BackgroundInternational partnerships in research are receiving ever greater attention, given that technology has diminished the restriction of geographical barriers with the effects of globalisation becoming more evident, and populations increasingly more mobile.DiscussionIn this article, we examine the merits and risks of such collaboration even when strict universal ethical guidelines are maintained. There has been widespread examples of outcomes beneficial and detrimental for both high and low –income countries which are often initially unintended.SummaryThe authors feel that extreme care and forethought (...) should be exercised by all involved parties, despite the fact that many implications from such international work can be extremely hard to predict. However ultimately the benefits gained by enhancing medical research and philanthropy are too extensive to be ignored. (shrink)

Human infection challenge studies (HCS) involve intentionally infecting research participants with pathogens (or other micro-organisms). There have been recent calls for more HCS to be conducted in low-income and middle-income countries (LMICs), where many relevant diseases are endemic. HCS in general, and HCS in LMICs in particular, raise numerous ethical issues. This paper summarises the findings of a project that explored ethical and regulatory issues related to LMIC HCS via (i) a review of relevant literature and (ii) 45 (...) qualitative interviews with scientists and ethicists. Among other areas of consensus, we found that there was widespread agreement that LMIC HCS can be ethically acceptable, provided that they have a sound scientific rationale, are accepted by local communities and meet usual research ethics requirements. Unresolved issues include those related to (i) acceptable approaches to trade-offs between the scientific aim to produce generalisable results and the protection of participants, (iii) the sharing of benefits with LMIC populations, (iii) the acceptable limits to risks and burdens for participants, (iv) the potential for third-party risk and whether the degree of acceptable third-party risk is different in endemic settings, (v) the conditions under which (if any) it would be appropriate to recruit children for disease-causing HCS, (v) appropriate levels of payment to participants and (vi) appropriate governance of (LMIC) HCS. This paper provides preliminary analyses of these ethical considerations in order to (i) inform scientists and policymakers involved in the planning, conduct and/or governance of LMIC HCS and (ii) highlight areas warranting future research. Insofar as this article focuses on HCS in (endemic) settings where diseases are present and/or widespread, much of the analysis provided is relevant to HCS (in HICs or LMICs) involving pandemic diseases including COVID19. (shrink)

Improvements of the happiness of the rural population are an essential sign of the effectiveness of relative poverty governance. In the context of today’s digital economy, assessing the relationship between digital literacy and the subjective happiness of rural low-income groups is of great practicality. Based on data from China Family Panel Studies, the effect of digital literacy on the subjective well-being of rural low-income groups was empirically tested. A significant happiness effect of digital literacy on rural low- (...) class='Hi'>income groups was found. Digital literacy promotes the subjective happiness of rural low-income groups through income increase and consumption growth effects. The observed happiness effect is heterogeneous among different characteristic groups, and digital literacy significantly positively impacts the subjective happiness of rural low-income groups. Decomposition of subjective happiness into life satisfaction and job satisfaction shows that digital literacy significantly positively affects the job and life satisfaction of rural low-income groups. This paper demonstrates that digital literacy induces a practical happiness effect. To further strengthen the subjective welfare effect of digital literacy in the construction of digital villages, the government should focus on cultivating digital literacy among low-income groups from the demand side. The construction of digital infrastructure should be actively promoted from the supply side. (shrink)

The rapid growth of pharmaceutical markets in the 20th century has increased the demand for human research participants in clinical trials. However, with the globalization of clinical research, most clinical trials are conducted in low-income countries (LICs) with political and economic instability, and lack of basic healthcare, but easy access to human subjects. This paper explores the unique ethical challenges faced during the pre-enrollment phase of cross-cultural research in a country like Pakistan, and how these challenges make the Pakistani (...) population vulnerable to exploitation. It also outlines recommendations regarding conducting research in Pakistan within ethical parameters adopted according to local culture. This discussion is important because researchers must focus on the pre-enrollment phase of the research process for it’s cultural suitability and acceptability so that the research conducted is credible and valid and has social value for the research population. (shrink)

Metaphysical realism is the view that most of the objects that populate the world exist independently of our thought and have their natures independently of how, if at all, we conceive of them. It is committed, in my opinion, to a robust form of essentialism. Many modern forms of anti-realism have their roots in a form of conceptualism, according to which all truths about essence knowable by us are ultimately grounded in our concepts, rather than in things 'in themselves'. My (...) aim is to show that conceptualist anti-realism is an incoherent doctrine and how we can support metaphysical realism and robust essentialism, while still properly acknowledging the cognitive role of concepts in mediating our grasp of the nature of mind-independent reality.RésuméLe réalisme métaphysique est la conception suivant laquelle la plupart des objets qui peuplent le monde existent indépendamment de notre pensée et possèdent une nature indépendante de la manière dont nous pouvons éventuellement la concevoir. A mon sens cette position engage à admettre une forme robuste d'essentialisme. Beaucoup des formes modernes de l'anti-réalisme tirent leurs origines d'une forme de conceptualisme, suivant laquelle toutes les vérités que nous puissions connaître au sujet des essences sont en dernière analyse fondées sur nos concepts, plutôt que dans les choses « en elles-mêmes ». Mon but est de montrer que l'anti-réalisme conceptualiste est une doctrine incohérente, et comment nous pouvons soutenir le réalisme métaphysique et l'essentialisme robuste, tout en reconnaissant clairement le rôle cognitif des concepts en tant qu'intermédiaires dans notre appréhension de la nature de la réalité indépendante de l'esprit. (shrink)

