Public Health

COVID-19 vaccine requirements have generated significant debate. Here, we argue that, on the evidence available, such policies should have recognised proof of natural immunity as a sufficient basis for exemption to vaccination requirements. We begin by distinguishing our argument from two implausible claims about natural immunity: natural immunity is superior to ‘artificial’ vaccine-induced immunity simply because it is ‘natural’ and it is better to acquire immunity through natural infection than via vaccination. We then briefly survey the evidence base for the (...) comparison between naturally acquired immunity and vaccine-induced immunity. While we clearly cannot settle the scientific debates on this point, we suggest that we lack clear and convincing scientific evidence that vaccine-induced immunity has a significantly higher protective effect than natural immunity. Since vaccine requirements represent a substantial infringement of individual liberty, as well as imposing other significant costs, they can only be justified if they are necessary for achieving a proportionate public health benefit. Without compelling evidence for the superiority of vaccine-induced immunity, it cannot be deemed necessary to require vaccination for those with natural immunity. Subjecting them to vaccine mandates is therefore not justified. We conclude by defending the standard of proof that this argument from necessity invokes, and address other pragmatic and practical considerations that may speak against natural immunity exemptions. There are no data in this work. (shrink)

In response to the COVID-19 pandemic, large-scale research and pharmaceutical regulatory processes have proceeded at a dramatically increased pace with new and effective, evidence-based COVID-19 interventions rapidly making their way into the clinic. However, the swift generation of high-quality evidence and the efficient processing of regulatory authorisation have given rise to more specific and complex versions of well-known research ethics issues. In this paper, we identify three such issues by focusing on the authorisation of Molnupiravir, a novel antiviral medicine aimed (...) at reducing the ability of SARS-CoV-2 to multiply in the body, for clinical use by the National Health Service in England and the concomitant testing of Molnupiravir through the large-scale PANORAMIC randomised control trial. By analysing the ways in which the authorisation and clinical use of Molnupiravir complicate standard approaches to clinical equipoise, standard of care, and participant consent in the PANORAMIC randomised control trial we will explain some of ethical implications for clinical trials that aim to study the efficacy and safety of new COVID-19 and other therapeutics when conditional authorisation has already been granted and when such treatments have already been made available to patients by national health providers. (shrink)

This paper addresses the recent rise of the use of alternative medicine in Western countries and it offers a novel explanation of that phenomenon in terms of cognitive and economic factors related to the free-market and patient-centric approach to medicine that is currently in place in those countries in contrast to some alternative explanations of this phenomenon. Moreover, the paper addresses this troubling trend in terms of the serious harms associated with the use of alternative medical modalities. The explanatory theory (...) defended here is then predicted on the idea that an extreme patient-centric model of medical practice that treats largely ignorant patients as consumers of medical products and services endowed with an essentially unrestricted power of freedom to choose treatments predictably leads serious and avoidable harms. Some important moral and epistemological consequences of this model are then articulated and corrective measures are suggested. (shrink)

Concerns of moral distress in health care have never been more relevant. In her book, Health Care Ethics Through the Lens of Moral Distress, Kristen Jones-Bonofiglio provides a comprehensive review of the effects of moral distress on providers and health care delivery, while highlighting the complexities of making ethical decisions in practice. Jones-Bonofiglio’s thoroughness and use of interdisciplinary, historical, and cultural scholarship makes this book an excellent introductory resource on moral distress for health care providers and researchers alike.

Background: According to Gelfand et al., COVID-19 infection and case mortality rates are closely connected to the strength of social norms: “Tighter” cultures that abide by strict social norms are more successful in combating the pandemic than “looser” cultures that are more permissive. However, countries with similar levels of cultural tightness exhibit big differences in mortality rates. We are investigating potential explanations for this fact. Using data from Germany and Japan—two “tight” countries with very different infection and mortality rates—we examined (...) how differences in socio-demographic and other determinants explain differences in individual preventive attitudes and behaviors. Methods: We compared preventive attitudes and behaviors in 2020 based on real-time representative survey data and used logit regression models to study how individual attitudes and behaviors are shaped by four sets of covariates: individual socio-demographics, health, personality, and regional-level controls. Employing Blinder-Oaxaca regression techniques, we quantified the extent to which differences in averages of the covariates between Japan and Germany explain the differences in the observed preventive attitudes and behaviors. Results: In Germany and Japan, similar proportions of the population supported mandatory vaccination, avoided travel, and avoided people with symptoms of a cold. In Germany, however, a significantly higher proportion washed their hands frequently and avoided crowds, physical contact, public transport, peak-hour shopping, and contact with the elderly. In Japan, a significantly higher proportion were willing to be vaccinated. We also show that attitudes and behaviors varied significantly more with covariates in Germany than in Japan. Differences in averages of the covariates contribute little to explaining the observed differences in preventive attitudes and behaviors between the two countries. Conclusion: Consistent with tightness-looseness theory, the populations of Japan and Germany responded similarly to the pandemic. The observed differences in infection and fatality rates therefore cannot be explained by differences in behavior The major difference in attitudes is the willingness to be vaccinated, which was much higher in Japan. Furthermore, the Japanese population behaved more uniformly across social groups than the German population. This difference in the degree of homogeneity has important implications for the effectiveness of policy measures during the pandemic. (shrink)

