined, and life expectancy has increased (Indian Health Services, 1999). Nonetheless, these improvements remain overshadowed by glaring health disparities among AI/ANs across a broad spectrum of diseases, both communicable and non-communicable, acute and chronic. Native Americans experience higher rates of obesity, diabetes, and cardiovascular disease than the general United States population. They are also more likely to die from alcohol-related causes and in accidents. Life expectancy remains more than five years less than that of the general U.S. population (U.S. Commission on Civil Rights, 2004; U.S. Department of Health and Human Services, 2000).Underlying these health indicators is the continued impoverished status of most AI/ANs. In Navajo, almost half of the population lives below the poverty line. According to the Navajo Nation, the current unemployment rate is 42% (Navajo Nation Department of Economic Development, 2011). Many Navajo on the reservation do not have running water or electricity. They heat with wood, which they chop and haul themselves—regardless... (shrink)

One of the main concerns in defining health is determining its status in relation to value. The main proposals in this direction generally assume a strict dichotomy between descriptive and evaluative dimensions. This essay argues that such a dichotomy leads to a theoretical inconsistency, which becomes evident once a definition of health is practically operative. A new conceptual framework uniting these two moments is proposed as an alternative, capable of preserving the fundamental insights of both descriptive and evaluative (...) accounts of health, and of avoiding the theoretical inconsistencies on the level of practical application. (shrink)

Effective stakeholder engagement and inclusive governance are essential for effective and equitable ocean management. However, few cross-national studies have been conducted to examine how stakeholders’ economic and cultural benefit perceptions influence their support level for policies focused on ocean preservation. The current study aims to fill this gap by employing the Bayesian Mindsponge Framework (BMF) analytics on a dataset of 709 stakeholders from 42 countries, a part of the MaCoBioS project funded by the European Commission H2020. We found that (...) economic and cultural benefit perceptions are generally negatively associated with the policy support level. Regarding economic aspects, stakeholders considering transportation and shipping, renewable energy generation, and oil and gas provision as the most crucial benefits their countries’ oceans provide tend to obtain less support for policies focusing on ocean preservation. Meanwhile, for cultural aspects, perceiving recreation and tourism, aesthetic pleasure, mental health and well-being support, and sense of identity provision as the most important benefits provided by the country’s ocean are negatively associated with the policy support level. The perceived economic, cultural, and environmental tradeoffs when supporting policies focused on ocean preservation were discussed. Recommendations for improving the effective management of multi-use marine space are also provided to reduce the perceived competing interests among stakeholders. (shrink)

This paper offers four arguments against a moral human right to health, two denying that the right exists and two denying that it would be very useful (even if it did exist). One of my sceptical arguments is familiar, while the other is not.The unfamiliar argument is an argument from the nature of health. Given a realistic view of health production, a dilemma arises for the human right to health. Either a state's moral duty to preserve (...) the health of its citizens is not justifiably aligned in relation to the causes of health or it does not correlate with the human right to health. It follows that no one holds a justified moral human right to health against the state.Education and herd immunity against infectious disease both illustrate this dilemma. In the former case, the state's moral duty correlates with the human right to health only if it demands too much from a cause of health; and in the latter, only if it demands nothing from a cause of health (that is, too little). (shrink)

The use of opaque, uninterpretable artificial intelligence systems in health care can be medically beneficial, but it is often viewed as potentially morally problematic on account of this opacity—because the systems are black boxes. Alex John London has recently argued that opacity is not generally problematic, given that many standard therapies are explanatorily opaque and that we can rely on statistical validation of the systems in deciding whether to implement them. But is statistical validation sufficient to justify implementation of (...) these AI systems in health care, or is it merely one of the necessary criteria? I argue that accountability, which holds an important role in preserving the patient‐physician trust that allows the institution of medicine to function, contributes further to an account of AI system justification. Hence, I endorse the vanishing accountability principle: accountability in medicine, in addition to statistical validation, must be preserved. AI systems that introduce problematic gaps in accountability should not be implemented. (shrink)

