This symposium of the Journal of Bioethical Inquiry illustrates structural competency: how clinical practitioners can intervene on social and institutional determinants of health. It will require training clinicians to see and act on structural barriers to health, to adapt imaginative structural approaches from fields outside of medicine, and to collaborate with disciplines and institutions outside of medicine. Case studies of effective work on all of these levels are presented in this volume. The contributors exemplify structural competency from many (...) angles, from the implications of epigenetics for environmental intervention in personalized medicine to the ways clinicians can act on fundamental causes of disease, address abuses of power in clinical training, racially desegregate cities to reduce health disparities, address the systemic causes of torture by police, and implement harm-reduction programs for addiction in the face of punitive drug laws. Together, these contributors demonstrate the unique roles that clinicians can play in breaking systemic barriers to health and the benefit to the U.S. healthcare system of adopting innovations from outside of the United States and outside of clinical medicine. (shrink)

In their article “The Civil Rights of Health,” Harris and Pamukcu offer a framework connecting civil rights law to unjust health disparities with the aims of creating broader awareness of subordination as a root cause of health inequities and inviting policymakers to create new legal tools for dismantling it. They close with a call to action. Here, we take up their call and propose cooperative enterprises as a health justice intervention. To illustrate this conceptualization, we focus (...) on childcare as a system with robust connections to social, economic, and health equity for children, workers, and families. (shrink)

Health inequalities are embedded in a complex array of social, political, and economic inequalities. Responding to health inequalities will require systematic action targeting all the underlying (“upstream”) social determinants that powerfully affect health and well‐being. Systemic inequalities are a major reason for the rise of modern populism that has deeply divided polities and infected politics, perhaps nowhere more so than in the United States. Concerted action to mitigate shocking levels of inequality could be a powerful antidote (...) to nationalist populism. A basic yet critical start to addressing health inequalities is to recognize them, which demands improving data collection and analysis. Certainly, global indicators show vast progress in reducing poverty and extending life. Yet aggregate health data mask a deeper reality: health gains have disproportionately benefited the well‐off, leaving the poor and middle‐class behind. (shrink)

Our health care system in the United States reflects the inequities that are part of the larger society, which is why our system for financing access to needed and effective health care is so complicated and unfair.

Many observers claim that business has become a powerful force in medicine and that the future of health care cannot escape that reality, even though some scholars lament it. The U.S. recently experienced the most devastating recession since the Great Depression. As health care costs rise, we face additional pressure to rein in health care spending. We also have important new legislation that could well mark a significant shift in how health care is provided and who (...) has access to care, namely the Affordable Care Act. These changes underscore the need to bring new thinking to the conversation about health care and to move beyond conceptual and practical obstacles that inhibit our progress.In this paper we do not to claim to have solutions. Rather, our aim is to try to identify some obstacles to fostering a better conversation about the future of health care and to envisioning a better health care system. (shrink)

The legacy of colonial rule has permeated into all aspects of life and contributed to healthcare inequity. In response to the increased interest in social justice, medical educators are thinking of ways to decolonise education and produce doctors who can meet the complex needs of diverse populations. This paper aims to explore decolonising ideas of healing within medical education following recent events including the University College London Medical School’s Decolonising the Medical Curriculum public engagement event, the Wellcome Collection ’s Ayurvedic (...) Man: Encounters with Indian Medicine exhibition and its symposium on Decolonising Health, SOAS University of London’s Applying a Decolonial Lens to Research Structures, Norms and Practices in Higher Education Institutions and University College London Anthropology Department’s Flourishing Diversity Series. We investigate implications of ‘recentring’ displaced indigenous healing systems, medical pluralism and highlight the concept of cultural humility in medical training, which while challenging, may benefit patients. From a global health perspective, climate change debates and associated civil protests around the issues resonate with indigenous ideas of planetary health, which focus on the harmonious interconnection of the planet, the environment and human beings. Finally, we look further at its implications in clinical practice, addressing the background of inequality in healthcare among the BAME populations, intersectionality and an increasing recognition of the role of inter-generational trauma originating from the legacy of slavery. By analysing these theories and conversations that challenge the biomedical view of health, we conclude that encouraging healthcare educators and professionals to adopt a ‘ decolonising attitude ’ can address the complex power imbalances in health and further improve person-centred care. (shrink)