In this paper, rather than focusing on genes as an organising concept around which historical considerations of theory and practice in genetics are elucidated, we place genetic markers at the heart of our analysis. This reflects their central role in the subject of our account, livestock genetics concerning the domesticated pig, Sus scrofa. We define a genetic marker as a element existing in different forms in the genome, that can be identified and mapped using a variety of quantitative, classical and (...) molecular genetic techniques. The conjugation of pig genome researchers around the common object of the marker from the early-1990s allowed the distinctive theories and approaches of quantitative and molecular genetics concerning the size and distribution of gene effects to align in projects to populate genome maps. Critical to this was the nature of markers as ontologically inert, internally heterogeneous and relational. Though genes as an organising and categorising principle remained important, the particular concatenation of limitations, opportunities, and intended research goals of the pig genetics community, meant that a progressively stronger focus on the identification and mapping of markers rather than genes per se became a hallmark of the community. We therefore detail a different way of doing genetics to more gene-centred accounts. By doing so, we reveal the presence of practices, concepts and communities that would otherwise be hidden. (shrink)

In this paper, rather than focusing on genes as an organising concept around which historical considerations of theory and practice in genetics are elucidated, we place genetic markers at the heart of our analysis. This reflects their central role in the subject of our account, livestock genetics concerning the domesticated pig, Sus scrofa. We define a genetic marker as a element existing in different forms in the genome, that can be identified and mapped using a variety of quantitative, classical and (...) molecular genetic techniques. The conjugation of pig genome researchers around the common object of the marker from the early-1990s allowed the distinctive theories and approaches of quantitative and molecular genetics concerning the size and distribution of gene effects to align in projects to populate genome maps. Critical to this was the nature of markers as ontologically inert, internally heterogeneous and relational. Though genes as an organising and categorising principle remained important, the particular concatenation of limitations, opportunities, and intended research goals of the pig genetics community, meant that a progressively stronger focus on the identification and mapping of markers rather than genes per se became a hallmark of the community. We therefore detail a different way of doing genetics to more gene-centred accounts. By doing so, we reveal the presence of practices, concepts and communities that would otherwise be hidden. (shrink)

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by social/communicative difficulties and perseverative behaviours. While research on autism has flourished recently, few studies have been conducted on the disorder in non‐Western contexts. In low‐ and middle‐income countries (LMICs), biomedical research on autism is required to better understand the needs of the population and to develop contextually appropriate interventions. However, autistic individuals are a vulnerable study population and LMICs present with various considerations. While the presentation of autism (...) is heterogeneous, stigma is a common social consequence affecting research. Drawing specifically on the South African context, the ethical intersections of these issues are discussed, along with the limitations of the current informed consent process. Community engagement is recommended as an adjunct to informed consent to ensure that biomedical research is conducted in a more inclusive way. Practical pointers are provided for implementing systematic support for conducting community engagement alongside biomedical research. (shrink)

Obtaining ‘informed consent’ from every individual participant involved in health research is a mandatory ethical practice. Informed consent is a process whereby potential participants are genuinely informed about their role, risk and rights before they are enrolled in the study. Thus, ethics committees in most countries require ‘informed consent form’ as part of an ethics application which is reviewed before granting research ethics approval. Despite a significant increase in health research activity in low-and middle-income countries in recent years, only (...) limited work has been done to address ethical concerns. Most ethics committees in LMICs lack the authority and/or the capacity to monitor research in the field. This is important since not all research, particularly in LMICs region, complies with ethical principles, sometimes this is inadvertently or due to a lack of awareness of their importance in assuring proper research governance. With several examples from Nepal, this paper reflects on the steps required to obtain informed consents and highlights some of the major challenges and barriers to seeking informed consent from research participants. At the end of this paper, we also offer some recommendations around how can we can promote and implement optimal informed consent taking process. We believe that paper is useful for researchers and members of ethical review boards in highlighting key issues around informed consent. (shrink)

Improvements in the health capital of citizens are central to the development of countries. By exploiting steep decreases in antiretroviral drug prices and the subsequent increases in antiretroviral therapy (ART) coverage, we test whether the resulting improvements in the health of the population are associated with the prevalence of entrepreneurial activity and whether entrepreneurial activity strengthens the relationship between ART coverage and a country’s development. Drawing on a sample of 87 low- and middle-income countries (2006–2019), we find that (...) a 1% increase in ART coverage is associated with a 1.5% increase in the number of newly registered limited liability firms; however, there is no significant relationship with (male or female) self-employment. Higher ART coverage is particularly associated with development—as proxied by gross domestic product (GDP) per capita and the Human Development Index—in countries with low levels of new business formation and high proportions of self-employment. (shrink)

A large proportion of the total global burden of disease is caused by emergency medical conditions. Emergency care research is essential to improving emergency medicine but this research can raise some distinctive ethical challenges, especially with regard to (1) standard of care and risk–benefit assessment; (2) blurring of the roles of clinician and researcher; (3) enrolment of populations with intersecting vulnerabilities; (4) fair participant selection; (5) quality of consent; and (6) community engagement. Despite the importance of research to improve emergency (...) care in low-income and middle-income countries (LMICs) and the widely acknowledged ethical challenges, very little has been written on the ethics of emergency care research in LMICs. This paper examines the ethical and regulatory challenges to conducting emergency care research with human participants in LMICs. We outline key challenges, present potential solutions or frameworks for addressing these challenges, and identify gaps. Despite the ethical and regulatory challenges, conducting high-quality, ethical emergency care research in LMICs is possible and it is essential for global health. (shrink)

