With this issue, we begin a regular feature on bioethics and public health. We welcome Matthew K. Wynia, M.D., M.P.H., Director of the Institute for Ethics of the American Medical Association as our new Contributing Editor. If you have comments or suggestions regarding this feature, please email us at manuscript@ bioethics.net.
Using medical advances to enhance human athletic, aesthetic, and cognitive performance, rather than to treat disease, has been controversial. Little is known about physicians? experiences, views, and attitudes in this regard. We surveyed a national sample of physicians to determine how often they prescribe enhancements, their views on using medicine for enhancement, and whether they would be willing to prescribe a series of potential interventions that might be considered enhancements. We find that many physicians occasionally prescribe enhancements, but doctors hold (...) nuanced and ambiguous views of these issues. Most express concerns about the potential effects of enhancements on social equity, yet many also believe specific enhancements that are safe and effective should be available but not covered by insurance. These apparently contradictory views might reflect inherent tensions between the values of equity and liberty, which could make crafting coherent social policies on medical enhancements challenging. [Supplementary materials are available for this article. Go to the publisher's online edition of American Journal of Bioethics for the following free supplemental resource(s): An additional table (Table 5) referred to on p. 5]. (shrink)
Patients and physicians often perceive the current health care system to be unfair, in part because of the ways in which coverage decisions appear to be made. To address this problem the Ethical Force Program, a collaborative effort to create quality improvement tools for ethics in health care, has developed five content areas specifying ethical criteria for fair health care benefits design and administration. Each content area includes concrete recommendations and measurable expectations for performance improvement, which can be used by (...) those organizations involved in the design and administration of health benefits packages, such as purchasers, health plans, benefits consultants, and practitioner groups. (shrink)
The threat of bioterrorism, the emergence of the SARS epidemic, and a recent focus on professionalism among physicians, present a timely opportunity for a review of, and renewed commitment to, physician obligations to care for patients during epidemics. The professional obligation to care for contagious patients is part of a larger "duty to treat," which historically became accepted when 1) a risk of nosocomial infection was perceived, 2) an organized professional body existed to promote the duty, and 3) the public (...) came to rely on the duty. Physicians' responses to epidemics from the Hippocratic era to the present suggests an evolving acceptance of the professional duty to treat contagious patients, reaching a long-held peak between 1847 and the1950's. There has been some professional retrenchment against this duty to treat in the last 40 years but, we argue, conditions favoring acceptance of the duty are met today. A renewed embrace of physicians' duty to treat patients during epidemics, despite conditions of personal risk, might strengthen medicine's relationship with society, improve society's capacity to prepare for threats such as bioterrorism and new epidemics, and contribute to the development of a more robust and meaningful medical professionalism. (shrink)
Confidentiality is a core value in medicine and public health yet, like other core values, it is not absolute. Medical ethics has typically allowed for breaches of confidentiality when there is a credible threat of significant harm to an identifiable third party. Medical ethics has been less explicit in spelling out criteria for allowing breaches of confidentiality to protect populations, instead tending to defer these decisions to the law. But recently, issues in military detention settings have raised the profile of (...) decisions to breach medical confidentiality in efforts to protect the broader population. National and international ethics documents say little about the confidentiality of detainee medical records. But initial decisions to use detainee medical records to help craft coercive interrogations led to widespread condemnation, and might have contributed to detainee health problems, such as a large number of suicide attempts several of which have been successful. More recent military guidance seems to reflect lessons learned from these problems and does more to protect detainee records. For the public health system, this experience is a reminder of the importance of confidentiality in creating trustworthy, and effective, means to protect the public's health. (shrink)
There are three broad ethical issues related to handling public health emergencies. They are the three R's - rationing, restrictions and responsibilities. Recently, a severe shortage of annual influenza vaccine in the US, combined with the threat of pandemic flu, has provided an opportunity for policy makers to think about rationing in very concrete terms. Some lessons from annual flu vaccination likely will apply to pandemic vaccine distribution, but many preparatory decisions must be based on very rough estimates. What ethical (...) principles should guide rationing decisions, what data should inform these decisions, how to revise decisions as new data emerge, and how to implement rationing decisions on the ground are all important considerations. In addition, ethicists might be able to help policy makers think through the importance of international cooperation in surmounting global rationing dilemmas and to accept the inevitable responsibilities of government in making and implementing rationing decisions. (shrink)
Each year, infection with Human Papillomavirus (HPV) leads to millions of abnormal Pap smears and thousands of cases of cervical cancer in the US. Throughout the developing world, where Pap smears are less common, HPV is a leading cause of cancer death among women. So when the international pharmaceutical giant Merck developed a vaccine that could prevent infection with several key strains of HPV, the public health community was anxious to celebrate a major advance. But then marketing and lobbying got (...) in the way. Merck chose to pursue an aggressive lobbying campaign, trying to make its new vaccine mandatory for young girls. The campaign stoked public mistrust about how vaccines come to be mandated, and now it's not just Merck's public image that has taken a hit. The public health community has also been affected. What is the lesson to be learned from this story? Public health communication relies on public trust. (shrink)