Machine intelligence already helps medical staff with a number of tasks. Ethical decision-making, however, has not been handed over to computers. In this proof-of-concept study, we show how an algorithm based on Beauchamp and Childress’ prima-facie principles could be employed to advise on a range of moral dilemma situations that occur in medical institutions. We explain why we chose fuzzy cognitive maps to set up the advisory system and how we utilized machine learning to train it. We report on the (...) difficult task of operationalizing the principles of beneficence, non-maleficence and patient autonomy, and describe how we selected suitable input parameters that we extracted from a training dataset of clinical cases. The first performance results are promising, but an algorithmic approach to ethics also comes with several weaknesses and limitations. Should one really entrust the sensitive domain of clinical ethics to machine intelligence? (shrink)

In recent years, genetically engineered (GE) mosquitoes have been proposed as a public health measure against the high incidence of mosquito-borne diseases among the poor in regions of the global South. While uncertainties as well as risks for humans and ecosystems are entailed by the open-release of GE mosquitoes, a powerful global health governance non-state organization is funding the development of and advocating the use of those bio-technologies as public health tools. In August 2016, the US Food and Drug Agency (...) (FDA) approved the uncaged field trial of a GE Aedes aegypti mosquito in Key Haven, Florida. The FDA’s decision was based on its assessment of the risks of the proposed experimental public health research project. The FDA is considered a global regulatory standard setter. So, its approval of the uncaged field trial could be used by proponents of GE mosquitoes to urge countries in the global South to permit the use of those bio-technologies. -/- From a public health ethics perspective, this paper evaluates the FDA’s 2016 risk assessment of the proposed uncaged field trial of the GE mosquito to determine whether it qualified as a realistic risk evaluation. -/- The FDA’s risk assessment of the proposed uncaged field trial did not proximate the conditions under which the GE mosquitoes would be used in regions of the global South where there is a high prevalence of mosquito-borne diseases. -/- Given that health and disease have political-economic determinants, whether a risk assessment of a product is realistic or not particularly matters with respect to interventions meant for public health problems that disproportionately impact socio-economically marginalized populations. If ineffective public health interventions are adopted based on risk evaluations that do not closely mirror the conditions under which those products would actually be used, there could be public health and ethical costs for those populations. (shrink)

Lockdowns in Australia have been strict and lengthy. Policy-makers appear to have given the preservation of quantity of lives strong priority over the preservation of quality of lives. But thought-experiments in population ethics suggest that this is not always the right priority. In this paper, I'll discuss both negative impacts on quantity of lives caused by the lockdowns themselves, including an increase in domestic violence, and negative impacts on quality of lives caused by lockdowns, in order to raise the question (...) of whether we each had reason to choose quantity over quality in our own lives in a way that would justify the lockdowns we had. (shrink)

ABSTRACT In this article, I indicate how the naturalized and individualized conception of disability that prevails in philosophy informs the indifference of philosophers to the predictable COVID-19 tragedy that has unfolded in nursing homes, supported living centers, psychiatric institutions, and other institutions in which elders and younger disabled people are placed. I maintain that, insofar as feminist and other discourses represent these institutions as sites of care and love, they enact structural gaslighting. I argue, therefore, that philosophers must engage in (...) conceptual engineering with respect to how disability and these institutions are understood and represented. To substantiate my argument, I trace the sequence of catastrophic events that have occurred in nursing homes in Canada and in the Canadian province of Ontario in particular during the pandemic, tying these events to other past and current eugenic practices produced in the Canadian context. The crux of the article is that the COVID-19 pandemic has thrown into vivid relief the carceral character of nursing homes and other congregate settings in which elders and younger disabled people are confined. -/- KEYWORDS carceral, conceptual engineering, nursing home-industrial-complex, philosophy of disability, structural gaslighting. (shrink)