Population-based genomics studies have proven successful in identifying genetic variants associated with diseases. High-quality biospecimens linked with informative health data from diverse segments of the population have made such research possible. However, the success of biobank research depends on the willingness of the public to participate in this type of research. We aimed to explore the factors associated with the willingness of the public to participate in biobank research from four low- and middle-income countries in the Arab (...) region (Egypt, Jordan, Morocco, and Sudan). We used a previously validated questionnaire to assess several constructs that included the public’s perceptions, attitudes, and willingness to participate in biobank research. We recruited 967 participants. More than half did not have prior awareness of biobanks. Participants’ willingness to donate biospecimens and health data was less than 10%. Our results also showed that participants harbored concerns with trust, privacy, and with data-sharing involving international researchers. Predictors of willingness to participate in biobank research included no previous involvement in research and positive attitudes toward biobanks. Finally, our study showed several differences between the four countries regarding several of the investigated constructs. We conclude there should be additional efforts to raise public awareness and enhance perceptions of the public in biobanking research to enhance trust. We further recommend qualitative research to explore the underlying factors that contribute to the public’s concerns with international data sharing that would enhance global health. (shrink)

Priority setting remains a big challenge for health managers and planners, yet there is paucity of literature on evaluating priority setting. The purpose of this paper is to present a framework for evaluating priority setting in low and middle income countries. We conducted a qualitative study involving a review of literature and Delphi interviews with respondents knowledgeable of priority setting in low and middle income countries. Respondents were asked to identify the measures of successful priority setting in low (...) and middle income countries. Responses were grouped as: immediate internal or external/delayed internal or external. We also identified some pre-requisites for successful priority setting. The immediate internal measures included increased efficiency in decision making, improved quality of decisions and fairer priority setting. Immediate External measures included—improved public understanding and acceptance of decisions, increased public participation, increased trust. Delayed Internal measures included increased satisfaction, understanding, compliance, balanced budget, achievement of organization goals, and improved internal accountability. Delayed External measures include impact on policy and practice, improved population health and reduction of health inequalities, achievement of health system goals and strengthening of health care systems. Identified pre-requisites for successful priority setting included; the presence of credible priority setting institutions, incentives for participation and implementation and resources, capacity and political will to implement. These would be augmented in a conducive political, social and economic context. This framework, although not exhaustive, provides a practical basis for planning and evaluating priority setting in low and middle income countries. (shrink)

Commonsense metaphysics populates the world with an enormous variety of macroscopic objects, conceived as being capable of persisting through time and undergoing various changes in their properties and relations to one another. Many of these objects fall under J. L. Austin’s memorable description, “moderate-sized specimens of dry goods.” More broadly, they include, for instance, all of those old favourites of philosophers too idle to think of more interesting examples—tables, books, rocks, apples, cats, and statues. Some of them are natural objects, (...) such as rocks, apples, and cats. Some are artefacts, such as tables, books, and statues. Some are living things, such as apples and cats. Some are inanimate things, such as tables, books, rocks, and statues. To such a list we could add much larger natural objects, such as planets and stars, as well as much smaller ones barely visible to the naked eye, such as mites and pollen grains. Telescopes and microscopes enable us to extend the scale further in both directions, to include such things as galaxies and microbes. To call into question the existence of all or any of these things would appear to be an extravagance of the sort that only a philosopher could indulge. Until fairly recently in the history of philosophy, however, the only way in which their existence would have been called into question was in the context of the debate between realism and idealism. Idealism calls their existence into question by questioning the existence of an “external world” as such, proposing instead that only minds and their experiences exist. What is much more recent is the suggestion that, although there is an external world of entities existing in space and time, it is not in fact populated by most, or perhaps even by any, of the objects recognized by common sense. Instead, it is suggested, the world is populated by submicroscopic entities of a highly esoteric kind best understood by theoretical physicists—entities which may not even qualify as “objects” in anything like the familiar sense because, quite possibly, they should not be thought of as having precise spatiotemporal locations or as persisting over time and through processes of qualitative change. Let us call these putative entities ‘atoms’, without prejudice as to whether they conform to the descriptions currently favoured by physicists in speaking of what they call ‘atoms’. In other words, let us use ‘atom’ as a place-holder for whatever kind or kinds of entities an ideal or completed physics would postulate as the “ultimate” constituents, as opposed to infinitely descending levels of ever more fine-grained physical structure, but let us set aside dispute over these alternatives for the time being, if only because we have little idea as to how to settle it. (shrink)

Given that health systems research involves different aims, approaches, and methodologies as compared to more traditional clinical trials, the ethical issues present in HSR may be unique or particularly nuanced. This article outlines eight pertinent ethical issues that are particularly salient in HSR and argues that the ethical review process should be better tailored to ensure more efficient and appropriate oversight of HSR with adequate human protections, especially in low- and middle-income countries. The eight ethical areas we discuss include (...) the nature of intervention, types of research subjects, units of intervention and observation, informed consent, controls and comparisons, risk assessment, inclusion of vulnerable groups, and benefits of research. HSR involving human participants is necessary to ensure health systems strengthening and quality of care and to guide public policy intelligently. Health systems researchers must carefully define their intent and goals and openly clarify the values that may influence the premises and design of protocols. As new types of population-level research activities become more commonplace, it is critical that institutional review board and research ethics committee review processes evolve to evaluate these research protocols in ways that address the nuanced features of these studies. (shrink)

