HIV/AIDS prevention campaigns have been overshadowed by conflicting, competing, and contradictory views between those who support condom use as a last resort and those who are against it for fear of promoting sexual immorality. We argue that abstinence and faithfulness to one partner are the best available moral solutions to the HIV/AIDS pandemic. Of course, deontologists may argue that condom use might appear useful and effective in controlling HIV/AIDS; however, not everything that is useful is always good. In principle, all (...) schools of thought and faith seem to agree on the question of faithfulness for married couples and abstinence for those who are not married. But they differ on condom use. On the ground, the situation is far more complex. We simply lack a single, entirely reliable way to resolve all disagreements regarding HIV/AIDS prevention strategies. (shrink)

BackgroundThere have been notable investments in large multi-partner research programmes across the agriculture-nutrition-health (ANH) nexus. These studies often involve human participants and commonly require research ethics review. These ANH studies are complex and can raise ethical issues that need pre-field work, ethical oversight and also need an embedded process that can identify, characterise and manage ethical issues as the research work develops, as such more embedded and dynamic ethics processes are needed. This work builds on notions of ‘ethics in practice’ (...) by developing an approach to facilitate ethical reflection within large research programmes. This study explores the application of a novel ‘real-time research ethics approach’ (RTREA) and how this can support ethical mindfulness. This involves embedding ethical analysis and decision-making within research implementation, with a continuous dialogue between participants and researchers. The aim is to improve ethical responsiveness and participant experience, which in turn may ethically support adherence and retention. In this case study, a bioethics team (BT) was embedded in a community-based randomised, controlled trial conducted in rural Malawi, titled the ‘Addressing Hidden Hunger with Agronomy’. To identify ethical issues, the researchers conducted ten focus group discussions, fourteen in-depth interviews with key informants, two workshops, observed two sensitisation and three activity meetings conducted by the trial team, and analysed fifteen reports from pre-trial to trial implementation.ResultsThe RTREA facilitated the identification of social and ethical concerns and made researchers aware of participants’ ‘lived research experience’. To address concerns and experiences, the BT worked with researchers to facilitate conversation spaces where social and ethical issues were discussed. Conversation spaces were designed to create partnerships and promote participatory methods to capture trial participants’ (TPs) perspectives and experiences.ConclusionsThe use of RTREA showed the value of real-time and continuous engagement between TPs and researchers. These real-time processes could be embedded to complement traditional ethical guidance and expert opinions. A deeper engagement appeared to support greater operationalising of principles of inclusion, empowerment, and participant autonomy and supported researchers ‘ethical mindfulness’ which in turn may support instrumental outcomes of high recruitment, retention, and adherence levels. (shrink)

BackgroundThe participant recruitment process is a key ethical pivot point when conducting robust research. There is a need to continuously review and improve recruitment processes in research trials and to build fair and effective partnerships between researchers and participants as an important core element in ensuring the ethical delivery of high-quality research. When participants make a fair, informed, and voluntary decision to enroll in a study, they agree to fulfill their roles. However, supporting study participants to fulfill study requirements is (...) an important ethical obligation for researchers, yet evidenced as challenging to achieve. This paper reports on participants’ motivations to volunteer and remain part of a dietary study conducted in Kasungu District, Malawi.MethodsWe conducted twenty in-depth interviews (with chiefs, religious leaders, trial participants, and health surveillance assistants), five systematic ethnographic observations, and fourteen focus group discussions with trial participants and their partners. Interviews were audio-recorded and transcribed verbatim. We used a grounded theory methodology to analyse data that included coding, detailed memo writing, and data interpretation.FindingsThe findings reveal that many participants had concerns during the trial. Thematically, experiences included anxieties, mistrust of researchers, rumours, fears of exploitation, and misconceptions. Anonymous concerns collected from the participants were reported to the trial team which enabled the researchers to appropriately support participants. Despite initial concerns, participants described being supported and expressed motivation to take up their role.ConclusionThese findings highlight a diverse map of multiple notions of what is ethically relevant and what can impact participation and retention within a study. The study has revealed how embedding a responsive approach to address participants’ concerns and ethical issues can support trust relationships. We argue for the need to employ embedded ethics strategies that enhance informed consent, focus on participants’ needs and positive experiences, and support researchers to fulfill their roles. This work highlights the need for research ethics committees to focus on the risks of undue influence and prevent exploitation especially in settings with a high asymmetry in resources and power between researcher and participant groups.Trial Registration: The Addressing Hidden Hunger with Agronomy (Malawi) trial was registered on 5th March 2019 (ISCRTN85899451). (shrink)

