Surveillance is essential for communicable disease prevention and control. Traditional notification of demographic and clinical information, about individuals with selected infectious diseases, allows appropriate public health action and is protected by public health and privacy legislation, but is slow and insensitive. Big data–based electronic surveillance, by commercial bodies and government agencies, which draws on a plethora of internet- and mobile device–based sources, has been widely accepted, if not universally welcomed. Similar anonymous digital sources also contain syndromic information, which can be (...) analysed, using customised algorithms, to rapidly predict infectious disease outbreaks, but the data are nonspecific and predictions sometimes misleading. However, public health authorities could use these online sources, in combination with de-identified personal health data, to provide more accurate and earlier warning of infectious disease events—including exotic or emerging infections—even before the cause is confirmed, and allow more timely public health intervention. Achieving optimal benefits would require access to selected data from personal electronic health and laboratory records and the potential to re-identify individuals found to be involved in outbreaks, to ensure appropriate care and infection control. Despite existing widespread digital surveillance and major potential community benefits of extending its use to communicable disease control, there is considerable public disquiet about allowing public health authorities access to personal health data. Informed public discussion, greater transparency and an ethical framework will be essential to build public trust in the use of new technology for communicable disease control. (shrink)
Emerging infectious diseases remain a significant and dynamic threat to the health of individuals and the well-being of communities across the globe. Over the last decade, in response to these threats, increasing scientific consensus has mobilised in support of a One Health approach so that OH is now widely regarded as the most effective way of addressing EID outbreaks and risks. Given the scientific focus on OH, there is growing interest in the philosophical and ethical dimensions of this approach, and (...) a nascent OH literature is developing in the humanities. One of the key issues raised in this literature concerns ethical frameworks and whether OH merits the development of its very own ethical framework. In this paper, we argue that although the OH approach does not demand a new ethical framework, an OH approach does furnish the theoretical resources to support a novel ethical framework, and there are benefits to developing one that may be lost in its absence. We begin by briefly explaining what an OH approach to the threats posed by EIDs entails before outlining two different ways of construing ethical frameworks. We then show that although on one account of ethical frameworks there is no need for OH to generate its own, there may be advantages for its advocates in doing so. (shrink)
One Health is a novel paradigm that recognizes that human and non-human animal health is interlinked through our shared environment. Increasingly prominent in public health responses to zoonoses, OH differs from traditional approaches to animal-borne infectious risks, because it also aims to promote the health of animals and ecological systems. Despite the widespread adoption of OH, culling remains a key component of institutional responses to the risks of zoonoses. Using the threats posed by highly pathogenic avian influenza viruses to human (...) and animal health, economic activity and food security as a case exemplar, we explore whether culling and other standard control measures for animal-borne infectious disease might be justified as part of OH approaches. Our central premise is that OH requires us to reformulate ‘health’ as universal good that is best shared across species boundaries such that human health and well-being are contingent upon identifying and meeting the relevant sets of human and non-human interests and shared dependencies. Our purpose is to further nascent discussions about the ethical dimensions of OH and begin to describe the principles around which a public health agenda that truly seeks to co-promote human and non-human health could potentially begin to be implemented. (shrink)
Overdiagnosis is an emerging problem in health policy and practice: we address its definition and ethical implications. We argue that the definition of overdiagnosis should be expressed at the level of populations. Consider a condition prevalent in a population, customarily labelled with diagnosis A. We propose that overdiagnosis is occurring in respect of that condition in that population when the condition is being identified and labelled with diagnosis A in that population ; this identification and labelling would be accepted as (...) correct in a relevant professional community; but the resulting label and/or intervention carries an unfavourable balance between benefits and harms. We identify challenges in determining and weighting relevant harms, then propose three central ethical considerations in overdiagnosis: the extent of harm done, whether harm is avoidable and whether the primary goal of the actor/s concerned is to benefit themselves or the patient, citizen or society. This distinguishes predatory, misdirected and tragic overdiagnosis; the degree of harm moderates the justifiability of each type. We end with four normative challenges: methods for adjudicating between professional standards and identifying relevant harms and benefits should be procedurally just; individuals, organisations and states are differently responsible for addressing overdiagnosis; overdiagnosis is a matter for distributive justice: the burdens of both overdiagnosis and its prevention could fall on the least-well-off; and communicating about overdiagnosis risks harming those unaware that they may have been overdiagnosed. These challenges will need to be addressed as the field develops. (shrink)
This article critically examines current responses to multi-drug resistant tuberculosis and argues that bioethics needs to be willing to engage in a more radical critique of the problem than is currently offered. In particular, we need to focus not simply on market-driven models of innovation and anti-microbial solutions to emergent and re-emergent infections such as TB. The global community also needs to address poverty and the structural factors that entrench inequalities—thus moving beyond the orthodox medical/public health frame of reference.