This article examines the (bio) ethical and professionalism issues that may arise in the context of medical practice in low and middle income countries (LAMIC), and the challenges this poses for medical regulatory bodies in the regions, in upholding ethics in professional practice. A quadrangle of source of the problems given rise to the breach of ethics in medical practice is identified, and suggested steps, based on ethical principles and concept, is proposed towards the resolution of the problems presented. (...) As LAMIC progress to improve the health of its population, this endeavour should occur hand in hand with contemporary medical ethics theories, taking in context the region’s ethnographic and cultural beliefs and practices. (shrink)

Health systems research is widely identified as an indispensable means to achieve the goal of health equity between and within countries. Numerous health systems research consortia comprised of institutions from high-income countries and low and middle-income countries are currently undertaking programs of research in LMICs. These partnerships differ from collaborations that carry out single projects in the multiplicity of their goals, scope of their activities, and nature of their management. Recent conceptual work has explored what features might be (...) necessary for health systems research consortia and their research programs to promote health equity. Identified features include selecting research priorities that focus on improving access to high-quality health services and/or financial protection for disadvantaged populations in LMICs and conducting research capacity strengthening that promotes the independent conduct of health systems research in LMICs. Yet, there has been no attempt to investigate whether existing consortia have such characteristics. This paper describes the results of a survey undertaken with health systems research consortia leaders worldwide to assess how consistent current practice is with the proposed ethical guidance. The findings suggest that consortia may be fairly well organised to promote health equity, but have scope for improvement, particularly in terms of achieving inclusive priority-setting. (shrink)

Lowe, Ian The evidence is overwhelming: unlimited growth is neither possible nor desirable. The 2013 Fenner Conference reviewed what we know about population growth, resource use and environmental damage. The volume that resulted shows clearly that we are near limits in some cases, already beyond them in others.

ABSTRACT The expansion of health research to low and middle income countries has increased the likelihood of exploitation and undue influence in economically vulnerable populations. In behavioral research, “reasonable availability”, which was originally developed for biomedical research and advocates for the equitable provision of any product developed during the research process, cannot always prevent exploitation. In such cases and settings, the informed consent process may lack cross-cultural validity and therapeutic misconceptions may arise. This article advocates for a mutual learning (...) framework where international researchers can gain cultural competence while training and empowering local partners, increasing community ownership of health research. (shrink)

Women’s fertility is the focus of most demographic analyses, for in most mammals, and in many preindustrial societies, variance in male fertility, while an interesting biological phenomenon, is irrelevant. Yet in monogamous societies, the reproductive ecology of men, as well as that of women, is important is creating reproductive patterns. In nineteenth-century Sweden, the focus of this study, male reproductive ecology responded to resource conditions: richer men had more children than poorer men. Men’s fertility also interacted with local and historical (...) factors in complex ways to have significant impact on population growth. As a result, “the” demographic transition was local, and locally reversible, in Sweden. Results cannot be simply translated from nineteenth-century studies to current attempts to promote fertility decline, because today, male and female resource-fertility curves differ in shape, not only in magnitude. When we translate studies of fertility decline, it is important to study individual fertility and to discern whether, in any particular case, male and female patterns are similar. (shrink)

BackgroundStreet-connected children and youth in low- and middle-income countries have multiple vulnerabilities in relation to participation in research. These require additional considerations that are responsive to their needs and the social, cultural, and economic context, while upholding core ethical principles of respect for persons, beneficence, and justice. The objective of this paper is to describe processes and outcomes of adapting ethical guidelines for SCCY’s specific vulnerabilities in LMIC.MethodsAs part of three interrelated research projects in western Kenya, we created procedures (...) to address SCCY’s vulnerabilities related to research participation within the local context. These consisted of identifying ethical considerations and solutions in relation to community engagement, equitable recruitment, informed consent, vulnerability to coercion, and responsibility to report.ResultsSubstantial community engagement provided input on SCCY’s participation in research, recruitment, and consent processes. We designed an assent process to support SCCY to make an informed decision regarding their participation in the research that respected their autonomy and their right to dissent, while safeguarding them in situations where their capacity to make an informed decision was diminished. To address issues related to coercion and access to care, we worked to reduce the unequal power dynamic through street outreach, and provided access to care regardless of research participation.ConclusionsAlthough a vulnerable population, the specific vulnerabilities of SCCY can to some extent be managed using innovative procedures. Engaging SCCY in ethical research is a matter of justice and will assist in reducing inequities and advancing their health and human dignity. (shrink)

A common exhortation by conservationists suggests that we can solve ecological problems by returning to the attitudes of traditional societies: reverence for resources, and willingness to assume short-term individual costs for long-term, group-beneficial sustainable management. This paper uses the 186-society Standard Cross-Cultural Sample to examine resource attitudes and practices. Two main findings emerge: (1) resource practices are ecologically driven and do not appear to correlate with attitude (including sacred prohibition) and (2) the low ecological impact of many traditional societies results (...) not from conscious conservation efforts, but from various combinations of low population density, inefficient extraction technology, and lack of profitable markets for extracted resources. (shrink)

First published in 1930, this book presents an imagined account of conversation between Plato and ‘A Modern Young Man’. In the first part, political and social institutions are considered and property, forms of government, socialism, the control of population, war and education, are discussed. The second part examines the idea of real Goods including the concepts of truth, art and love. In this work, the author sees Plato reaffirming his belief that real Goods come from some higher world, which (...) it is the destiny of the spirits to pursue. (shrink)