Memory, funerals, and the communion of the saints: growing old and practices of remembering / M. Therese Lysaught -- God bends over backward to accommodate humankind...while the Civil Rights Acts and the Americans with Disabilities Act require [only] minimum effort / Mary Jo Iozzio -- Radical solidarity: migration as challenge ofr contemporary Christian ethics / Kristin E. Heyer -- Catholic lesbian feminist theology / Mary E. Hunt -- Theology of whose body? Sexual conplementarity, intersex conditions, and La Virgen de Guadalupe (...) / Katie M. Grimes -- Social conscience and politics in the United States of America: reflections / Mary Jo Bane -- Pope Francis, women, and the church for the poor / Lisa A. Fullam -- Floodwaters and the ticking clock: the systematic oppression and stigmatization of poor, single mothers in American and Christian theological responses / Julie A. Mavity Maddalena --What causes inequity? / Dean Baker -- Engaging the U.S. Bishops' pastoral on crime and criminal justice: from atomism to community justice / Robert DeFina and Lance Hannon -- Reconstructing the moral claim of racially unjust mass incarceration / Alison Benders -- The systemic erasure of the Black/dark-skinned body in Catholic ethics / Bryan Massingale -- Anti-blackness and white supremacy in the making of American Catholicism / M. Shawn Copeland -- White privilege / Charles E. Curran -- The Black Lives Matter Movement: justice and health equity / Michael P. Jaycox -- Mujerista theology: a challenge to traditional theology / Ada María Isasi-Díaz -- Faith of our mothers; Catholic womanist God-talk / Diana L. Hayes. (shrink)

This paper provides an analysis of U.S. farmland owners, operators, and workers by race, ethnicity, and gender. We first review the intersection between racialized and gendered capitalism and farmland ownership and farming in the United States. Then we analyze data from the 2014 Tenure and Ownership Agricultural Land survey, the 2012 Census of Agriculture, and the 2013–2014 National Agricultural Worker Survey to demonstrate that significant nation-wide disparities in farming by race, ethnicity and gender persist in the U.S. In 2012–2014, White (...) people owned 98% and operated 94% of all farmland. They generated 98% of all farm-related income from land ownership and 97% of income from farm owner-operatorship. Meanwhile, People of Color farmers were more likely to be tenants rather than owners, owned less land, and generated less farm-related wealth per person than their White counterparts. Hispanic farmers were also disproportionately farm laborers. In addition to racial and ethnic disparities, there were disparities by gender. About 63% of non-operating landowners, 86% of farm operators, and 87% of tenant farmers were male, and female farmers tended to generate less income per farmer than men. This data provides evidence of ongoing racial, ethnic and gender disparities in agriculture in the United States. We conclude with a call to address the structural drivers of the disparities and with recommendations for better data collection. (shrink)

Book reviewed in this article: Health Policies, Health Politics: The British and American Experience, 1911–1965. By Daniel M. Fox.

Schools are interesting as complex organizations in and of themselves but even more so for how they refract the societal dynamics by which inequality is reproduced, an enduringly vexing question (Fligstein & McAdam, 2012:3). Educational attainment is core to socioeconomic status and connected to outcomes in housing, health, and employment. Unequal schools in fields characterized by stratification are often the subject of reform attempts (Tyack, 1974). We examine how a wealthier and a poorer school responded to a state-level (...) regulatory mandate for change, in the U.S. context of schools as putative engines of opportunity. Bourdieu’s “master concepts” of field, habitus, and cultural capital (Swartz, 2008) are often applied, and we used them to answer frequent but still relatively unanswered calls in the literature: first, to use the master concepts together rather than singularly, and second, to attend specifically to the organization level and what it refracts (Dobbin, 2008; Emirbayer & Johnson, 2008; Hallett & Gougherty, 2018; Lounsbury & Ventresca, 2003; Mohr, 2013). For this integrative and organizational level approach, we derived the concept of “class signature,” which enabled us to focus on practices in organizations. This lens revealed “resistant compliance” in the wealthier school and “compliant resistance” in the poorer school, both of which reshaped the stratified field, even if stratification was not rectified. These responses appeared to reproduce inequality, not simplistically, we argue, but along a winding path fraught with practical experiments, protection against penalties, redefinition of the reform’s terms, and some small gains to remedy intra-organizational inequalities. (shrink)