Southern African countries have the highest HIV infection rates in the world. In most of the countries in the region, the rate among adults is at least 10%. The fight against HIV/AIDS has mostly been inadequate owing to the lack of proper consideration of ethical and cultural issues. In this article, the authors discuss the ethical and cultural dilemmas concerning HIV/AIDS, with Malawi as a case in point. It is argued that increasing financial resources alone, as exemplified by the Global (...) Fund to Fight AIDS, Tuberculosis and Malaria initiative, without proper attention to ethical issues, morals and appropriate legal obligations, are unlikely to reduce the spread of HIV in southern Africa. (shrink)

The principle of individual medical confidentiality is one of the moral principles that Africa inherited unquestioningly from the West as part of Western medicine. The HIV/AIDS pandemic in Southern Africa has reduced the relevance of the principle of individual medical confidentiality. Individual medical confidentiality has especially presented challenges for practitioners among the Bantu communities that are well known for their social inter-connectedness and the way they value their extended family relations. Individual confidentiality has raised several unforeseen problems for persons living (...) with HIV/AIDS, ranging from stigma and isolation to feelings of dejection as it drives them away from their families as a way of trying to keep information about their conditions confidential. The involvement of family members in treatment decisions is in line with the philosophy of Ubuntu and serves to respect patients’ and families’ autonomy while at the same time benefiting the individual patient. (shrink)

There is currently a global shortage of nurses. Developing countries such as Malawi are among those hardest hit by this shortage. The demands on available nurses have increased and at the same time there is a lack of interest in becoming a nurse owing to the poor working conditions among those still employed in the service. It is questionable if developed nations should recruit nurses from countries such as Malawi, where severe human resource constraints are being experienced. We argue in (...) this article that the current phenomenon of nurses leaving developing nations for western countries is complex. Human rights issues of individual autonomy and public interest are at stake. (shrink)

HIV/AIDS is a major public health problem in Africa. Stigmatization, discrimination and lack of appropriate health care are among the commonest challenges that HIV infected persons and their families face. It has been suggested that among the tools available in the fight against stigmatization and discrimination is public disclosure of a person’s HIV seropositive status. While public disclosure of HIV status has a place in the fight against HIV and AIDS, especially by resulting in behavioural change among people who know (...) of an HIV infected person, we argue that such disclosure also has potential attendant harms. The posthumous disclosure of HIV status is particularly problematic. Public disclosure should be accompanied by appropriate individual counselling and preparation of the community to deal with the situation, and should have regard for cultural sensitivity after consideration of the risks and benefits to individuals, families and the community. Health practitioners should keep in mind that their main duty is to the best interest of the patient, the family and the community, in that order. (shrink)