First published in 1930, this book presents an imagined account of conversation between Plato and ‘A Modern Young Man’. In the first part, political and social institutions are considered and property, forms of government, socialism, the control of population, war and education, are discussed. The second part examines the idea of real Goods including the concepts of truth, art and love. In this work, the author sees Plato reaffirming his belief that real Goods come from some higher world, which (...) it is the destiny of the spirits to pursue. (shrink)

First published in 1930, this book presents an imagined account of conversation between Plato and ‘A Modern Young Man’. In the first part, political and social institutions are considered and property, forms of government, socialism, the control of population, war and education, are discussed. The second part examines the idea of real Goods including the concepts of truth, art and love. In this work, the author sees Plato reaffirming his belief that real Goods come from some higher world, which (...) it is the destiny of the spirits to pursue. (shrink)

Male to male unprotected anal sex is the main route of HIV transmission in Australia. The Australian Study of Health and Relationships, a large, representative population survey of sexual health behaviors, found that six percent of males in the general population have engaged in homosexual activity. These findings were consistent with studies in Europeand North America. Condoms have been shown to reduce the transmission of HIV in the community. Barriers to the use of condoms include access,stigma,and cost? Nevertheless, (...) increased condom use has been reported among homosexual males, sex workers and injecting drug users although recent declines in condom use among homosexuals has presented new challenges in HIV prevention.The prevalence of male to male sexual activity may be higher in prison than in the general population. Sexual activity in prison can be consensual and non-consensual involving both homosexual / bisexual and heterosexual men. (shrink)

Male to male unprotected anal sex is the main route of HIV transmission in Australia. The Australian Study of Health and Relationships, a large, representative population survey of sexual health behaviors, found that six percent of males in the general population have engaged in homosexual activity. These findings were consistent with studies in Europeand North America. Condoms have been shown to reduce the transmission of HIV in the community. Barriers to the use of condoms include access,stigma,and cost? Nevertheless, (...) increased condom use has been reported among homosexual males, sex workers and injecting drug users although recent declines in condom use among homosexuals has presented new challenges in HIV prevention.The prevalence of male to male sexual activity may be higher in prison than in the general population. Sexual activity in prison can be consensual and non-consensual involving both homosexual / bisexual and heterosexual men. (shrink)

Recent literature has highlighted issues of racial discrimination in medicine. In order to explore the sometimes subtle influence of racial determinants in decisions about resource allocation, we present the case of a 53-year-old Australian Aboriginal woman with end-stage renal failure. The epidemiology of renal failure in the Australian Aboriginal population and amongst other indigenous peoples is discussed. We show that the use of utilitarian outcome criteria for resource allocation may embody subtle racial discrimination where consideration is not given to (...) issues of justice, race, culture and gender. It is only where the processes by which resources are allocated are transparent, clearly defined and based upon consultation with individual patients that issues and justice are likely to be adequately addressed. (shrink)

In controlled human infection studies (CHIs), participants are deliberately exposed to infectious agents in order to better understand the mechanism of infection or disease and test therapies or vaccines. While most CHIs have been conducted in high‐income countries, CHIs have recently been expanding into low‐ and middle‐income countries (LMICs). One potential ethical concern about this expansion is the challenge of obtaining the voluntary informed consent of participants, especially those who may not be literate or have limited education. In (...) some CHIs in LMICs, researchers have attempted to address this potential concern by limiting access to literate or educated populations. In this paper, we argue that this practice is unjustified, as it does not increase the chances of obtaining valid informed consent and therefore unfairly excludes illiterate populations and populations with lower education. Instead, we recommend that investigators improve the informed consent process by drawing on existing data on obtaining informed consent in these populations and interventions aimed at improving their understanding. Based on a literature review, we provide concrete suggestions for how to follow this recommendation and ensure that populations with lower literacy or education are given a fair opportunity to protect their rights and interests in the informed consent process. (shrink)

There is unanimous agreement regarding the need to ethically conduct research for improving therapy for patients admitted to hospital with acute conditions, including in emergency obstetric care. We present a conceptual analysis of ethical tensions inherent in the informed consent process for randomized clinical trials for emergency obstetric care and suggest ways in which these could be mitigated. A valid consenting process, leading to an informed consent, is a cornerstone of this aspect necessary for preservation and maintenance of respect for (...) autonomy and dignity. In emergency obstetric care research, obtaining informed consent can be problematic, leading to ethical tension between different moral considerations. Potential participants may be vulnerable due to severity of disease, powerlessness or impaired decisional capacity. Time for the consent process is limited, and some interventions have a narrow therapeutic window. These factors create ethical tension in allowing potentially beneficial research while avoiding potential harms and maintaining respect for dignity, human rights, justice and autonomy of the participants. Informed consent in emergency obstetric care in low- and middle-income countries poses numerous ethical challenges. Allowing research on vulnerable populations while maintaining respect for participant dignity and autonomy, protecting participants from potential harms and promoting justice underlie the ethical tensions in the research in emergency obstetric and newborn care. Those involved in research conduct or oversight have a duty of fair inclusion, to avoid denying participants the right to participate and to any potential research benefits. (shrink)

