Public Health Ethics - Advance Access

Moral Combat in An Enemy of the People: Public Health versus Private Interests

McConnell, T. — Fri, 06 Nov 2009 08:03:20 PST

Dr Thomas Stockmann, the protagonist of Ibsen's play, An Enemy of the People, discovers a serious health threat in the Baths of his Norwegian town. The Baths have been marketed as a health resort to lure visitors. Dr Stockmann alerts officials about the problem and assumes that they will close the Baths until it is corrected. He is met with fierce resistance, however. His brother, the town's mayor, favors keeping the Baths open and correcting the problem gradually. He advances multiple arguments that appeal to the economic interests of the town and Thomas's role-related obligation as a citizen. His wife, Katherine, wants him to cooperate with the mayor. She marshals several arguments that appeal to his obligations as a father. This paper reconstructs and examines the competing arguments, shows how Ibsen's play has both contemporary relevance and moral depth, and demonstrates how Dr Stockmann's responses can be interpreted as an argument that complying with his duties to protect the public health do not force him to renege on his core commitments as a parent and as a citizen.

Two Models in Global Health Ethics

Lowry, C., Schuklenk, U. — Thu, 29 Oct 2009 23:02:50 PDT

This paper examines two strategies aimed at demonstrating that moral obligations to improve global health exist. The ‘humanitarian model’ stresses that all human beings, regardless of affluence or global location, are fundamentally the same in terms of moral status. This model argues that affluent global citizens’ moral obligations to assist less fortunate ones follow from the desirability of reducing disease and suffering in the world. The ‘political model’ stresses that the lives of the world's rich and poor are inextricably linked because of harmful state-to-state actions and because of the currently existing transnational institutions. These institutions’ design at once secures the high standard of living of the affluent and reinforces the continued foreseeable—and avoidable—deprivation of many of the global poor; and these give rise to compensatory health-related moral obligations beyond borders. This paper argues that political reasoning is unsuitable for the crucial task of determining priority in the receipt of health aid. We conclude that in the context of global health ethics, political reasoning must be supplemented with, if not replaced by, humanitarian reasoning.

A Bird's Eye View. Two Topics at the Intersection of Social Determinants of Health and Social Justice Philosophy

Venkatapuram, S. — Thu, 29 Oct 2009 23:02:50 PDT

The article discusses two areas at the intersection of social determinants of health research and social justice theory. The first section examines the affinity between social epidemiology and the capabilities approach. The second section examines how social epidemiology's expansion of the scope of the causal chain and determinants raises questions about epistemology and ontology in epidemiology as well as the field's link to the moral concern for human health.

Public Health Paternalism: Continuing the Dialogue

Nys, T. — Mon, 26 Oct 2009 21:00:59 PDT

According to Stephen Holland, the challenges I mention in my original paper can be met, so that, in a way, the problem of paternalism in public health care—which I intended to put into perspective by drawing out some possible justifications for it—returns in all its might and glory. But of course, as Holland observes, I never suggested that my challenges could never be met. I only wanted to point out that for each and every particular public health policy that should come to our attention we should reflect upon these challenges and see whether they could provide reasons for justification. I believe that the discussion is often stalled because these measures—in the absence of individual consent and in their aim to benefit the public's ‘best interests’—seem to be paternalist by default. In my paper, I wanted to call this assumption into question, but never intended to prove that there is no such thing as unjustified paternalism in public health care. Nevertheless, Holland's criticism is very insightful and he has done a lot to clarify my position. However, he also puts me on the spot by urging me to argue to what extent I can meet his rebuttal, and I am very grateful for that opportunity.