This article is guided by principles and practices of bioethics and public health ethics focused on health care reform within the context of promoting Optimal Health. The Tuskegee University National Center for Bioethics in Research and Health Care is moving beyond the traditions of bioethics to incorporate public health ethics and Optimal Health. It is imperative to remember the legacy of the ill-fated research entitled Tuskegee Study of Untreated Syphilis in the Negro Male. Human (...) participant research and health care must be connected to principles of bioethics and public health ethics if the Affordable Care Act is expected to positively impact on the health of people living in the United States. Optimal Health describes a strategy to achieve individual and population health. Health care reform offers an opportunity to shift from the traditional pathology focus of managing diseases to target disease prevention and health promotion with a new set of tools. Transformational change is possible if the lessons learned from the U.S. Public Health Service Syphilis Study at Tuskegee are considered and strategies in bioethics and public heath ethics are employed. (shrink)

The dialogue about the future of health care in the US has been impeded by flawed conceptions about medicine and business. The present paper re-examines some of the underlying assumptions about both medicine and business, and uses more nuanced readings of both terms to frame debates about the ACA and the emerging health care environment.

For much of 2021, allocating the scarce supply of Covid‐19 vaccines was the world's most pressing bioethical challenge, and similar challenges may recur for novel therapies and future vaccines. In the United States, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) identified three fundamental ethical principles to guide the process: maximize benefits, promote justice, and mitigate health inequities. We argue that critical components of the recommended protocol were internally inconsistent with these principles. Specifically, the (...) ACIP violated its principles by recommending overly broad health care worker priority in phase 1a, using being at least seventy‐five years of age as the only criterion to identify individuals at high risk of death from Covid‐19 during phase 1b, failing to recommend place‐based vaccine distribution, and implicitly endorsing first‐come, first‐served allocation. More rigorous empirical work and the development of a complete ethical framework that recognizes trade‐offs between principles may have prevented these mistakes and saved lives. (shrink)

The past 20 years have seen dramatic rises in suicide rates in the U.S. and other countries around the world. These trends have been identified as a public health crisis in urgent need of new solutions and have spurred significant research efforts to improve our understanding of suicide and strategies to prevent it. Unfortunately, despite making significant contributions to the founding of suicidology – through Emile Durkheim’s classic Suicide (1897 [1951]) – sociology’s role has been less prominent in contemporary (...) efforts to address these tragic trends, though as we will show, sociological theories offer great promise for advancing our understanding of suicide and improving the efficacy of suicide prevention. Here, we review sociological theory and empirical research on suicide. We begin where all sociologists must: with Durkheim. However, we offer a more comprehensive understanding of Durkheim’s insights into suicide than the prior reviews provided by those in other disciplines. In so doing, we reveal the nuance and richness of Durkheim’s insights that have been largely lost in modern suicidology, despite being foundational to all sociological theories of suicide – even those that have moved beyond his model. We proceed to discuss broadly acknowledged limitations to Durkheim’s theory of suicide and review how more recent theoretical efforts have not only addressed those concerns, but have done so by bringing a larger swatch of sociology’s theoretical and empirical toolkit to bare on suicide. Specifically, we review how recent sociological theories of suicide have incorporated insights from social network theories, cultural sociology, sociology of emotions, and sociological social psychology to better theorize how the external social world matters to individual psychological pain and suffering. We conclude by making explicit bridges between sociological and psychological theories of suicide; by noting important limitations in knowledge about suicide – particularly regarding the roles of organizations, inequality, and intersectionality in suicide – that sociology is well situated to help address. (shrink)