Given that health systems research involves different aims, approaches, and methodologies as compared to more traditional clinical trials, the ethical issues present in HSR may be unique or particularly nuanced. This article outlines eight pertinent ethical issues that are particularly salient in HSR and argues that the ethical review process should be better tailored to ensure more efficient and appropriate oversight of HSR with adequate human protections, especially in low- and middle-income countries. The eight ethical areas we discuss include (...) the nature of intervention, types of research subjects, units of intervention and observation, informed consent, controls and comparisons, risk assessment, inclusion of vulnerable groups, and benefits of research. HSR involving human participants is necessary to ensure health systems strengthening and quality of care and to guide public policy intelligently. Health systems researchers must carefully define their intent and goals and openly clarify the values that may influence the premises and design of protocols. As new types of population-level research activities become more commonplace, it is critical that institutional review board and research ethics committee review processes evolve to evaluate these research protocols in ways that address the nuanced features of these studies. (shrink)

Infertility is an unpredictable but widespread condition. While high‐income countries grapple with when, or how to cover the costs of assisted reproductive technology (ART), such as in‐vitro fertilisation (IVF), these services are generally only available to wealthy persons at private facilities in low‐ and middle‐income countries (LMICs). Although the principle of non‐interference with normal individual reproductive rights is robust, whether it is also the responsibility of collective society to provide the means (when ART applies) to achieve pregnancy, is (...) controversial. Recently, a low‐cost model was developed at a South African public institution. The target population for this model was “helpless and marginalised, childless couples”, but a new threat has arisen, namely, infertile couples who could conceivably afford private care. In the allocation of this scarce resource, we argue for a prioritarian response that first addresses the worst‐off, in order to even out unequal access imposed by sharp differences in income. (shrink)

Based on European National Transfer Accounts data from 2010, this paper quantifies and evaluates the balance of intergenerational transfer flows in 16 EU countries, including transfers in the form of unpaid household work. On average, the value of net transfers received by a child amounts to sixteen times the labour income of a full-time worker, and the net transfers received by an elderly person to six times the labour income of a full-time worker. Intergenerational transfers can be regarded (...) as the reciprocal exchange between two generations: the size of the transfers to the child generation determines their potential to generate income and finance public transfers to the elderly population once they enter employment. We develop and calculate an indicator to analyse if there is a balance between transfers to children and transfers expected by the elderly population. The results indicate that in most of the analysed countries the human capital investments in children are far too low to finance the generous transfers to the elderly population in the future. (shrink)

This article analyzes the bioethical implications of using a control/placebo group when conducting clinical trials (CTs) investigating the treatment of periodontitis. For this, the deductive method was used, proposing the interrelation of values, and a scoping systematic review was carried out. A total of 53% of the CTs reviewed were performed in low- and middle-income (LMI) countries, and 92% used a control/placebo group as a comparison group. Although there is a gold standard for the adjunctive treatment of periodontitis, the (...) research ethics committees of most of the analyzed studies approved the use of control/placebo groups for the performance of CTs that did not explore new therapeutic alternatives. In some cases, the CT protocols were not approved by ethics committees, nor was informed consent used. In the LMI countries, a shorter period of recruitment was observed for patients who attended universities and public hospitals. Likewise, most of the CTs reviewed had public funding, a significant amount of which came from the pharmaceutical industry. Only one CT reported the low economic and educational level of its participants. Furthermore, none of the authors of the reviewed CTs declared conflicts of interest. Although the axiology of techno-science always takes into account at least the epistemic, technical and economic value systems, the hegemony of the economic values imposed by the pharmaceutical industry is evident in the performance of CTs investigating the treatment of periodontitis in LMI countries. (shrink)

This article analyzes the bioethical implications of using a control/placebo group when conducting clinical trials (CTs) investigating the treatment of periodontitis. For this, the deductive method was used, proposing the interrelation of values, and a scoping systematic review was carried out. A total of 53% of the CTs reviewed were performed in low- and middle-income (LMI) countries, and 92% used a control/placebo group as a comparison group. Although there is a gold standard for the adjunctive treatment of periodontitis, the (...) research ethics committees of most of the analyzed studies approved the use of control/placebo groups for the performance of CTs that did not explore new therapeutic alternatives. In some cases, the CT protocols were not approved by ethics committees, nor was informed consent used. In the LMI countries, a shorter period of recruitment was observed for patients who attended universities and public hospitals. Likewise, most of the CTs reviewed had public funding, a significant amount of which came from the pharmaceutical industry. Only one CT reported the low economic and educational level of its participants. Furthermore, none of the authors of the reviewed CTs declared conflicts of interest. Although the axiology of techno-science always takes into account at least the epistemic, technical and economic value systems, the hegemony of the economic values imposed by the pharmaceutical industry is evident in the performance of CTs investigating the treatment of periodontitis in LMI countries. (shrink)

This article analyzes the bioethical implications of using a control/placebo group when conducting clinical trials (CTs) investigating the treatment of periodontitis. For this, the deductive method was used, proposing the interrelation of values, and a scoping systematic review was carried out. A total of 53% of the CTs reviewed were performed in low- and middle-income (LMI) countries, and 92% used a control/placebo group as a comparison group. Although there is a gold standard for the adjunctive treatment of periodontitis, the (...) research ethics committees of most of the analyzed studies approved the use of control/placebo groups for the performance of CTs that did not explore new therapeutic alternatives. In some cases, the CT protocols were not approved by ethics committees, nor was informed consent used. In the LMI countries, a shorter period of recruitment was observed for patients who attended universities and public hospitals. Likewise, most of the CTs reviewed had public funding, a significant amount of which came from the pharmaceutical industry. Only one CT reported the low economic and educational level of its participants. Furthermore, none of the authors of the reviewed CTs declared conflicts of interest. Although the axiology of techno-science always takes into account at least the epistemic, technical and economic value systems, the hegemony of the economic values imposed by the pharmaceutical industry is evident in the performance of CTs investigating the treatment of periodontitis in LMI countries. (shrink)