On 26 January 2021, while announcing that the country had reached the mark of 100,000 deaths within 28 days of COVID-19, UK Prime Minister Boris Johnson said that he took “full responsibility for everything that the Government has done” as part of British efforts to tackle the pandemic. The force of this statement was undermined, however, by what followed: -/- What I can tell you is that we truly did everything we could, and continue to do everything that we can, (...) to minimise loss of life and to minimise suffering... -/- Taking these sentiments together, it was hard to avoid the conclusion that the government took responsibility only for doing everything right. Such an admission of responsibility, accommodating no admission of error or wrongdoing, is not really about responsibility at all. Indeed, the UK’s pandemic response has been marked from its earliest days by a shifting of focus from institutional responsibility to personal responsibility for individual UK residents. -/- This paper explores the relationship between these two sites of responsibility—the institutional and the personal—in the context of the sort of pandemic that is ongoing as we write. Section 2 offers some initial definitions and discussions of key terms. Section 3 outlines how these two ideas interact in principle during such emergencies. Section 4 turns to the ‘non-ideal’ implications for personal responsibility of failures of institutional responsibility. While our focus is on the specific context with which we are most familiar, the UK governmental approach, where appropriate we also include examples from other states. (shrink)

The COVID-19 global pandemic has shone a light on several important ethical questions, ranging from fairness in resource allocation to the ethical justification of government mandates. In addition to these institutional issues, there are also several ethical questions that arise at the interpersonal level. This essay focuses on several of these issues. In particular, I argue that, despite the insistence in public health messaging that avoiding infecting others constitutes ‘saving lives’, virus transmission that results in death constitutes an act of (...) killing. Whether this killing is wrongful depends on several factors. I consider one intuitively plausible view—namely, that in many cases, killing via unintentional transmission is not wrongful, because the parties in question have implicitly waived their rights against this harm, often via reciprocal risk imposition. I argue that this view is mistaken, but that its central insight can be better captured by identifying the appropriate standards of blame that we ought to apply during a pandemic. I conclude by showing how these conclusions can be fruitfully applied to certain institutional questions, such as helping to justify restricting government mandates. (shrink)

Critical social theories examine social arrangements from the point of view of the obstacles that these structures pose to human flourishing, with the purpose of bringing about social change for the better. In this article, I contest the idea that these changes have to be guided by an idea of the good society. I argue that actual struggles are not guided by abstract ethical representations of the good life, but more negatively, by contestation of the limits of articulated universals by (...) the ones who are excluded and marginalised. (shrink)

By examining the global public good nature of pandemic preparedness we can identify key social justice issues that need to be confronted to increase citizens’ voluntary compliance with prevention and mitigation measures. As people tend to cooperate on a voluntary basis only with systems they consider fair, it becomes difficult to ensure compliance with public health measures in a context of extreme inequality. Among the major inequalities that need to be addressed we can find major differences in the extensiveness and (...) intensiveness of quarantine experiences, lack of opportunities to participate in common efforts, hardship in complying with disease control recommendations, and an unfair distribution of the cooperative surplus. (shrink)

COVID-19 vaccination of children has begun in various high-income countries with regulatory approval and general public support, but largely without careful ethical consideration. This trend is expected to extend to other COVID-19 vaccines and lower ages as clinical trials progress. This paper provides an ethical analysis of COVID-19 vaccination of healthy children. Specifically, we argue that it is currently unclear whether routine COVID-19 vaccination of healthy children is ethically justified in most contexts, given the minimal direct benefit that COVID-19 vaccination (...) provides to children, the potential for rare risks to outweigh these benefits and undermine vaccine confidence, and substantial evidence that COVID-19 vaccination confers adequate protection to risk groups, such as older adults, without the need to vaccinate healthy children. We conclude that child COVID-19 vaccination in wealthy communities before adults in poor communities worldwide is ethically unacceptable and consider how policy deliberations might evolve in light of future developments. (shrink)

How could the initial, drastic decisions to implement “lockdowns” to control the spread of COVID-19 infections be justifiable, when they were made on the basis of such uncertain evidence? We defend the imposition of lockdowns in some countries by first, and focusing on the UK, looking at the evidence that undergirded the decision, second, arguing that this provided us with sufficient grounds to restrict liberty given the circumstances, and third, defending the use of poorly-empirically-constrained epidemiological models as tools that can (...) legitimately guide public policy. (shrink)