BackgroundThis paper discusses the contentious issue of reuse of stored biological samples and data obtained from research participants in past clinical research to answer future ethical and scientifically valid research questions. Many countries have regulations and guidelines that guide the use and exportation of stored biological samples and data. However, there are variations in regulations and guidelines governing the reuse of stored biological samples and data in Sub-Saharan Africa including Malawi.DiscussionThe current research ethics regulations and guidelines in Malawi do not (...) allow indefinite storage and reuse of biological samples and data for future unspecified research. This comes even though the country has managed to answer pertinent research questions using stored biological samples and data. We acknowledge the limited technical expertise and equipment unavailable in Malawi that necessitates exportation of biological samples and data and the genuine concern raised by the regulatory authorities about the possible exploitation of biological samples and data by researchers. We also acknowledge that Malawi does not have bio-banks for storing biological samples and data for future research purposes. This creates room for possible exploitation of biological samples and data collected from research participants in primary research projects in Malawi. However, research ethics committees require completion and approval of material transfer agreements and data transfer agreements for biological samples and data collected for research purposes respectively and this requirement may partly address the concern raised by the regulatory authorities. Our concern though is that there is no such requirement for biological samples and data collected from patients for clinical or diagnostic purposes.SummaryIn conclusion, we propose developing a medical data and material transfer agreement for biological samples and data collected from patients for clinical or diagnostic purposes in both public and private health facilities that may end up in research centers outside Malawi. We also propose revision of the current research ethics regulations and guidelines in Malawi in order to allow secondary use of biological samples and data collected from primary research projects as a way of maximizing the use of collected samples and data. Finally, we call for consultation of all stakeholders within the Malawi research community when regulatory authorities are developing policies that govern research in Malawi. (shrink)

Background Research ethics is intertwined with and depends on building robust and responsive research governance systems alongside researchers. Globally there has been substantial investment in agriculture, nutrition, and health (ANH) research motivated by the need to improve health outcomes, such as micronutrient deficiencies in Sub-Saharan Africa. Although there has been a notable focus on ethical issues inherent in ANH studies, there has been scanty research examining researchers’ attitudes related to ANH research. This study was conducted to explore the perspectives of (...) researchers who conducted an agronomic biofortification study in Malawi. Methodology In-depth interviews were conducted with a purposive sample of ten ANH researchers. Interviews were conducted online via Zoom, audio-recorded, transcribed verbatim, and thematically analysed using the Leadership, Ethics, Governance and Systems Framework. Results Four core aspects emerged: Leadership: The relevance of building ethics leadership and ethical competence among researchers. Ethics: There is a need to develop a framework that operationalises core ethical values that can guide the implementation of ANH research. Governance: Research guidelines were perceived to be too generic to guide ANH research. Systems: Researchers’ recommended the establishment of a specialised ANH research ethics committee. Conclusions The findings highlight the significance of building ethics leadership and supporting ethical competency amongst researchers. Researchers recommended the development of tailored approaches rather than utilising generic governance systems and frameworks that are drawn from medical research and thus not fit for purpose in this field. In Malawi, specialised ethics review committees are needed to guide ANH research. (shrink)

BackgroundThere is growing interest in the collection, storage and reuse of biological samples for future research. Storage and future use of biological samples raise ethical concerns and questions about approaches that safeguard the interests of participants. The situation is further complicated in Africa where there is a general lack of governing ethical frameworks that could guide the research community on appropriate approaches for sample storage and use. Furthermore, there is limited empirical data to guide development of such frameworks. A qualitative (...) study to address this gap was conducted with key stakeholders in Malawi to understand their experiences and perspectives regarding storage and usage of samples for future research.MethodsThis study conducted 13 in-depth interviews with ethics committee members, regulators and researchers, and five focus group discussions with community representatives and clinical trial participants in Malawi. Interviews and focus group discussions were audio-recorded, transcribed verbatim, and thematically analysed.ResultsOn the current regulatory guidelines that governs the collection, storage and reuse of samples in Malawi, participants highlighted their different understanding of it, with some indicating that it prohibited the reuse and sharing of samples, while others believed it permitted.Views on the informed consent model used in Malawi, some stakeholders expressed that the current model limited options for sample contributors regarding future use. Researchers supported storing samples for future use in order to maximize their value and reduce research costs. However, they expressed concern over the exportation of samples highlighting that it could lead to misuse and would not support the development of research capacity within Malawi. They recommended use of broad consent or tiered consent and establishment of biobanks to address these concerns.ConclusionsStudy findings highlighted the need for a review of the current regulatory guideline and the development of infrastructure to support the use of stored biological samples for future use among the research community in Malawi. At the moment, there are ethical and practical concerns arising from the collection, storage and secondary use of biological samples make it hard to reconcile scientific progress and the protection of participants. (shrink)