Within the field of medical ethics, discussions related to public health have mainly concentrated on issues that are closely tied to research and practice involving technologies and professional services, including vaccination, screening, and insurance coverage. Broader determinants of population health have received less attention, although this situation is rapidly changing. Against this backdrop, our specific contribution to the literature on ethics and law vis-à-vis promoting population health is to open up the ubiquitous presence of pets within cities and towns for (...) further discussion. An expanding body of research suggests that pet animals are deeply relevant to people’s health (negatively and positively). Pet bylaws adopted by town and city councils have largely escaped notice, yet they are meaningful to consider in relation to everyday practices, social norms, and cultural values, and thus in relation to population health. Nevertheless, not least because they pivot on defining pets as private property belonging to individual people, pet bylaws raise emotionally charged ethical issues that have yet to be tackled in any of the health research on pet ownership. The literature in moral philosophy on animals is vast, and we do not claim to advance this field here. Rather, we pragmatically seek to reconcile philosophical objections to pet ownership with both animal welfare and public health. In doing so, we foreground theorizations of personhood and property from sociocultural anthropology. (shrink)
With attention to the experiences, agency, and rights of tuberculosis patients, this symposium on TB and ethics brings together a range of different voices from the social sciences and humanities. To develop fresh insights and new approaches to TB care and prevention, it is important to incorporate diverse perspectives from outside the strictly biomedical model. In the articles presented in this issue of the Journal of Bioethical Inquiry, clinical experience is married with historical and cultural context, ethical concerns are brought (...) to bear on global health, and structural analyses shed light upon the lived experience of people living with TB. The relational and reciprocal dimensions of care feature strongly in these discussions, which serve as a poignant reminder that behind each of the yearly deaths from TB is a deeply personal story. No single discipline holds a monopoly on how to care for each of these people, but strong cases are made for support from mental health and social workers in addressing the kaleidoscope of needs in TB prevention. As the World Health Organization moves towards the goal of eliminating TB globally by 2050, attending to the needs of TB patients serves global interests to lower disease burden and to develop better integrated communities worldwide. (shrink)
In this paper we propose a new way of conceptualizing animals in experimentation – the animal-as-patient. Construing and treating animals as patients offers a way of successfully addressing some of the entrenched epistemological and ethical problems within a practice of animal experimentation directed to human clinical benefit. This approach is grounded in an epistemological insight and builds on work with so-called ‘pet models’. It relies upon the occurrence and characterization of analogous human and nonhuman animal diseases, where, if certain criteria (...) of homology and mechanism are met, the animal simultaneously becomes a patient and a spontaneous model of the human disease. (shrink)
The public can influence animal welfare law and regulation. However what constitutes ‘the public’ is not a straightforward matter. A variety of different publics have an interest in animal use and this has implications for the governance of animal welfare. This article presents an ethnographic content analysis of how the concept of a public is mobilized in animal welfare journals from 2003 to 2012. The study was undertaken to explore how experts in the discipline define and regard the role of (...) the public in determining animal welfare standards. Analysis indicates that experts in animal welfare constitute different types of citizen and consumer publics around specific types of animal use, framed by different theories of value. These results suggest a need for greater clarity about the roles and responsibilities of experts and publics in animal welfare reform processes. Clearly citizens and consumers can both contribute to promoting higher welfare standards, but an over-reliance on market mechanisms and consumer behaviour to assign value is beset by moral hazards, foremost being the risk of disarticulating the concept of animal welfare from the public good. (shrink)
(2013). What to Think of Canine Obesity? Emerging Challenges to Our Understanding of Human–Animal Health Relationships. Social Epistemology: Vol. 27, No. 1, pp. 90-104. doi: 10.1080/02691728.2012.760662.