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

It is well documented that the higher the socioeconomic status (SES) of patients, the better their health and life expectancy. SES also influences the use of health services—the higher the patients' SES, the more time and specialised health services provided. This leads to the following question: should clinicians give priority to individual patients with low SES in order to enhance health equity? Some argue that equity is best preserved by physicians who remain loyal to ‘ordinary medical (...) fairness’ in non-ideal circumstances when health disparities persist; ie, doctors should allocate care according to needs only and treat everyone with equal regard by being neutral with respect to patients' SES. This paper furthers a discussion of this view by questioning how equitable needs relate to SES. To clarify, it distinguishes between four versions of ‘healthcare need’ and approaches an acceptable conceptualisation of the notion supported by Norman Daniels' theory on health equity. It concludes that doctors should remain neutral to patients' SES in cases in which several patients require the same health care. However, equitable health care requires considerations of the impact of socioeconomic factors (SEF) on patients' capacity to benefit from the care. Remaining neutral towards patients' SES in this respect does not promote equal regard. It follows that priority setting on the basis of SEF is required in fair clinical distribution of care, eg, through allocating more time to patients with low SES. In order to advance equity accurately, the concept of ordinary medical fairness should be amplified according to this clarification. (shrink)

Is it possible to interfere with individual decision-making while preserving freedom of choice? The purpose of this article is to assess whether ‘libertarian paternalism’, a set of political and ethical principles derived from the observations of behavioural sciences, can form the basis of a viable framework for the ethical analysis of public health interventions. First, the article situates libertarian libertarianism within the broader context of the law and economics movement. The main tenets of the approach are then presented and (...) particular attention is given to its operationalization through the notion of a ‘nudge’. Essentially, a ‘nudge’ consists in an intervention, which aims to suggest one choice over another by gently steering individual choices in welfare-enhancing directions yet without imposing any significant limit on available choices. Finally, the article concludes that, while it fails as an overreaching framework of ethical analysis, libertarian paternalism nonetheless constitutes a valuable addition to the conceptual toolbox of public health ethics. (shrink)

A comprehensive assessment of a health technology requires that a wide variety of questions are addressed. These range from whether the use of a technology results in achievement of its intended effects (e.g., better tumour control, pain relief, improved mobility, etc.) at acceptable costs and without incurring undue risks to the patient, to whether its use may challenge existing social arrangements and values (e.g., individual responsibility for preserving good health, the value of human life, etc.). Clearly, this is (...) a major challenge, since it requires the use of quite different methods of inquiry. In the past decades, we have rarely witnessed assessments where both types of questions were addressed in a balanced way. Rather, a wide gap exists between inquiries with a strong empirical focus and an almost complete neglect of underlying normative issues, and inquiries which are largely discursive, but with a serious disregard of relevant empirical data. The complex interplay between normative frameworks and empirical data in the assessment of health technologies is illustrated in two case studies: the assessment of surgical management of children with glue ears, and the assessment of Extra Corporeal Membrane Oxygenation in neonates. (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)

It is an imperative within health care, medicine, and public health to restore, preserve, and enhance health. Therefore, it is important to determine what kinds of enhancement are increases in health and what kinds are not. Taking as its point of departure two conceptions of health, namely, “manifest health” and “fundamental health,” the paper discusses various means used to enhance ability and well-being, and if those means, such as wheelchairs, implants, medicines, stimulants, or (...) narcotics, enhance health. The fact that some means that enhance ability or well-being are not usually considered health enhancing, for example, narcotics, constitutes a problem. The paper ends with a discussion of some suggestions about how to distinguish between those enhancements that are health related and those that are not. One plausible idea holds that an enhancement is health related when the substance, or aid, increases ability or well-being, is integrated into the body, and does not harm the individual’s fundamental health. (shrink)

Person‐centred practice indubitably seems to be the antithesis of technology. The ostensible polarity of technology and person‐centred practice is an easy road to travel down and in their various forms has been probably travelled for decades if not centuries. By forging ahead or enduring these dualisms, we continue to approach and recede, but never encounter the elusive and the liminal space between technology and person‐centred practice. Inspired by Haraway's work, we argue that healthcare practitioners who critically consider their cyborg ontology (...) may begin the process to initiate and complicate the liminal and sought after space between technology and person‐centred practice. In this paper, we draw upon Haraway's idea that we are all materially and ontologically cyborgs. Cyborgs, the hybridity of machine and human, are part of our social reality and embedded in our everyday existence. By considering our cyborg ontology, we suggest that person‐centred practice can be actualized in the contextualized, embodied and relational spaces of technology. It is not a question of espousing technology or person‐centred practice. Such dualisms have been historically produced and reproduced over many decades and prevented us from recognizing our own cyborg ontology. Rather, it is salient that we take notice of our own cyborg ontology and how technological, habitual ways of being may prevent (and facilitate) us to recognize the embodied and contextualized experiences of patients. A disruption and engagement with the habitual can ensure we are not governed by technology in our logics and practices of care and can move us to a conscious and critical integration of person‐centred practice in the technologized care environments. By acknowledging ourselves as cyborgs, we can recapture and preserve our humanness as caregivers, as well as thrive as we proceed in our technological way of being. (shrink)