This article analyzes the bioethical implications of using a control/placebo group when conducting clinical trials (CTs) investigating the treatment of periodontitis. For this, the deductive method was used, proposing the interrelation of values, and a scoping systematic review was carried out. A total of 53% of the CTs reviewed were performed in low- and middle-income (LMI) countries, and 92% used a control/placebo group as a comparison group. Although there is a gold standard for the adjunctive treatment of periodontitis, the (...) research ethics committees of most of the analyzed studies approved the use of control/placebo groups for the performance of CTs that did not explore new therapeutic alternatives. In some cases, the CT protocols were not approved by ethics committees, nor was informed consent used. In the LMI countries, a shorter period of recruitment was observed for patients who attended universities and public hospitals. Likewise, most of the CTs reviewed had public funding, a significant amount of which came from the pharmaceutical industry. Only one CT reported the low economic and educational level of its participants. Furthermore, none of the authors of the reviewed CTs declared conflicts of interest. Although the axiology of techno-science always takes into account at least the epistemic, technical and economic value systems, the hegemony of the economic values imposed by the pharmaceutical industry is evident in the performance of CTs investigating the treatment of periodontitis in LMI countries. (shrink)

The Global Code of Conduct for Research in Resource-Poor Settings (GCC) aims to stop the export of unethical research practices from higher to lower income settings. Launched in 2018, the GCC was immediately adopted by European Commission funding streams for application in research that is situated in lower and lower-middle income countries. Other institutions soon followed suit. This article reports on the application of the GCC in two of the first UK-funded projects to implement this new code, one (...) situated in India and one in Pakistan. Through systematic ethics evaluation of both projects, the practical application of the GCC in real-world environments was tested. The findings of this ethics evaluation suggest that while there are challenges for implementation, application of the GCC can promote equity in international research collaborations. (shrink)

A large proportion of nursing home residents in developed countries come from ethnic minority groups. Unmet care needs and poor quality of care for this resident population have been widely reported. This systematic review aimed to explore social conditions affecting ethnic minority residents' ability to exercise their autonomy in communication and care while in nursing homes. In total, 19 studies were included in the review. Findings revealed that ethno‐specific nursing homes create the ideal social condition for residents to express (...) their care needs and preferences in a language of choice. In nonethno‐specific nursing homes, staff cultural competence and nursing home commitment to culturally safe care are crucial social conditions that enable this group of residents to fulfil their autonomy in communicating and in participating in their care. In contrast, social conditions that undermine residents' ability to express their care needs and preferences include low levels of staff cultural awareness and cultural desire, negative attitudes towards residents and limited organisational support for staff to improve culturally responsive and culturally safe care. In conclusion, it is important to optimise the social conditions to support ethnic minority residents to communicate their care needs and preferences. (shrink)

Many older people need external support for their daily living. A large minority of older adults with low or modest pension incomes face financial strains from the high cost of illness, and many older people in urban areas live in social isolation. Indeed, population aging has become a policy topic of concern. The policy debate since the end of the twentieth century about the future of public pensions and health and long‐term care programs has increasingly framed the growing numbers (...) of older people in alarmist terms. Unfounded claims about the unaffordability and unsustainability of social policies supporting older people have become common currency, often disguised as concerns about intergenerational justice. Such claims and concerns hinder clear thinking about proper social and fiscal policies, housing, health care, and labor markets to safeguard the well‐being of older people in aging societies. (shrink)

For some thirteen years now, the World Bank (‘the Bank’) has regularly reported the number of people living below an international poverty line, colloquially known as ‘$1/day’.3 Reports for the most recent year, 1998, put this number at 1,175.14 million.4 The Bank’s estimates of severe income poverty — its global extent, geographical distribution, and trend over time — are widely cited in official publications by governments and international organizations and in popular media, often in support of the view that (...) liberalization and globalization have helped to reduce poverty worldwide. For instance, the President of the World Bank recently declared: “Over the past few years, these better policies have contributed to more rapid growth in developing countries’ per capita incomes than at any point since the mid-1970s. And faster growth has meant poverty reduction: the proportion of people worldwide living in absolute poverty has dropped steadily in recent decades, from 29% in 1990 to a record low of 23% in 1998. After increasing steadily over the past two centuries, since 1980 the total number of people living in poverty worldwide has fallen by an estimated 200 million — even as the world’s population grew by 1.6 billion.”. (shrink)

As the per capita income level increases, both environmental quality and income inequality will change significantly, which arouses people’s attention on the relationship between income inequality and environmental quality. Based on mathematical derivations, we first prove that when the relationship between per capita income and environmental pollution is nonlinear, and environmental pollution is not only related to per capita income, but also, among other potential determinants, to income inequality. Then, we use the two-way fixed (...) estimator to estimate the impact of income inequality on environmental quality by decomposing the Stochastic Impacts by Regression on Population, Affluence, and Technology model. The impact of income inequality on environmental pollution is significantly positive, that is, as the income gap widens, industrial pollutant emissions, carbon dioxide emissions, and PM2.5 in the air will increase; there is an “Inverted U-shaped” impact relationship between income inequality and environmental quality, that is, environmental pollution increases first and then decreases with the increase of per capita GDP; per capita income is the intermediate variable between income inequality and environmental quality. The relationship between income inequality and environmental quality should be fully considered when formulating relevant policies. The government should adopt differentiated environmental policies targeted at low-and-high income groups to achieve a win-win situation of economic growth and environmental protection. (shrink)