Research collaboration beyond national jurisdiction is one aspect of the globalisation of health research. It has potential to complement researchers in terms of research skills, equipment and lack of adequate numbers of potential research subjects. Collaboration at an equal level of partnership though desirable, may not be practicable. Sometimes, human research specimens must be transported from one country to other. Where this occurs, there should be clear understanding between the collaborating research institutions regarding issues of access and control of the (...) specimens as well as the duration of storage of specimens. The researchers have the duty to inform the research participants about specimen storage and transport across national boundaries. While obtaining informed consent from study subjects if specimens are to be stored beyond the life of the present study could be the ideal, there still remains significant challenges in a multi-cultural world. (shrink)

Legal professionals in Malawi rely on a limited number of textbooks, outdated law reports and inadequate library services. Most documents available are in image form, are un-structured, i.e. contain no useful legal meta-data, summaries, keynotes, and do not support a system of citation that is essential to legal research. While advances in document processing and machine learning have benefited many fields, legal research is still only marginally affected. In this interdisciplinary research, the authors build semi-automatic tools for creating a corpus (...) of Malawi criminal law decisions annotated with legal meta-data, case and law citations. We used this corpus to extract legal meta-data, including law and case citations as used in Malawi by employing machine learning tools, spaCy and Gensim LDA. We set the foundation for a new methodology for classifying Malawi criminal case law according to the recently introduced International Classification of Crime for Statistical Purposes (ICCS). (shrink)

Most philosophical defences of the state’s right to exclude immigrants derive their strength from the normative importance of self-determination. If nation-states are taken to be the political institutions of a people, then the state’s right to exclude is the people’s right to exclude – and a denial of this right constitutes an abridgement of self-determination. In this paper, I argue that this view of self-determination does not cohere with a group-agency view of nation-states. On the group-agency view that I defend, (...) a nation-state is the kind of group-agent that does not supervene on the intentionality of member/citizens. If we think that a nation-state is an intentional group-agent in its own right, then we should think that self-determination resides with the institutions of the state rather than with the citizens. If nation-states do not supervene on the intentionality of citizens, then it is unclear why citizens might have the right to control membership in the state as a feature of self-determination. (shrink)

In this paper I propose a novel defence of political cosmopolitanism grounded in a familiar principle: universal moral equality. Critics of cosmopolitanism generally agree to universal moral equality, but disagree about what moral equality means politically. According to my argument, if we accept that all people are morally equal, then we ought to accept their equal moral standing. We should therefore prefer socio-political arrangements that reflect the equal moral standing of all people over those that reflect differentiated moral standing. A (...) reasonable cosmopolitanism need not preclude partialist attachment to co-nationals, or undermine the significance of self-determination, so long as political arrangements do not produce differentiated moral standing. As the political application of an uncontroversial moral principle, I defend reasonable cosmopolitanism against nationalism and statism. Neither of these, I argue, are suitable foundations for global justice in migration because they each conceive of justice as a local concern for insiders. (shrink)

A good therapeutic relationship in mental health services is a predictor of positive clinical outcomes for people who seek help for distressing experiences, such as voice hearing and paranoia. One factor that may affect the quality of the therapeutic relationship and raises further ethical issues is the impact of the clinical encounter on users’ sense of self, and in particular on their sense of agency. In the paper, we discuss some of the reasons why the sense of epistemic agency may (...) be especially fragile in young people with unusual experiences and beliefs. We argue that it is important to identify and avoid behaviours that can undermine young people’s contributions as epistemic agents in the clinical encounter. (shrink)