Health equity can be defined as the absence of disadvantage to individuals and communities in health outcomes, access to health care, and quality of health care regardless of one’s race, gender, nationality, age, ethnicity, religion, and socioeconomic status. Health equity concerns those disparities in public health that can be traced to unequal, systemic economic, and social conditions. Despite significant improvements in the health of the overall population, health inequities in America persist. Racial (...) and ethnic minorities continue to experience higher rates of morbidity and mortality than non-minorities across a range of health issues. For example, African-American children with asthma have a seven times greater mortality rate than Non-Hispanic white children with the illness. While cancer is the second leading cause of death among all populations in the U.S., ethnic minorities are especially burdened with the disease. (shrink)

This paper addresses the intertwined issues of rising income inequality and food insecurity in the U.S. The ways that food security and insecurity are defined anddiscussed by the major agricultural companies are contrasted with the concepts and definitions used by food sovereignty activists. We argue that the hegemonic discourse of hunger and food security articulated and disseminated by the agricultural production companies, such as Monsanto and Cargill, contributes to, rather than alleviates widespread food insecurity. Local and regional food production (...) offer alternatives that enable low income people to control and optimize their food choices. (shrink)

Meat is a multi-billion-dollar industry that relies on people performing risky physical work inside meat-processing facilities over long shifts in close proximity. These workers are socially disempowered, and many are members of groups beset by historic and ongoing structural discrimination. The combination of working conditions and worker characteristics facilitate the spread of SARS-CoV-2, the virus that causes COVID-19. Workers have been expected to put their health and lives at risk during the pandemic because of government and industry pressures to (...) keep this “essential industry” producing. Numerous interventions can significantly reduce the risks to workers and their communities; however, the industry’s implementation has been sporadic and inconsistent. With a focus on the U.S. context, this paper offers an ethical framework for infection prevention and control recommendations grounded in public health values of health and safety, interdependence and solidarity, and health equity and justice, with particular attention to considerations of reciprocity, equitable burden sharing, harm reduction, and health promotion. Meat-processing workers are owed an approach that protects their health relative to the risks of harms to them, their families, and their communities. Sacrifices from businesses benefitting financially from essential industry status are ethically warranted and should acknowledge the risks assumed by workers in the context of existing structural inequities. (shrink)

This book focuses on justice and its demands in the way of providing people with medical care. Building on recent insights on the nature of moral perceptions and motivations from the neurosciences, it makes a case for the traditional medical ethic and examines its financial feasibility. The book starts out by giving an account of the concept of justice and tracing it back to the practices and tenets of Hippocrates and his followers, while taking into account findings from the neurosciences. (...) Next, it considers whether the claim that it is just to limit medical care for everyone to some basic minimum is justifiable. The book then addresses finances and expenditures of the US health care system and shows that the growth of expenditures and the percentage of the gross national product spent on health care make for an unsustainable trajectory. In light of the question what should be changed, the book suggests that overdiagnosis and medicalizing normal behavior lead to harmful, costly and unnecessary interventions and are the result of unethical behavior on the part of the pharmaceutical industry and extensive ethical failures of the FDA. The book ends with suggestions about what can be done to put the U.S. health care system on the path to sustainability, better medical care, and compliance with the demands of justice. (shrink)

Many segments of society have systems of values arising from collective beliefs and motivations. For agriculture, and our food system, increasing production to feed the growing human population clearly is a core value. However, a survey we conducted, together with a previously reported survey, showed that the curricula of most U.S. colleges of agriculture do not offer ethics courses that examine the basis of this core value or include discussion of agriculture’s ethical dilemmas such as misuse of pesticides, not progressing (...) rapidly enough toward sustainability goals, relative lack of involvement in addressing diet-related health issues, and lack of commitment to reducing agriculture’s role as a contributor to global climate change. These surveys provide strong evidence that few students have an opportunity to learn ethical concepts and apply them to issues of importance to the agriculture/food system. We suggest that such issues are both growing societal concerns and serious ethical problems that demand attention if our agricultural/food system is not see its relationship with the public further imperiled. Further, we suggest that there is a need for, indeed an obligation of, the faculty of colleges of agriculture to embrace a thorough analysis and discussion of agriculture’s values and their ethical foundation. We offer our thoughts on why curricula of colleges of agriculture do not provide such opportunities and on the importance of agricultural faculties providing leadership in ethical analysis and discussion. (shrink)