O presente texto versa e discute a tese há muito defendida nas ciências sociais de que haveria um predileção dos pentecostais pelos pobres. Em outro tempo, houve mesmo e fez parte de seu processo constituinte enquanto uma religião recente que precisava encontrar espaço para se expandir nos grandes centros urbanos. Contudo, com o passar dos anos essa predileção foi mudando e o pentecostalismo adentrou no interior de outros estratos sociais de renda ganhando espaço e força. O cuidado com os mais (...) pobres, daqueles que percebem rendimentos inferiores a 1 salário mínimo, não foi deixado de lado, e ganhou espaço em seus templos o atendimento à indivíduos que situam-se nos estratos de renda que vão de 1 a 2 salários mínimos, além de outros, mais abastados. A Igreja Católica, por sua fez, ao mesmo tempo em que via seus fiéis saindo pela porta de suas Igrejas investiu nesse segmento, os pobres, e tomou para si o lido para com estes. Dez anos se passaram deste o Censo de 2000 e, hoje, olhando para os dados da contagem censitária de 2011, torna-se praticamente impossível diferenciar, no que se refere a sua distribuição nos diferentes estratos de renda, católicos e pentecostais. Palavras-chave : Censo 2010. Religião. Renda. Pentecostalismo. Catolicismo.This article examines and discusses the preference of Pentecostals for individuals of low income. The author affirms that such preference was true some time ago, but it has changed nowadays. Some years ago this new religion needed to find its space in large urban centers. However, through the years, their predilection for people with low income started changing and as the Pentecostalism got space and strength it started to move to others incomes population, mainly to the higher ones. Though, the assistance to that population whose incomes range below 12 minimum salaries per year wasn’t left aside, their assistance gained spaces in the temples. Not only low income got assistance but it was also provided to the ones who receive incomes around 12 to 24 minimum salaries per year. The Catholic Church, for its part, as it saw its faithful leaving the churches, it started to invest in the poor segment of society, by given them spiritual assistance. After ten years of the last census in 2000, looking at the new data released in 2011, it becomes quite impossible to make a difference in the distribution of Catholics and Pentecostals in different income strata. Keywords: Census 2010. Religion. Income. Pentecostalism. Catholicism. (shrink)

This paper examines whether low income is a barrier to contraceptive use in Pakistan, a country in which economic conditions are deteriorating at a time when the private sector is becoming a more important supplier of contraception. Multivariate regression analysis performed using the Pakistan Contraceptive Demand Survey suggests that low income is a deterrent to modern contraceptive use in Pakistan. This is particularly the case for contraceptive methods supplied through the private sector. It is concluded that, if the (...) aim of family planning programmes is to reach low[hyphen]income people, the prices of contraceptives supplied through the private sector should be kept as low as possible. (shrink)

A large literature documents the correlates and causes of subjective well-being, or happiness. But few studies have investigated whether people choose happiness. Is happiness all that people want from life, or are they willing to sacrifice it for other attributes, such as income and health? Tackling this question has largely been the preserve of philosophers. In this article, we find out just how much happiness matters to ordinary citizens. Our sample consists of nearly 13,000 members of the UK and (...) US general populations. We ask them to choose between, and make judgments over, lives that are high in different types of happiness and low in income, physical health, family, career success, or education. We find that people by and large choose the life that is highest in happiness but health is by far the most important other concern, with considerable numbers of people choosing to be healthy rather than happy. We discuss some possible reasons for this preference. (shrink)

Purpose: To analyze how individual characteristics and the social context are associated with mental distress symptoms in the Brazilian population.Method: A multilevel cross-sectional study with data from the 2013 National Health Survey. There were two dependent variables: decreased vital energy and somatic symptoms, the presence of depressive thoughts. The independent variables were biological characteristics, education and income, habits and lifestyle, and context variables. Bivariate analysis was performed, and Prevalence Ratios calculated in a Poisson Regression. A multilevel Poisson Regression (...) was performed to verify the effect of individual and contextual variables.Results: Regarding depressive thoughts, young and middle-aged individuals, low education, women, absence of partner, smokers or former smokers, and absence of health insurance were the categories at highest risk; belonging to classes D-E and living in states with lower expected years of schooling proved to be protective factors. Similar results were found for the second outcome.Conclusions: Symptoms of mental distress were associated with the individual characteristics and contextual aspects of the federation unit. These findings indicate the importance of strengthening psychosocial care aimed at vulnerable groups. (shrink)

The Affordable Care Act1 promises to improve access to coverage and care for two vulnerable groups: low-income persons who are excluded by a lack of resources and chronically ill and disabled people who are excluded by the dysfunction of our existing insurance and care delivery systems. ACA’s sprawling provisions raise a wealth of implementation challenges that are exacerbated by the compromises required to move reform through Congress. In particular, the compromise between regulatory/public program advocates and advocates for private, market-driven (...) programs requires thoughtful regulatory coordination between public and private health systems. (shrink)

The Affordable Care Act1 promises to improve access to coverage and care for two vulnerable groups: low-income persons who are excluded by a lack of resources and chronically ill and disabled people who are excluded by the dysfunction of our existing insurance and care delivery systems. ACA’s sprawling provisions raise a wealth of implementation challenges that are exacerbated by the compromises required to move reform through Congress. In particular, the compromise between regulatory/public program advocates and advocates for private, market-driven (...) programs requires thoughtful regulatory coordination between public and private health systems. (shrink)