Global Health Justice

Ruger, J. P. — Wed, 14 Oct 2009 05:07:37 PDT

What are the respective roles and responsibilities of global, national, and local communities as well as individuals themselves to address health deprivations and avert health threats? This article offers the beginnings of a theory of global health justice, arguing for universal ethical norms (general duty) with shared global and domestic responsibility (specific duties) for health. It offers a global minimalist view I call ‘provincial globalism’ as a mean between nationalism and cosmopolitanism, in which a provincial consensus must accompany a global consensus on health morality. This minimalist account asserts global and national duties to promote human flourishing and, more specifically, individuals’ central health capabilities. In this view, justice requires prioritizing responsibilities through shared health governance to reduce shortfall inequalities in central health capabilities—a general duty to reduce premature mortality and escapable morbidity. It examines the difficulties presented by the philosophical principles of connectedness, causality, remediation, partiality, and capacity in the allocation of responsibility for global health. It offers a theory of responsibility allocation based on a functional, health agency centered and homeostatic balanced understanding of the analytical components required to solve global health problems and parcels out roles and responsibilities at the global, national, local, and individual levels accordingly. Allocations of responsibility rest on the effectiveness and special obligations of different actors, respecting self-determination by groups and individuals and seeking voluntary commitments. This view understands that the remedy for global health problems must be sustainable to take nations and the global health community to a new global health equilibrium that remedies current problems and prepares for new health threats to come.

Ethics and Epidemiology: Residual Health Inequalities

Sreenivasan, G. — Tue, 13 Oct 2009 21:21:59 PDT

This paper examines the fairness of avoidable inequalities in health. It contrasts two approaches to this question, a direct approach and an indirect approach. Most of the discussion focuses on the indirect approach advocated by Daniels, Kennedy and Kawachi (2000). Their argument that avoidable inequalities in health are not unfair when their causes are otherwise fair is criticised on two counts. First, it encounters a surprising difficulty when one attends carefully to the point at which ethics intersects with epidemiology here. Second, it fails to address the fundamental issue, which is whether any version of the direct approach is valid.

Commentary on "Cholera and Nothing More"

Hunt, M. R. — Fri, 09 Oct 2009 06:42:05 PDT

Public Health Doctors' Ancillary-Care Obligations

Richardson, H. S. — Thu, 01 Oct 2009 21:46:53 PDT

This comment on the case presented in ‘Cholera and Nothing More’ argues that the physicians at this public-health centre did not have an ordinary clinician's obligations to promote the health of the people who came to them for care, as they were instead set up to serve a laudable and urgent public-health goal, namely, controlling a cholera outbreak. It argues that, nonetheless, these physicians did have some limited moral duties to care for other diseases they encountered—some ancillary-care duties—arising from their voluntarily entering into a kind of intimate relationship with the patients they took in, one in which those patients effectively waive certain rights to bodily and medical privacy.

Non-Professional Healthcare Workers and Ethical Obligations to Work during Pandemic Influenza

Thu, 01 Oct 2009 06:45:38 PDT

Most academic papers on ethics in pandemics concentrate on the duties of healthcare professionals. This paper will consider non-professional healthcare workers: do they have a moral obligation to work during an influenza pandemic? If so, is this an obligation that outweighs others they might have, e.g., as parents, and should such an obligation be backed up by the coercive power of law? This paper considers whether non-professional healthcare workers—porters, domestic service workers, catering staff, clerks, IT support workers, etc.—have an obligation to work during an influenza pandemic. It uses data collected as part of a study looking at the attitudes of healthcare workers to working during a pandemic to suggest the philosophical arguments explored. These include: being in a position to do good, the ethics of work, competing obligations to family members and in particular to children and the obligations of citizens in a state of national emergency. We also look at whether compulsory measures are justified to support a national health service during a health emergency. We conclude that even if they are, compulsion should not be restricted to non-professionals who happen to be working in the health service at the time. Rather, compulsion involving a larger pool of people with the relevant skills and abilities is more equitable.

Defining the Limits of Emergency Humanitarian Action: Where, and How, to Draw the Line?

Ford, N., Zachariah, R., Mills, E., Upshur, R. — Tue, 22 Sep 2009 09:07:16 PDT

Decisions about targeting medical assistance in humanitarian contexts are fraught with dilemmas ranging from non-availability of basic services, to massive demographic and epidemiological shifts, and to the threat of insecurity and evacuations. Aid agencies are obliged, due to capacity constraints and competing priorities, to clearly define the objectives and the beneficiaries of their actions. That aid agencies have to set limits to their actions is not controversial, but the process of defining the limits raises ethical questions. In MSF, frameworks for resource allocation are subject to constant reflection and reiteration, and perspectives are sought at all levels, from implementers at the programme level to the operational directors at headquarters. The perspectives of the programmes staff hold considerable weight as they have the knowledge and experience with particular communities to assess the degree of vulnerability and need, and are also the people who ultimately have to give explanations to beneficiaries when changes or closures are going to be instituted. Humanitarian agencies have a responsibility to ensuring that their workers are prepared to reflect on these dilemmas, and challenge the status quo when it costs lives.