The Centers for Disease Control and Prevention (CDC) recently recommended that HIV screening should become routine for all adults in the United States. Implicit in the CDC proposal is the notion that pre-test counseling would be more limited than at present, and that written informed consent to screening would no longer be required. If widely implemented, routine testing would mark a tremendous shift in the US HIV screening strategy. There are a number of considerations used to determine what screening tests (...) should be routine, and HIV fits the bill in almost every regard. Yet the stigma associated with HIV infection remains, making the CDC's recommendation highly controversial. Will minimizing requirements for pre-test counseling and special written informed consent lead to unexpected or unwanted HIV testing, or do these stringent counseling and consent requirements needlessly scare people away? Will widespread and routine testing be associated with declining stigmatization, or will it drive some patients away from seeking desperately needed health care? These are high stakes questions, and we're about to find out the answers. (shrink)
Recent arguments over whether certain public health interventions should be mandatory raise questions about what counts as a "mandate." A mandate is not the same as a mere recommendation or the standard of practice. At minimum, a mandate should require an active opt-out and there should be some penalty for refusing to abide by it. Over-loose use of the term "mandate" and the easing of opt-out provisions could eventually pose a risk to the gains that truly mandatory public health interventions, (...) such as childhood vaccines, have provided over the last 50 years. Already, confusion about what counts as a mandate, and about what criteria should be used to determine when a public health intervention should be implemented as a mandate, has led to some inappropriate public policy decisions. For instance, by any reasonable criteria, the yearly influenza vaccine should be mandatory for health care workers. To enforce this mandate, those who refuse vaccination should be required to sign a waiver, and patients - especially those at high risk from flu - should be informed when they receive care from unvaccinated practitioners. (shrink)
Responses to public health emergencies can entail difficult decisions about restricting individual liberties to prevent the spread of disease. The quintessential example is quarantine. While isolating sick patients tends not to provoke much concern, quarantine of healthy people who only might be infected often is controversial. In fact, as the experience with severe acute respiratory syndrome (SARS) shows, the vast majority of those placed under quarantine typically don't become ill. Efforts to enforce involuntary quarantine through military or police powers also (...) can backfire, stoking both panic and disease spread. Yet quarantine is part of a limited arsenal of options when effective treatment or prophylaxis is not available, and some evidence suggests it can be effective, especially when it is voluntary, home-based and accompanied by extensive outreach, communication and education efforts. Even assuming that quarantine is medically effective, however, it still must be ethically justified because it creates harms for many of those affected. Moreover, ethical principles of reciprocity, transparency, non-discrimination and accountability should guide any implementation of quarantine. (shrink)
The three primary ethical challenges in preparing for public health emergencies - addressing questions of rationing, restrictions and responsibilities - all entail confronting uncertainty. But the third, considering whether people and institutions will live up to their responsibilities in a crisis, is perhaps the hardest to predict and therefore plan for. The quintessential example of a responsibility during a public health emergency is that of health care professionals' obligation to continue caring for patients during epidemics. Historically, this 'duty to treat' (...) has sometimes gone unrecognized or ignored, but it has also famously been adhered to, including during the recent SARS epidemic. And non-crisis examples of health professionals working in the face of personal risk are very common. The duty to treat should be circumscribed by several considerations, including the levels or risk and benefit at issue, the degree of public reliance on health professional action, and the nature of the individual health professional's acceptance of greater than usual risk. Examining the professional duty to treat and the legitimate questions it raises can provide insight into other actors' responsibilities. Public health ethics as well as professional ethics can help frame answers to some key questions: How strong are ethical responsibilities during crises? To whom do they apply? Should they be more explicit - and hence more circumscribed - or less explicit and hence largely aspirational? And how can public health policies encourage responsible actions? (shrink)
Johan Huizinga u svojoj knjizi Homo ludens tvrdi kako civilizacija proizlazi i razvija se u igri i kao igra. Ona jest jedna od ljudskih karakteristika, ljudski obred, a služi za rekreaciju, zabavu, ali i učenje. Može li se onda dobro usmjerenom igrom razvijati ljudsko mišljenje? Cilj programa filozofije za djecu jest uvježbavanje multidimenzioniranog mišljenja. Po Mathew Lipmanu multidimenzionirano mišljenje jest cjelina koja se sastoji od kritičkog, kreativnog i skrbnog mišljenja. Program filozofije za djecu usmjeren je i prema predškolskoj i (...) osnovnoškolskoj populaciji. Radi toga je u programu neizbježna igra kao put k razvitku multidimenzioniranog mišljenja. U radu ćemo prikazati i nekoliko igara usmjerenih k uvježbavanju umnih sposobnosti koje se koriste u programu filozofije za djecu.Johan Huizinga, in his book Homo ludens, claims that civilization arises and develops through play and as a play. Playing is a characteristic of humans, a human ritual and yet it is for recreation, fun, but also for learning. Can it be then that well-directed play leads to a development of human thinking? The aim of philosophy for children programme is practising multidimensional thinking. According to Mathew Lipman, multidimensional thinking is the entirety consisted of critical, creative and caring thinking. Philosophy for children programme is directed towards pre-school as well as towards elementary-school population. For that reason this programme considers play as an inevitable way into the development of multidimensional thinking. In this paper we will also present a few games which are being used in philosophy for children programme, and which are also directed towards practising intellectual abilities. (shrink)