What position on dualism does medicine require? Our understanding of that ques- tion has been dictated by holism, as defined by the biopsychosocial model, since the late twentieth century. Unfortunately, holism was characterized at the start with con- fused definitions of ‘dualism’ and ‘reductionism’, and that problem has led to a deep, unrecognized conceptual split in the medical professions. Some insist that holism is a nonreductionist approach that aligns with some form of dualism, while others insist it’s a reductionist view (...) that sets out to eradicate dualism. It’s important to consider each version. Nonreductive holism is philosophically consistent and clinically unprob- lematic. Reductive holism, however, is conceptually incoherent—yet it is the basis for the common idea that the boundary between medical and mental health disorders must be vague. When we trace that idea through to its implementation in medical practice, we find evidence that it compromises the safety of patient care in the large portion of cases where clinicians grapple with diagnosis at the boundary between psychiatry and medicine. Having established that medicine must embrace some form of nonreduc- tionism, I argue that Chalmers’ naturalistic dualism is a stronger prima facie candidate than the nonreductive alternatives. Regardless of which form of nonreductionism we prefer, some philosophical corrections are needed to give medicine a safe and coherent foundation. (shrink)

The COVID-19 pandemic has coincided with the proliferation of ethical guidance documents to assist public health authorities, health care providers, practitioners and staff with responding to ethical challenges posed by the pandemic. Like ethical guidelines relating to infectious disease that have preceded them, what unites many COVID-19 guidance documents is their dependency on an under-developed approach to bioethical principlism, a normative framework that attempts to guide actions based on a list of prima facie, unranked ethical principles. By situating them in (...) relation to the key philosophical debates concerning bioethical principlism, we aim to explore the limits and limitations of pandemic ethical guidance documents as, specifically, ethics documents – documents that fulfil the functions of ethics as a fundamentally normative discipline. This means not only determining whether such ethical guidance documents can, in principle, provide adequate action guidance and action justification, but also, more importantly where pandemics are concerned, determining whether they support consistent decision making and transparent processes of justification. Having highlighted the problems with merely furnishing ethical guidelines with substantive ethical content in terms of principles and values, we argue that organizations that develop these documents should, instead, focus on the procedural dimensions of action guidance and action justification, which extend to questions regarding the make-up of the committees, panels and groups that develop such guidelines, the public transparency of justifications for specific pandemic-related advice or interventions and the development of explicit procedures for transparent and consistent decision making. (shrink)

This paper explores the prospects of radical hope for addressing the devastation of the Covid-19 pandemic. Hope is useful for conceptualizing the proper balance between too much fear and too little about our uncertain future. First, I describe the ethical challenge of the pandemic as a wicked problem. Because accepted ethical theories fail to motivate solutions, wicked problems pressure us to develop our value systems, exercise moral imaginations, and discover creative solutions. Second, I develop an Aristotelian account of radical hope, (...) drawing from ancient philosophy, virtue ethics, and recent climate ethics. Radical hope is a novel form of courage, which balances the goal of external success, that something good will emerge from the tragedy, against the goal of living well for its own sake through practical wisdom. I conclude by applying some lessons to our present situation. (shrink)

Traditional medical practices and relationships are changing given the widespread adoption of AI-driven technologies across the various domains of health and healthcare. In many cases, these new technologies are not specific to the field of healthcare. Still, they are existent, ubiquitous, and commercially available systems upskilled to integrate these novel care practices. Given the widespread adoption, coupled with the dramatic changes in practices, new ethical and social issues emerge due to how these systems nudge users into making decisions and changing (...) behaviours. This article discusses how these AI-driven systems pose particular ethical challenges with regards to nudging. To confront these issues, the value sensitive design approach is adopted as a principled methodology that designers can adopt to design these systems to avoid harming and contribute to the social good. The AI for Social Good factors are adopted as the norms constraining maleficence. In contrast, higher-order values specific to AI, such as those from the EU High-Level Expert Group on AI and the United Nations Sustainable Development Goals, are adopted as the values to be promoted as much as possible in design. The use case of Amazon Alexa's Healthcare Skills is used to illustrate this design approach. It provides an exemplar of how designers and engineers can begin to orientate their design programs of these technologies towards the social good. (shrink)

In a recent article, Ethan Bradley and Mark Navin (2021) argue that vaccine refusal is not akin to free riding. Here, I defend one connection between vaccine refusal and free riding and suggest that, when viewed in conjunction with their other arguments, this might constitute a reason to mandate Covid-19 vaccination.