: This paper presents a method of moral problem solving in clinical practice that is inspired by the philosophy of John Dewey. This method, called "clinical pragmatism," integrates clinical and ethical decision making. Clinical pragmatism focuses on the interpersonal processes of assessment and consensus formation as well as the ethical analysis of relevant moral considerations. The steps in this method are delineated and then illustrated through a detailed case study. The implications of clinical pragmatism for the use of principles in (...) moral problem solving are discussed. (shrink)

Are there natural kinds of things around which our theories cut? The essays in this volume offer reflections by a distinguished group of philosophers on a series of intertwined issues in the metaphysics and epistemology of classification.

In this book, leading Christian political thinkers and practitioners critique the Rawlsian concepts of “justice as fairness” and “public reason” from the perspective of Christian political theory and practice. It provides a new level of analysis from Christian perspectives, including implications for such hot topics as the culture war.

_Foucault and Animals_ is the first collection to explore the relevance of Foucault’s thought for the animal question. Chrulew and Wadiwel bring together essays that open up his influential range of concepts and methods to new domains of human-animal relations.

: This response to Lynn Jansen's critique of clinical pragmatism concentrates on two themes: (1) contrasting approaches to moral epistemology and (2) the connection between theory and practice in clinical ethics. Particular attention is paid to the status of principles and the role of consensus, with some closing speculations on how Dewey might view the current state of bioethics.

Der folgende Artikel ist im Jahr 2003 unter dem Titel „Clinical Pragmatism: A Method of Moral Problem Solving“ in dem Sammelband „Pragmatic bioethics“ erschienen, welcher sich mit der Bedeutung der pragmatistischen Philosophie für die Praxis befasst. In dem vom Internisten und Bioethiker Joseph J. Fins, dem Thoraxchirurgen Matthew D. Bacchetta und dem Philosophen und Medizinethiker Franklin G. Miller verfassten Beitrag wird der pragmatistische Ansatz in der klinischen Ethik anhand eines Fallbeispiels gleichzeitig beschrieben, begründet und demonstriert. Obgleich die Denkrichtung (...) der pragmatistischen Philosophie sowohl wissenschaftstheoretisch wie praktisch hoch bedeutsam ist – ohne diese ist weder die heutige sozialwissenschaftliche Forschung noch die angewandte, insbesondere die klinische Ethik denkbar –, werden pragmatistische Ansätze im deutschsprachigen Raum bis heute eher rudimentär rezipiert. (shrink)

Translating ethical theories into clinical practice presents a perennial challenge to educators. While many suggestions have been put forth to bridge the theory-practice gap, none have sufficiently remedied the problem. We believe the ascendance of hospital medicine, as a dominant new force in medical education and patient care, presents a unique opportunity that could redefine the way clinical ethics is taught. The field of hospital medicine in the United States is comprised of more than 50,000 hospitalists—specialists in inpatient medicine—representing the (...) fastest growing subspecialty in the history of medicine, and its members have emerged as a dominant new force around which medical education and patient care pivot. This evolution in medical education presents a unique opportunity for the clinical ethics community. Through their proximity to patients and trainees, hospitalists have the potential to teach medical ethics in real time on the wards, but most hospitalists have not received formal training in clinical ethics. We believe it is time to strengthen the ties between hospital medicine and medical ethics, and in this article we outline how clinical ethicists might collaborate with hospitalists to identify routine issues that do not rise to the level of an “ethics consult,” but nonetheless require an intellectual grounding in normative reasoning. We use a clinical vignette to explore how this approach might enhance and broaden the scope of medical education that occurs in the inpatient setting: A patient with an intra-abdominal abscess is admitted to the academic hospitalist teaching service for drainage of the fluid, hemodynamic support, and antimicrobial therapy. During the initial encounter with the hospitalist and his team of medical students and residents, the patient reports night sweats and asks if this symptom could be due to the abscess. How should the hospitalist approach this question? (shrink)