Resistance is a concept understudied in the context of health and healthcare. This is in part because visible forms of social protest are sometimes understood as incongruent with professional identity, leading healthcare workers to separate their visible actions from their working life. Resistance takes many forms, however, and focusing exclusively on the visible means more subtle forms of everyday resistance are likely to be missed. The overarching aim of this study was to explore how resistance was enacted within the (...) workplace amongst a sample of twelve healthcare workers, based in the United Kingdom; exploring the forms that such action took and how this intersected with health and healthcare. In depth-interviews were conducted and results were analysed utilizing Lilja’s framework ( 2022 ). Our findings suggest that resistance took a number of forms, from more direct confrontational acts, to those which sought to avoid power or which sought to create alternative or prefigurative practices or norms. These findings speak to the complexities, ambiguities, and contradictions of resistance, as carried out by healthcare workers in the workplace. While many acts had clear political motives, with issues like climate change in mind for example, participants also described how the act of providing care itself could be an act of resistance. While saying something about our participants, this also said something about the healthcare systems in which they worked. These findings also raise a range of normative issues. Perhaps needless to say, there appears to be substantial scope to expand and interrogate our findings and apply the idea of resistance to health and healthcare. (shrink)

Health equity can be defined as the absence of disadvantage to individuals and communities in health outcomes, access to health care, and quality of health care regardless of one’s race, gender, nationality, age, ethnicity, religion, and socioeconomic status. Health equity concerns those disparities in public health that can be traced to unequal, systemic economic, and social conditions. Despite significant improvements in the health of the overall population, health inequities in America persist. Racial (...) and ethnic minorities continue to experience higher rates of morbidity and mortality than non-minorities across a range of health issues. For example, African-American children with asthma have a seven times greater mortality rate than Non-Hispanic white children with the illness. While cancer is the second leading cause of death among all populations in the U.S., ethnic minorities are especially burdened with the disease. (shrink)

American Indian/Alaska Native (AI/AN) populations in the United States continue to experience overall health inequity, despite significant improvement in health status for nearly all other racial‐ethnic groups over the past 30 years. Nurses comprise the bulk of healthcare providers in the U.S. and are in an optimal position to improve AI/AN health by transforming both nursing education and practice. This potential is dependent, however, on nurses’ ability to recognize the distinct historical and political conditions through which AI/AN (...) health inequities have been produced and sustained. Nurse providers, educators, and leaders must in turn recognize how the sustained conditions of marginalization and expropriation that underpin current AI/AN health inequities continue to shape contemporary AI/AN health outcomes. This manuscript builds upon the extant literature of AI/AN historical health policy and utilizes decolonial theorizations of nursing and a cultural safety framework to propose a series of immediately actionable steps for nursing intervention into AI/AN health inequity. Ultimately, we suggest that it is crucial for nurses to collaborate with AI/AN individuals and communities across educational and clinical settings to further refine these approaches in alignment with the disciplinary obligation of promoting social justice within healthcare. (shrink)