It is a relatively uncontroversial proposition that without “ethics,” an “ethics of homelessness” is impossible. What is less uncontroversial, though, is that philosophy—or at least philosophical analysis—is a necessary condition of ethical discourse. The distrust—or skepticism regarding the utility of— philosophical analysis is predicated on rendering philosophy as useless. This, though, should create a sense of cognitive dissonance, since we universally acknowledge that ethics informs how we interact with ourselves and others, while we also accept, and rightly so, the uselessness (...) of philosophy. While pop- ular parlance has it that uselessness is logically and semantically equivalent to not needed or conceptually irrelevant, this, I will argue, is mistaken. This mis- take, as I see it, is a result of the failure to recognize that liberal arts are intrinsi- cally useless—and ought to be treated as such. To mend this mistake, I will outline the liberal arts in contrast to the servile arts and explain how Aristotle, and his later defender Josef Pieper, correctly understood the distinction. I will then move onto suggest that while philosophy—as a liberal art—is useless, and rightfully so, it is a conceptually relevant, necessary condition for dealing with conceptual problems which arise in ethics—and therefore in the ethics of homelessness. To explicate and defend this thesis, I argue that Plato’s three- fold division of goods, originating in Book ii of his Republic, helps to amalgamate our reservations in accepting philosophy as useless—strictly speaking—and simultaneously useful. From this, I move on to provide various ways in which philosophy is relevant to questions of home and homelessness generally, and display how philosophers themselves have, historically, taken seriously the question of home and homelessness as serious philosophical concepts. Finally, I outline how philosophers can work on the ethics of home- lessness by taking seriously the necessary presuppositions which make work- ing on the alleviation of homelessness not merely possible, but morally obligatory. Having sketched a broad picture of how philosophy interacts with the practical problems of homelessness, I conclude that progress in the field of the ethics of homelessness—as a conceptual endeavor—will ultimately arise from overcoming our prima facie interpretation of the liberal/servile arts distinction and thereby preserve its original meaning. (shrink)

Despite having a set of well-intended tobacco control policies since 2003, the production and consumption of tobacco in Bangladesh have increased. This paper explains why the tobacco control policies in Bangladesh failed to deliver their intended outcomes. Using a combined framework of political economy and policy implementation analysis, this study examines the information collected from primary and secondary sources. Based on the findings, the paper argues that the game of interests among the stakeholders have made the state institutions inactive and (...) ineffective. Lack of political commitment and politics of interests have failed the implementation and skewed the outcome. (shrink)

Gay men have been severely affected by the AIDS crisis, and gay subjectivity, sexual ethics, and politics continue to be deeply influenced by HIV to this day. PrEP (Pre-Exposure Prophylaxis) is a new, drug-based HIV prevention technique, that allows disentangling gay sex from its widespread, 40 yearlong association with illness and death. This article explores PrEP’s fundamental impact on gay subjectivity, sexual ethics, and politics. It traces the genealogy of gay politics regarding homophobia and HIV stigma, suggesting a new biopolitical (...) and body political framework that accounts for the agency of activists as well as pharmapower, and proposing that PrEP is an example of democratic biopolitics. Highlighting the entanglement of medical technology, sexual ethics, and politics, the article shows how conservative and homonormative gay politics developed as a reaction to HIV stigma and how, by overcoming this stigma, PrEP enables a new era of intersectional queer politics and solidarities. It thereby develops a Foucauldian account of sexual liberation beyond the repression hypothesis that accounts for the ambivalence of sexual subjectification and the political potential of sexuality. (shrink)

The development of artificial womb technology is proceeding rapidly and will present important ethical and theological challenges for Christians. While there has been extensive secular discourse on artificial wombs in recent years, there has been little Christian engagement with this topic. There are broadly two primary uses of artificial womb technology—ectogestation as a form of enhanced neonatal care, where some of the gestation period takes place in an artificial womb, and ectogenesis, where the entire gestation period is within an artificial (...) womb. Ectogestation for the latter weeks or months of pregnancy could be possible within a decade or so, while ectogenesis for humans is far more speculative. Ectogestation is likely to significantly decrease maternal and neonatal morbidity and mortality, and so there is a strong case for supporting its development. Ectogenesis, however, may bring a number of challenges, including the commodification of children, and the pathologizing of pregnancy and childbirth. Its long-term effects on those who are created through this process are also unknown. In the event that it becomes ubiquitous, we may also find the central theological significance of pregnancy and birth diminished. The dilemma for Christians is that the development of ectogestation seems likely to normalise the use of artificial gestation, and, in time, pave the way for ectogenesis. (shrink)