ABSTRACTAlthough scholars increasingly recognize the debts of twentieth-century Roman Catholic theologians to Søren Kierkegaard, no one has yet traced this influence to Joseph Ratzinger. As is frequently observed, Ratzinger’s most famous book, Introduction to Christianity, opens with a meditation on a Kierkegaardian parable from Either/or. We argue that Ratzinger’s use of Kierkegaard extends well beyond this opening image, to some central moments in his articulation of the idea of God, Christology, and theological anthropology. Upon closer inspection, we argue, Ratzinger’s (...) use of these arguments is owing to the fact that his diagnosis of the ills of contemporary society and the orientation of contemporary Christian theology is the same as that of Kierkegaard, despite their seemingly different contexts. Identifying the Kierkegaardian influence on Introduction to Christianity helps draw our attention to the necessarily ‘introductory’ character of Christianity, which otherwise risks being lost. (shrink)

There has been increasing interest in recent years in the development of approaches to estimate causal effects when the number of potential confounders is prohibitively large. This growth in interest has led to a number of potential estimators one could use in this setting. Each of these estimators has different operating characteristics, and it is unlikely that one estimator will outperform all others across all possible scenarios. Coupling this with the fact that an analyst can never know which approach is (...) best for their particular data, we propose a synthetic estimator that averages over a set of candidate estimators. Averaging is widely used in statistics for problems such as prediction, where there are many possible models, and averaging can improve performance and increase robustness to using incorrect models. We show that these ideas carry over into the estimation of causal effects in high-dimensional scenarios. We show theoretically that averaging provides robustness against choosing a bad model, and show empirically via simulation that the averaging estimator performs quite well, and in most cases nearly as well as the best among all possible candidate estimators. Finally, we illustrate these ideas in an environmental wide association study and see that averaging provides the largest benefit in the more difficult scenarios that have large numbers of confounders. (shrink)

Over the course of the last four decades, William Leon McBride has distinguished himself as one of the most esteemed and accomplished philosophers of his generation. This volume—which celebrates the occasion of his seventy-fifth birthday—includes contributions from colleagues, friends, and formers students and pays tribute to McBride’s considerable achievements as a teacher, mentor, and scholar.

In a document penned under the direction of its then-president Cardinal Joseph Ratzinger, the Vatican’s International Theological Commission observed that many neo-Darwinian materialists and their Christian critics share a misunderstanding of the nature of divine causality. This article explores the thought of Joseph Ratzinger in view of proposing the features of a path that seeks to eschew these faulty understandings of how God causes evolutionary change within our world, thus providing an alternative to the Intelligent Design movement’s approach (...) to creation.. Ratzinger has a deep respect for the integrity of nature, rejecting the notion that God is a “craftsman” who “tinkers” with the world. According to Ratzinger, evolutionary change occurs “precisely in the processes of a living being” even as human beings are “not the mere product of development.” Finally, the emeritus pontiff insists that creation is an ever-present act that unfolds “in the manner in which thought is creative,” a dynamic that he describes variously as a story, drama, melody, and symphony. Wedding these and other key insights, this article submits that Ratzinger’s thought on evolution should lead us to conceive of creation less along the lines of an intelligently designed machine and more as a masterpiece story that is continually being told as its plot unfolds naturally over the course of time. (shrink)

International courts are an integral component of the international legal system. These courts have been proliferating over time and increasingly working to ensure state compliance with the rules of the international regulatory regimes they join. However, these courts face a fundamental challenge: while they can rule against governments in violation of the regime’s rules, they cannot enforce those decisions. Working from the first principle that the regulatory regime is designed to help resolve collective action problems among the signees, this Article (...) proposes a formal model of international court influence that helps to explain the extent and limits of international court influence on national government behavior. (shrink)