Case Discussion: Cholera and Nothing More

Sorell, T. — Fri, 18 Sep 2009 00:32:39 PDT

Benevolence, Justice, Well-Being and the Health Gradient

Hausman, D. M. — Thu, 10 Sep 2009 14:36:54 PDT

The health gradient among those who are by historical standards both remarkably healthy and well-off is of considerable moral importance with respect to benevolence, justice and the theory of welfare. Indeed it may help us to realize that for most people the good life lies in close and intricate social ties with others which can flourish only when inequalities are limited. The health gradient suggests that there is a story to be told in which egalitarian justice, solidarity, health and well-being go hand-in-hand.

Obesity, Identity and Community: Leveraging Social Networks for Behavior Change in Public Health

Mulvaney-Day, N., Womack, C. A. — Thu, 10 Sep 2009 14:36:54 PDT

Obesity is a public health problem influenced by behavioral patterns that span an ecological spectrum of individual-level factors, social network factors and environmental factors. Both individual and environmental approaches necessarily include significant influences from social networks, but how and under what conditions social networks influence behavior change is often not clearly mapped out either in the obesity literature or in many intervention designs. In this paper, we provide an analysis of recent empirical work in obesity research that explicates social network influences on eating behaviors. We argue that a relational rather than individualistic view of personhood should help us better understand the content and context of social network relations that inform health behavior choices. We introduce the concept of ‘identity-constitutive affiliations’ as the glue that binds these social relationships together. Finally, we outline the implications for public health ethics in the development of effective interventions to address overweight and obesity, leveraging the content and context of social network ties to reinforce healthy (or alter unhealthy) eating. More complex treatment of positive and negative behaviors stemming from social network connections should lead to more comprehensive theoretical models of health behavior change and more effective public health interventions.

A Reform Proposal in Need of Reform: A Critique of Thomas Pogge's Proposal for How to Incentivize Research and Development of Essential Drugs

Sonderholm, J. — Fri, 03 Jul 2009 05:28:30 PDT

In two recent essays, Thomas Pogge addresses the question of how research and development of essential drugs should be incentivized. Essential drugs are drugs for diseases that ruin human lives. The current incentivizing scheme for such drugs is, according to Pogge, a significant causal factor in bringing about a state of affairs in which millions of people die or suffer from lack of access to essential drugs. Pogge, therefore, suggests a reform plan for how to incentivize research and development of these drugs, and he is of the opinion that implementation of this plan will have a significant positive impact on the global disease burden. This paper is a critical examination of Pogge's reform plan. In the first part of the paper, Pogge's reasons for being dissatisfied with the current incentivizing scheme are spelled out. The reform plan is then presented, and in the final part of the paper, it is argued that the reform plan is flawed at a number of levels.

Public Health Paternalism--A Response to Nys

Holland, S. — Thu, 25 Jun 2009 17:23:43 PDT

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.

Inclusion of Adolescent Women in Microbicide Trials: A Public Health Imperative!

Pomfret, S., Karim, Q. A., Benatar, S. R. — Fri, 12 Jun 2009 08:30:42 PDT

Conventional and well-established guidelines for the ethical conduct of clinical research are necessary but not sufficient for addressing research dilemmas related to public health research. There is a particular need for a public health ethics framework when, in the face of an epidemic, research is urgently needed to promote the common good. While there is limited experience in the use of a public health ethics framework, the value and potential of such an approach is increasingly being appreciated. Here we use two examples of adolescent women as potential candidates for participation in microbicide trials to illustrate how ethical decisions for public health research can be enhanced by drawing on both traditional research ethics guidance, and the emerging framework for public health ethics.

Case Discussion Cholera and Nothing More

Devakumar, D. — Tue, 01 Jan 2008 00:00:00 PST

This is a personal account highlighting some of the difficulties in dealing with a contagious epidemic in a resource poor setting. It shows a situation where you are limited in what you can do and asks what you should do when the interests of the population and of the individual conflict.