BackgroundAs hospitals have grown more complex, the ethical concerns they confront have grown correspondingly complicated. Many hospitals have consequently developed health care ethics programs that include far more than ethics consultation services alone. Yet systematic research on these programs is lacking.MethodsBased on a national, cross-sectional survey of a stratified sample of 600 US hospitals, we report on the prevalence, scope, activities, staffing, workload, financial compensation, and greatest challenges facing HCEPs.ResultsAmong 372 hospitals whose informants responded to an online survey, 97% of (...) hospitals have HCEPs. Their scope includes clinical ethics functions in virtually all hospitals, but includes other functions in far fewer hospitals: ethical leadership, regulatory compliance, business ethics, and research ethics. HCEPs are responsible for providing ongoing ethics education to various target audiences including all staff, nurses, staff physicians, hospital leadership, medical residents and the community/general public. HCEPs staff are most commonly involved in policy work through review of existing policies but are less often involved in development of new policies. HCEPs have an ethics representative in executive leadership in 80.5% of hospitals, have representation on other hospital committees in 40.7%, are actively engaged in community outreach in 22.6%, and lead large-scale ethics quality improvement initiatives in 17.7%. In general, major teaching hospitals and urban hospitals have the most highly integrated ethics programs with the broadest scope and greatest number of activities. Larger hospitals, academically affiliated hospitals, and urban hospitals have significantly more individuals performing HCEP work and significantly more individuals receiving financial compensation specifically for that work. Overall, the most common greatest challenge facing HCEPs is resource shortages, whereas underutilization is the most common greatest challenge for hospitals with fewer than 100 beds. Respondents’ strategies for managing challenges include staff training and additional funds.ConclusionsWhile this study must be cautiously interpreted due to its limitations, the findings may be useful for understanding the characteristics of HCEPs in US hospitals and the factors associated with these characteristics. This information may contribute to exploring ways to strengthen HCEPs. (shrink)

Parents respond to the death of a child in very different ways. Some parents may be violent or angry, some sad and tearful, some quiet and withdrawn, and some frankly delusional. We present a case in which a father’s reaction to his daughter’s death is a desire to protect his wife from the stressful information. The wife is in the second trimester of a high-risk pregnancy and so is particularly fragile. We asked pediatricians and bioethicists to discuss the ways in (...) which they might respond to the father’s understandable but troubling request. -/- The death of a young child is one of the most stressful events that can happen to parents. The stress of such a loss is compounded if the parents are in a foreign country, far from home, and without a network of family and friends to provide social support. The stress may be more difficult to deal with if the parents have acute health problems of their own. In this month’s “Ethics Rounds,” we present a case in which a father whose daughter died requested that the doctors delay telling his wife. His reason: She is pregnant, in the second trimester, and on bed rest because of preterm labor. He does not want to add to her stress. We asked both pediatricians and bioethicists to respond to this request. (shrink)

In Italy, during the first wave of the Covid-19 pandemic, the Italian Society of Resuscitators and Pain Therapists (SIAARTI) and the Italian National Bioethics Committee (CNB) published ethical guidance on the allocation of scarce intensive care resources. In this paper, we outline and compare these documents in detail, highlighting differences and similarities. In particular, we argue that major differences exist with respect to the principles and values underpinning the documents and the normative allocation criteria proposed. Conversely, similarities can be traced (...) with respect to a functional rather than substantial endorsement of the age criterion, the importance of transparency, and the consideration over healthcare professionals’ responsibility regarding allocative decisions. In conclusion, we argue that Italy has lacked a comprehensive and publicly-accountable policy articulating principles and operational criteria geared to strengthen the “ethical preparedness” of the country in dealing with current and possible future public health emergencies. (shrink)

The COVID-19 pandemic has led to intense conversations about ventilator allocation and reallocation during a crisis standard of care. Multiple voices in the media and multiple state guidelines mention reallocation as a possibility. Drawing upon a range of neuroscientific, phenomenological, ethical, and sociopolitical considerations, the authors argue that taking away someone’s personal ventilator is a direct assault on their bodily and social integrity. They conclude that personal ventilators should not be part of reallocation pools and that triage protocols should be (...) immediately clarified to explicitly state that personal ventilators will be protected in all cases. (shrink)