The pursuit of health is one of the most basic and prevalent concerns of humanity. In order to better attain and preserve health, a fundamental and unified description of the concept is required. Using Paul Tillich's ontological framework, I introduce a complete characterization of health and disease is that is useful to the philosophy of medicine and for health-care workers. Health cannot be understood merely as proper functioning of the physical body or of the separated (...) levels of body, mind, and soul. Rather, the multidimensional unity that is the essence of human life requires a new understanding of health as balanced self-integration within the multiple human dimensions. The ontological description of health and disease has concrete implications for how health-care workers should approach healing. It calls for a multidimensional approach to healing in which particular healing is needed and helpful if it considers the other realms of the human. It reveals the importance of accepting limited health as well as the value of faith understood as an ultimate concern because of its ability to wholly integrate the person. (shrink)

BackgroundIncreasingly, hospitals and research institutes are developing technical solutions for sharing patient data in a privacy preserving manner. Two of these technical solutions are homomorphic encryption and distributed ledger technology. Homomorphic encryption allows computations to be performed on data without this data ever being decrypted. Therefore, homomorphic encryption represents a potential solution for conducting feasibility studies on cohorts of sensitive patient data stored in distributed locations. Distributed ledger technology provides a permanent record on all transfers and processing of patient data, (...) allowing data custodians to audit access. A significant portion of the current literature has examined how these technologies might comply with data protection and research ethics frameworks. In the Swiss context, these instruments include the Federal Act on Data Protection and the Human Research Act. There are also institutional frameworks that govern the processing of health related and genetic data at different universities and hospitals. Given Switzerland’s geographical proximity to European Union (EU) member states, the General Data Protection Regulation (GDPR) may impose additional obligations.MethodsTo conduct this assessment, we carried out a series of qualitative interviews with key stakeholders at Swiss hospitals and research institutions. These included legal and clinical data management staff, as well as clinical and research ethics experts. These interviews were carried out with two series of vignettes that focused on data discovery using homomorphic encryption and data erasure from a distributed ledger platform.ResultsFor our first set of vignettes, interviewees were prepared to allow data discovery requests if patients had provided general consent or ethics committee approval, depending on the types of data made available. Our interviewees highlighted the importance of protecting against the risk of reidentification given different types of data. For our second set, there was disagreement amongst interviewees on whether they would delete patient data locally, or delete data linked to a ledger with cryptographic hashes. Our interviewees were also willing to delete data locally or on the ledger, subject to local legislation.ConclusionOur findings can help guide the deployment of these technologies, as well as determine ethics and legal requirements for such technologies. (shrink)

Despite the prevalence of the terms utilitarianism and utilitarian in the health care and health policy literature, anecdotal evidence suggests that authors are often not fully aware of the diversity of utilitarian theories, their principles, and implications. Further, it seems that authors often categorically reject utilitarianism under the assumption that it violates individual rights. The tendency of act utilitarianism to neglect individual rights is attenuated, however, by the diminishing marginal utility of wealth and the disutility of a protest (...) by those who are disadvantaged. In practice, act utilitarians tend to introduce moral rules and preserve traditional rules. At the same time, the tenability of rule utilitarianism is limited because it ultimately collapses into act utilitarianism or a deontological theory. Negative utilitarianism is a viable utilitarian variant only if we accept complete aversion to suffering, ie, if we disregard any forgone opportunities to increase pleasure. Finally, the adoption of preference utilitarianism requires us to accept the subjectivity of individual claims which may be perceived as unfair. (shrink)

Many countries have not considered palliative care a public health problem. With limited resources, disease-oriented therapies and prevention measures take priority. In this paper, I intend to describe the moral framework for considering palliative care as a public health priority in resource-poor countries. A distributive theory of justice for health care should consider integrative palliative care as morally required as it contributes to improving normal functioning and preserving opportunities for the individual. For patients requiring terminal care , (...) we are guided less by principles of justice and more by the duty to relieve suffering and society's commitment to protecting the professional's obligation to uphold principles of beneficence, compassion and non-abandonment. A fair deliberation process is necessary to allow these strong moral commitments to serve as reasons when setting priorities in resource poor countries. (shrink)