Disproportional morbidity and mortality experienced by ethnic minorities in the UK have been highlighted by the COVID-19 pandemic. The ‘Black Lives Matter’ movement has exposed structural racism’s contribution to these health inequities. ‘Cultural Safety’, an antiracist, decolonising and educational innovation originating in New Zealand, has been adopted in Australia. Cultural Safety aims to dismantle barriers faced by colonised Indigenous peoples in mainstream healthcare by addressing systemic racism.This paper explores what it means to be ‘culturally safe’. The ways in which (...) New Zealand and Australia are incorporating Cultural Safety into educating healthcare professionals and in day-to-day practice in medicine are highlighted. We consider the ‘nuts and bolts’ of translating Cultural Safety into the UK to reduce racism within healthcare. Listening to the voices of black, Asian and minority ethnic National Health Service (NHS) consumers, education in reflexivity, both personal and organisational within the NHS are key. By listening to Indigenous colonised peoples, the ex-Empire may find solutions to health inequity. A decolonising feedback loop is required; however, we should take care not to culturally appropriate this valuable reverse innovation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 14.1 (2004) 97-114 [Access article in PDF] Stem Cell Research in the U.S. after the President's Speech of August 2001 Cynthia B. Cohen On 9 August 2001, in a nationally televised speech, President Bush addressed the contentious question of whether to provide federal funds for human embryonic stem cell research (White House 2001).1 This research involves taking the primordial cells found in embryos and (...) transforming them into certain specialized cells, such as those of the heart, nerves, and muscles, with the ultimate goal of transferring these cells into patients to repair damaged cells and tissues. In his remarks, the President authorized funding for research only on stem cells already harvested from remaining embryos at in vitro fertilization (IVF) centers as of 9 August 2001, the date of the speech. In a "Fact Sheet" about embryonic stem cell research, he added the ethical requirements that (1) the donors of embryos gave informed consent to the derivation of stem cells from their embryos, (2) the embryos were created solely for reproductive purposes, and (3) no financial inducements were given to the embryo donors. The President also prohibited federally funded research on embryonic stem cells derived from embryos after 9 August 2001, as well as the creation of embryos for research purposes and the cloning of human embryos for both reproductive and research purposes. He did not seek to ban the pursuit of embryonic stem cell research with private funds. "This allows us to explore the promise and potential of stem-cell research without crossing a fundamental moral line by providing taxpayer funding that would sanction or encourage further destruction of embryos," the President stated (White House 2001).The President's speech stirred intense controversy. Many applauded the new policy because it allowed some embryonic stem cell research to proceed, thereby raising hope that treatments might be developed for those suffering from such conditions as Parkinson's disease, Alzheimer's disease, and diabetes. Others supported it on grounds that it would discourage the future destruction of embryos in stem cell research. They maintained that although it was wrong to have derived stem cells from embryos, this wrong was no longer remediable and it therefore was justifiable to allow research using such embryos to proceed. Some, however, objected to the new policy because they held that it unduly limited the [End Page 97] number of embryonic stem cells available for federally funded research. Still others opposed it on grounds that it made the federal government complicit in what they took to be the wrongful destruction of human embryos that had taken place prior to 9 August 2001. The President established the President's Council on Bioethics by executive order in November 2001 and charged it, among other tasks, with monitoring stem cell research and recommending guidelines and regulations for biomedical innovations.Questions about the moral status of human embryos have so captured public attention since the President issued his remarks that other significant ethical and policy issues raised about stem cell research inside the Beltway have remained in the shadows. A number of individuals and organizations—legislators, scientists, patient groups, the President's Council on Bioethics, ethicists, religious task forces, and social commentators—have attempted to bring these other issues to legislative and public attention. They also have revisited the more publicly prominent question of what sorts of protections we owe to human embryos. In response, Congress has attempted to address several of these newly emerging issues at hearings and in legislation. I review these efforts, consider developing issues and arguments, and conclude by exploring possible future directions for federal and private sector stem cell policy. The Availability of Embryonic Stem Cell Lines to Federally Funded Researchers President Bush, in developing his stem cell research policy, accepted a distinction between the "derivation" and the "use" of embryos enunciated by the General Counsel of the Department of Health and Human Services toward the end of the Clinton administration. This distinction was adopted to avoid contravening the Dickey-Wicker Amendment (added... (shrink)

A growing body of literature has engaged with mass incarceration as a public health problem. This article reviews some of that literature, illustrating why and how bioethicists can and should engage with the problem of mass incarceration as a remediable cause of health inequities. “Mass incarceration” refers to a phenomenon that emerged in the United States fifty years ago: imprisoning a vastly larger proportion of the population than peer countries do, with a greatly disproportionate number of incarcerated people (...) being members of marginalized racial and ethnic groups. Bioethicists have long engaged with questions of health justice for incarcerated people, including consent issues for those participating in research and access to health care. This article provides an overview of the individual and public health impacts of mass incarceration. The article argues that mass incarceration is a bioethics issue that should be addressed in medical education, identifies opportunities for bioethicists to guide hospitals’ interactions with law enforcement officials, and calls on bioethicists to be in conversation with medical and nursing students and health care professionals about these groups’ advocacy efforts concerning structural racism, police violence, and mass incarceration. (shrink)