The comparison of corporate social performance with corporate financial performance has been a popular field of study over the past 25 years. The results, while broadly conclusive of a positive relationship, are not entirely consistent. In addition, most of the previous studies have concentrated on large-scale cross-industry studies and often with a single variable for corporate social performance, in order to produce statistically significant results. This weakens the richness of understanding that might be obtained from a single industry study with (...) multiple social variables, which would also allow investigation of inter-relationships between individual and sub-sets of social performance measures and between individual and sub-sets of social performance and financial performance measures. There have also been criticisms that the results lack a rigorous theoretical basis, and the paper demonstrates clearly how stakeholder theory must form the basis for this area of research. Following a review of the literature this paper presents the initial findings from a study of the U.K. Supermarket industry which suggest that contemporaneous social and financial performance are negatively related, while prior-period financial performance is positively related with subsequent social performance. Positive relationships between both age and size of the company with social performance are also found. (shrink)
Whilst there is a growing volume of literature exploring the ethical implications of organisational change for HRM and the ethical aspects of certain HRM activities, there have been few published U.K. studies of how HR managers actually behave when faced with ethical dilemmas in their work. This paper seeks to enhance the foundations of such knowledge through an examination of the influence of organisational values on the ethical behaviour of Human Resource Managers within a sample of charities in the U.K. (...) and the Republic of Ireland. A qualitative research design is adopted utilising semi-structured interviews. Findings highlight ethical inconsistency in people management in the charity sector arising from the clear application of strong and explicit organisational values to external client groups but their limited influence on people management strategies and practices within the organisation. Many of the ethical issues faced by HRM professionals in both countries arise from this inconsistency. In their handling of ethical dilemmas, the HRM professionals exhibit a combination of a care ethic and a concern for justice but it is also clear that in situations of management intransigence, a desire to be conscience driven often gives way to a contingent approach. Whilst respondents considered it inappropriate for the HRM function to be the conscience of the organisation, it is seen to have a key role in providing management with advice on ethical action. However, the ability of HRM to influence ethical behaviour is highly dependent on the status of the function within the organisation. (shrink)
From the beginning of the 20th Century to the present day, it has rarely been doubted that whenever formal aesthetic methods meet their iconological counterparts, the two approaches appear to be mutually exclusive. In reality, though, an ahistorical concept is challenging a historical analysis of art. It is especially Susanne K. Langer´s long-overlooked system of analogies between perceptions of the world and of artistic creations that are dependent on feelings which today allows a rapprochement of these positions. Krois’s insistence on (...) a similar point supports this analysis. Their perspectives are grounded in the concept that the feelings within perception are elicited by analogue formal structures in the world and in the arts. This leads to the conclusion that – dependent on the logical and carefully designed formal structure of an artist´s composition and its living interpretation by its recipient – the artistic creation can be identified as a meaningful statement of the creator, which generates an affirmative or critical reply of his consumer. In such a way, on the basis of formal aesthetics and iconology the arts can be affirmed to be relevant for cultural processes: they form parts of the communicative processes that constitute life. (shrink)
Attempts to extend the classical Hausdorff difference hierarchy to the case of partitions of a space to k > 2 subsets lead to non-equivalent notions. In a hope to identify the right extension we consider the extensions appeared in the literature so far: the limit-, level-, Boolean and Wadge hierarchies of k -partitions. The advantages and disadvantages of the four hierarchies are discussed. The main technical contribution of this paper is a complete characterization of the Wadge degrees of [ ¿ (...) ] º 2-measurable k -partitions of the Baire space. (shrink)
The theoretical description of particle decay by a single particle theory requires the use of a probability density in time that is not present in conventional theories. The problem of single particle decay is consistently described here within the context of a single particle, relativistic dynamical theory. We derive experimentally testable differences between the standard model and Relativistic Dynamics for a two-state system: the neutral K-meson (K 0) system. We show that the estimate of mass difference between the two states (...) is theory dependent. (shrink)
We study some metamathematical properties of various classicaland paraconsistent logical systems. In particular, we discuss the concept ofa k-transform of a formula and consider some of its applications.
In this paper rejection systems for the “nonsense-logic” W and the k-valued implicational-negational sentential calculi of Sobociński are given. Considered systems consist of computable sets of rejected axioms and only one rejection rule: the rejection version of detachment rule.