Pro-life advocates commonly argue that fetuses have the moral status of persons, and an accompanying right to life, a view most pro-choice advocates deny. A difficulty for this pro-life position has been Judith Jarvis Thomson’s violinist analogy, in which she argues that even if the fetus is a person, abortion is often permissible because a pregnant woman is not obliged to continue to offer her body as life support. Here, we outline the moral theories underlying public health ethics, and examine (...) the COVID-19 pandemic as an example of public health considerations overriding individual rights. We argue that if fetuses are regarded as persons, then abortion is of such prevalence in society that it also constitutes a significant public health crisis. We show that on public health considerations, we are justified in overriding individual rights to bodily autonomy by prohibiting abortion. We conclude that in a society that values public health, abortion can only be tolerated if fetuses are not regarded as persons. (shrink)

At the beginning of the COVID-19 pandemic, high hopes were placed on digital contact tracing. Digital contact tracing apps can now be downloaded in many countries, but as further waves of COVID-19 tear through much of the northern hemisphere, these apps are playing a less important role in interrupting chains of infection than anticipated. We argue that one of the reasons for this is that most countries have opted for decentralised apps, which cannot provide a means of rapidly informing users (...) of likely infections while avoiding too many false positive reports. Centralised apps, in contrast, have the potential to do this. But policy making was influenced by public debates about the right app configuration, which have tended to focus heavily on privacy, and are driven by the assumption that decentralised apps are “privacy preserving by design”. We show that both types of apps are in fact vulnerable to privacy breaches, and, drawing on principles from safety engineering and risk analysis, compare the risks of centralised and decentralised systems along two dimensions, namely the probability of possible breaches and their severity. We conclude that a centralised app may in fact minimise overall ethical risk, and contend that we must reassess our approach to digital contact tracing, and should, more generally, be cautious about a myopic focus on privacy when conducting ethical assessments of data technologies. (shrink)

As many Western countries emerged from initial periods of lockdown in spring 2020, they had brought COVID-19 infection rates down significantly. This was followed, however, with more drastic second and third waves of viral spread, which many of these same countries are struggling to bring under control, even with the implementation of further periods of lockdown. Could this have been prevented by policymakers? We revisit two strategies that were focus of much discussion during the early stages of the pandemic, and (...) which were implemented in several Western countries, albeit in a weakened form. These strategies both proceed by targeting certain segments of the population, while allowing others to go about their lives unhindered. The first suggests selectively isolating those that would most likely suffer severe adverse effects if infected – in particular the elderly. The second involves identifying and quarantining those who are likely to be infected through a contact tracing app that would centrally store users’ information. We suggest that both strategies showed promise in preventing the need for further lockdowns, albeit in a significantly more stringent form than anything that was implemented in Western countries. We then proceed to an ethical evaluation of these more stringent policies. We contend that selective isolation strategies face severe ethical problems due to its discriminatory nature, while the ethical issues with a more aggressive contact tracing regime can be mitigated. This analysis has implications for how to respond effectively and ethically to future pandemics, and perhaps contains lessons on how to successfully emerge from our current predicament. (shrink)

Drawing on the SAGE minutes and other documents, I consider the wider lessons for norms of scientific advising that can be learned from the UK’s initial response to coronavirus in the period January-March 2020, when an initial strategy that planned to avoid total suppression of transmission was abruptly replaced by an aggressive suppression strategy. I introduce a distinction between “normatively light advice”, in which no specific policy option is recommended, and “normatively heavy advice” that does make an explicit recommendation. I (...) argue that, although scientific advisers should avoid normatively heavy advice in normal times in order to facilitate democratic accountability, this norm can be permissibly overridden in situations of grave emergency. SAGE’s major mistake in early 2020 was not that of endorsing a particular strategy, nor that of being insufficiently precautionary, but that of relying too heavily on a specific set of “reasonable worst-case” planning assumptions. I formulate some proposals that assign a more circumscribed role to “worst-case” thinking in emergency planning. In an epilogue, I consider what the implications of my proposals would have been for the UK’s response to the “second wave” of late 2020. (shrink)

This book offers a philosophically-based, yet clinically-oriented perspective on current medical reasoning aiming at 1) identifying important forms of uncertainty permeating current clinical reasoning and practice 2) promoting the application of an abductive methodology in the health context in order to deal with those clinical uncertainties 3) bridging the gap between biomedical knowledge, clinical practice, and research and values in both clinical and philosophical literature. With a clear philosophical emphasis, the book investigates themes lying at the border between several disciplines, (...) such as medicine, nursing, logic, epistemology, and philosophy of science; but also ethics, epidemiology, and statistics. At the same time, it critically discusses and compares several professional approaches to clinical practice such as the one of medical doctors, nurses and other clinical practitioners, showing the need for developing a unified framework of reasoning, which merges methods and resources from many different clinical but also non-clinical disciplines. In particular, this book shows how to leverage nursing knowledge and practice, which has been considerably neglected so far, to further shape the interdisciplinary nature of clinical reasoning. Furthermore, a thorough philosophical investigation on the values involved in health care is provided, based on both the clinical and philosophical literature. The book concludes by proposing an integrative approach to health and disease going beyond the so-called “classical biomedical model of care”. (shrink)