Developments in biomedical science continue to transform our understanding of concepts such as health and disease. The creation of this expertise has also had a substantive role in changing the veterinary approach to animal diseases. Traditionally, companion animal veterinarians modelled their practices on developments in the diagnosis and treatment of human patients. As science and technology have realigned the boundaries between normalcy, intra-species variation and pathology in particular domains of expertise such as orthopaedic surgery, these patterns of knowledge translation have (...) changed. Not so long ago, treatments for the rupture of the cruciate ligament in human and canine patients were based on pathoanatomical comparison and designed to reestablish the stability of the joint by the functional restoration of ligament anatomy. Recently, a radically different characterization of the canine injury—with a corresponding alternative intervention—has been proposed within the field of veterinary orthopaedics. It views the normal anatomy of the canine knee as being in some way inherently pathogenic and proposes the surgical creation of an idealized structure as a remedy to dysfunction and disease. The veterinary focus on an ideal of patient performance, rather than a specific pathology, is now influencing how orthopaedists choose to approach analogous human injuries. In this article, I chart the history of canine ‘cruciate disease’ therapies as a means to map some of the epistemic assumptions, interplays of idealized and analogical reasoning and patterns of knowledge translation central to the biomedicalization of the science and practice of orthopaedic surgery. (shrink)
Background Outbreaks of infectious disease cause serious and costly health and social problems. Two new technologies – pathogen whole genome sequencing and Big Data analytics – promise to improve our capacity to detect and control outbreaks earlier, saving lives and resources. However, routinely using these technologies to capture more detailed and specific personal information could be perceived as intrusive and a threat to privacy. Method Four community juries were convened in two demographically different Sydney municipalities and two regional cities in (...) New South Wales, Australia to elicit the views of well-informed community members on the acceptability and legitimacy of: making pathogen WGS and linked administrative data available for public health researchusing this information in concert with data linkage and machine learning to enhance communicable disease surveillance systems Fifty participants of diverse backgrounds, mixed genders and ages were recruited by random-digit-dialling and topic-blinded social-media advertising. Each jury was presented with balanced factual evidence supporting different expert perspectives on the potential benefits and costs of technologically enhanced public health research and communicable disease surveillance and given the opportunity to question experts. Results Almost all jurors supported data linkage and WGS on routinely collected patient isolates for the purposes of public health research, provided standard de-identification practices were applied. However, allowing this information to be operationalised as a syndromic surveillance system was highly contentious with three juries voting in favour, and one against by narrow margins. For those in favour, support depended on several conditions related to system oversight and security being met. Those against were concerned about loss of privacy and did not trust Australian governments to run secure and effective systems. Conclusions Participants across all four events strongly supported the introduction of data linkage and pathogenomics to public health research under current research governance structures. Combining pathogen WGS with event-based data surveillance systems, however, is likely to be controversial because of a lack of public trust, even when the potential public health benefits are clear. Any suggestion of private sector involvement or commercialisation of WGS or surveillance data was unanimously rejected. (shrink)
At the beginning of the twentieth century, human and veterinary surgeons faced the challenge of a medical marketplace transformed by technology. The socioeconomic value ascribed to their patients was changing, reflecting the increasing mechanization of industry and the decreasing dependence of society on nonhuman animals for labor. In human medicine, concern for the economic consequences of fractures “pathologized” any significant level of posttherapeutic disability, a productivist perspective contrary to the traditional corpus of medical values. In contrast, veterinarians adapted to the (...) mechanization of horsepower by shifting their primary professional interest to companion animals; a type of patient generally valued for the unique emotional attachment of the owner and not their productive capacity. The economic rationalization of human fracture care and the “sentimental” transformation of veterinary orthopedic expertise indicate how these specialists utilized increasingly convergent rhetorical arguments to justify the application of innovative fracture care technologies to their human and animal patients. (shrink)
Since the 1990s, glycated haemoglobin (HbA1C) has been the gold standard for monitoring glycaemic control in people diagnosed as having either type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM). Discussions are underway about diagnosing diabetes mellitus on the basis of HbA1C titres and using HbA1C tests to screen for T2DM. These discussions have focused on the relative benefits for individual patients, with some attention directed towards reduced costs to healthcare systems and benefits to society. We argue that (...) there are strong ethical reasons for adopting HbA1C-based diagnosis and T2DM screening that have not yet been articulated. The rationale includes the differential impact of HbA1C-based diabetic testing on disadvantaged groups, and what we are beginning to learn about HbA1C vis-à-vis population health. Although it is arguable that screening must primarily benefit the individual, using HbA1C to diagnose and screen for T2DM may promote a more just distribution of health resources and lead to advances in investigating, monitoring and tackling the social determinants of health. (shrink)
We thank Zohar Lederman and Benjamin Capps for engaging with our paper on One Health and ethical frameworks, however we want to take issue with them on three points. First, they appear to misunderstand the distinction we appeal to between ethical theory and ethical frameworks, and so misinterpret what we are trying to achieve in our paper. Second, in spite of what they seem to imply, we agree that an OH approach can obscure differences in values, and that to progress (...) the field there needs to be recognition of competing values and their implications for OH. Finally, we are puzzled by their interest in pursuing a deliberative process, as this seems at odds with other positions they take in their paper, and also opens up many questions that need to be addressed. (shrink)
Surgery is an increasingly common and expensive mode of medical intervention. The ethical dimensions of the surgeon-patient relationship, including respect for personal autonomy and informed consent, are much discussed; but broader equity issues have not received the same attention. This paper extends the understanding of surgical ethics by considering the nature of evidence in surgery and its relationship to a just provision of healthcare for individuals and their populations.