The recent and ongoing refugee crisis in Europe highlights conflicting attitudes about the rights of migrants and refugees to health care in transition and destination countries. Some European and Scandinavian states, such as Germany and Sweden, have welcomed large numbers of migrants, while others, such as the U.K., have been significantly less open. In part, this is because of reluctance by certain national governments to incur what are seen as the high costs of delivering aid and care to migrants. (...) In response to these assumptions, some theorists have argued that the appropriate way to view the health needs of migrants is not in terms of rights, but in terms of the interests of destination and transition countries—and have argued that providing care to migrants and refugees will generate benefits for their host countries. However, self‐interest alone is less effective at motivating the provision of care for health deprivations that do not pose a threat to third parties, or to migrants and refugees in poor or distant countries. In this paper, I argue that while self‐interest is unlikely in itself to motivate the provision of all necessary health care to all migrants and refugees, and may risk stigmatizing already vulnerable persons, it can provide the foundation upon which such motivations can be built. My goal is therefore to show how and why a more just approach to the provision of health care to migrants can and should be derived from narrower, self‐interested commitments to preserving citizen health. (shrink)

There is a tension between the preservation of academic freedom and the economic context in which the university currently finds itself. This tension embodies serious threats to global health as a result of three overlapping phenomena which impede the production and diffusion of valuable knowledge about health. These phenomena, the privatisation, commercialisation and instrumentalisation of knowledge are identified and examined in this paper in relation to human rights and international morality.

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

Male circumcision—partial or total removal of the penile prepuce—has been proposed as a public health measure in Sub-Saharan Africa, based on the results of three randomized control trials showing a relative risk reduction of approximately 60 per cent for voluntary, adult male circumcision against female-to-male human immunodeficiency virus transmission in that context. More recently, long-time advocates of infant male circumcision have argued that these findings justify involuntary circumcision of babies and children in dissimilar public health environments, such as (...) the USA, Australasia and Europe. In this article, we take a close look at the necessary ethical and empirical steps that would be needed to bridge the gap between the African RCTs and responsible public health policy in developed countries. In the course of doing so, we discuss some of the main disagreements about the moral permissibility of performing a nontherapeutic surgery on a child to benefit potential future sexual partners of his. In this context, we raise concerns not only about weaknesses in the available evidence concerning such claims of benefit, but also about a child’s moral interest in future autonomy and the preservation of his bodily integrity. We conclude that circumcision of minors in developed countries on public health grounds is much harder to justify than proponents of the surgery suggest. (shrink)

Shortly following the Second World War, and under the medical direction of ex-army psychiatrist T. F. Main, the Cassel Hospital for Functional Nervous Disorders emerged as a pioneering democratic ‘therapeutic community’ in the treatment of mental illness. This definitive movement away from conventional ‘custodial’ assumptions about the function of the psychiatric hospital initially grew out of a commitment to sharing therapeutic responsibility between patients and staff and to preserving patients’ pre-admission responsibilities and social identities. However, by the mid-1950s, hospital practices (...) had come to focus pre-eminently on patients’ relationships with family members, and staff had developed a social model of mental health that focused on the family as the irreducible unit of mental treatment. By the late 1950s, this culminated in the in-patient admission of entire families for mental treatment, even when only one family member was exhibiting symptoms. At the heart of this growing post-war social-psychiatric preoccupation with the family was a new emphasis on the close relationship between mental health and individuals’ successful development toward mature responsible adulthood. The family came to be conceived as the quintessential space where both were forged. This article examines the process through which the Cassel’s social-psychiatric commitment to ‘therapeutic community’ became focused on the family as a key therapeutic site. While the family had become a central point of focus in social, political and psychological discussions of the foundation for stable democratic culture and political peace in post-war Britain, the Cassel Hospital actively experimented with these connections in therapeutic practice. This article thus illuminates the important, but frequently overlooked, role of psychiatric practices in the development of a post-war psychopolitics that established important links between the nuclear family, mental health and democratic social life. (shrink)

Sir Edmund Leach argues that doctors in the modern world, fortified by the traditional concept that the life of the sick person must at all costs be preserved, are to some extent guilty of the false antitheses current today between youth and age. Moreover youth means health, age illness and senility. Until this imbalance is corrected society will be in danger of `a kind of civil war between the generations'. Society must be taught again that mortality cannot be avoided (...) or conquered by medical science, and at the same time that `health' is not enshrined in the young alone. (shrink)