BackgroundViral pandemics present a range of ethical challenges for policy makers, not the least among which are difficult decisions about how to allocate scarce healthcare resources. One important question is whether healthcare workers should receive priority access to a vaccine in the event that an effective vaccine becomes available. This question is especially relevant in the coronavirus pandemic with governments and health authorities currently facing questions of distribution of COVID-19 vaccines.Main textIn this article, we critically evaluate the most common ethical (...) arguments for granting healthcare workers priority access to a vaccine. We review the existing literature on this topic, and analyse both deontological and utilitarian arguments in favour of HCW prioritisation. For illustrative purposes, we focus in particular on the distribution of a COVID-19 vaccine. We also explore some practical complexities attendant on arguments in favour of HCW prioritisation.ConclusionsWe argue that there are deontological and utilitarian cases for prioritising HCWs. Indeed, the widely held view that we should prioritise HCWs represents an example of ethical convergence. Complexities arise, however, when considering who should be included in the category of HCW, and who else should receive priority in addition to HCWs. (shrink)

Disparities exist in the health, livelihood, and opportunities for the 46-60 million people living in America’s rural communities. Rural communities across the United States need a new energy and focus concentrated around health and health care that allows for the designing capturing, and spreading of existing and new innovations. This paper aims to provide a framework for policy solutions to build a healthier rural America describing both the current state of rural health policy and the policies and practices in states (...) that could be used as a national model for positive change. (shrink)

Decision-Making Capacity First published Tue Jan 15, 2008; substantive revision Fri Aug 14, 2020 In many Western jurisdictions the law presumes that adult persons, and sometimes children that meet certain criteria, are capable of making their own medical decisions; for example, consenting to a particular medical treatment, or consenting to participate in a research trial. But what exactly does it mean to say that a subject has or lacks the requisite capacity to decide? This question has to do with what (...) is commonly called “decisional capacity”, a central concept in health care law and ethics, and increasingly an independent topic of philosophical inquiry. -/- Decisional capacity can be defined as the ability of subjects to make their own medical decisions. Somewhat similar questions of capacity arise in other contexts, such as capacity to stand trial in a court of law and the ability to make decisions that relate to personal care and finances. However, the history behind the more general legal notions of capacity to stand trial and capacity to manage one’s life is different and operates somewhat differently in law (Roth, Meisel, & Litz 1977; Zapf & Roesch 2005). For the purposes of this discussion the notion of decisional capacity will be limited to medical contexts only; most notably, those where decisions to consent or to refuse treatment or participation in clinical research are concerned. (shrink)

In response to crises, people sometimes prioritize fewer specific identifiable victims over many unspecified statistical victims. How other factors can explain this bias remains unclear. So two experiments investigated how complying with public health recommendations during the COVID19 pandemic depended on victim portrayal, reflection, and philosophical beliefs (Total N = 998). Only one experiment found that messaging about individual victims increased compliance compared to messaging about statistical victims—i.e., "flatten the curve" graphs—an effect that was undetected after controlling for other factors. (...) However, messaging about flu (vs. COVID19) indirectly reduced compliance by reducing perceived threat of the pandemic. Nevertheless, moral beliefs predicted compliance better than messaging and reflection in both experiments. The second experiment’s additional measures revealed that religiosity, political preferences, and beliefs about science also predicted compliance. This suggests that flouting public health recommendations may be less about ineffective messaging or reasoning than philosophical differences. (shrink)

Opioid litigation continues a growing public health litigation trend in which governments seek to hold companies responsible for population harms related to their products. The litigation can serve to address gaps in regulatory and legislative policymaking and in market self-regulation pervasive in the prescription opioid domain. Moreover, prior opioid settlements have satisfied civil tort litigation objectives of obtaining compensation for injured parties, deterring harmful behavior, and holding certain opioid manufacturers, distributors and pharmacies accountable for their actions. In this way, opioid (...) litigation represents progress over prior public health litigation campaigns involving tobacco, lead paint, and asbestos, which had more limited tort litigation effects. Although opioid litigation is not a comprehensive solution to the opioid crisis, it can complement other strategies and infuse much needed money, behavior changes, and public accountability for prescription opioid and related harms. (shrink)