Nearly two decades of debate have not settled the definition of research misconduct. The literature provides four explanatory frameworks for misconduct. The paper examines these frameworks and maps them onto efforts by the U.S. Public Health Service to define research misconduct and subsequent responses to these efforts by the scientific community. The changing frameworks suggest that closure will not be achieved without an authoritative effort, which may occur through the Research Integrity Panel’s recent attempt to create a government-wide definition.

This special issue addresses the legacy of the U.S. Public Health Service Syphilis Study on health reform, particularly the Affordable Care Act. This article offers readers a guide to the themes that emerge in this issue. These themes include individual consent interrelated to consequences in populations issues, need for better government oversight in research and health care, and the need for overhauling our bioethics training to develop a population-level, culturally driven approach to research bioethics. We hope the (...) guidance offered in this issue will help shape a new framework to bioethics that can be integrated into the foundation of health care reform. (shrink)

The U.S. Food and Drug Administration (FDA) announced recently that food products derived from some animal clones and their offspring are safe for human consumption. In response to criticism that it had failed to engage with ethical, social, and economic concerns raised by livestock cloning, the FDA argued that addressing normative issues prior to issuing a final ruling on animal cloning is not part of its mission. In this article, the authors reject the FDA's claim that its mission to protect (...) and advance public health can be accomplished without considering ethical issues or without making value judgments. The authors offer two arguments in support of their position. First, the agency's mission statement presupposes significant normative commitments and judgments. Second, the FDA's risk assessment of food products from cloned animals and their offspring is itself clearly shaped by a variety of normative commitments. (shrink)

Antibiotic use triggers evolutionary and ecological responses from bacteria, leading to antibiotic resistance and harmful patient outcomes. Two complementary strategies support long-term antibiotic effectiveness: conservation of existing therapies and production of novel antibiotics. Conservation encompasses infection control, antibiotic stewardship, and other public health interventions to prevent infection, which reduce antibiotic demand. Production of new antibiotics allows physicians to replace existing drugs rendered less effective by resistance.In recent years, physicians and policymakers have raised concerns about the pipeline for new antibiotics, (...) pointing to a decline in the number of antibiotics approved since the 1980s. This trend has been attributed to high research and development costs, low reimbursement for antibiotics, and regulatory standards for review and approval. Professional societies and researchers around the world have called for renewed emphasis on antimicrobial stewardship, while also supporting antibiotic research and development through grants, changes to intellectual property laws to extend market exclusivity periods, and modification of premarket testing regulations to reduce antibiotic development time and expenses. (shrink)

Based on a qualitative study, this paper explores how United States public health professionals view and think about the existing U.S. healthcare system, while also allowing these study participants to imagine new ways of structuring and practicing public health. Using semi-structured qualitative interviews, I show how public health professionals engage with the concept of “the social” and their personal experiences with public health to question the status quo. By giving public health professionals space in which (...) to imagine changes and different ways of practicing public health, I demonstrate the effectiveness of imagination as a capacity that public health professionals possess to take the lead in creating the changes they hope for. (shrink)

There are grave issues with how the U.K. government approaches the issue of wellbeing. Specifically, policy interventions that might improve the material conditions of citizens are being down-played, and at times out-rightly dismissed. Instead, an individualist, instrumental message is being promoted, namely, that the best way to improve wellbeing is by improving individual happiness and mental health. I argue that this instrumental message – which in practice blames the victims for their lack of happiness and removes state responsibility – (...) can be made to sound feasible because of a reliance on positivist-based research, whether obtained objectively or subjectively. In this paper, I therefore detail the failings of mainstream wellbeing research and its policy conclusions, and argue that critical realism offers solutions. (shrink)

On the eve of the presidential inauguration, the U.S. health system faces rising costs of care, growing numbers of uninsured, wide variations in quality of care, and mounting public dissatisfaction. Despite spending more on health care than any other country, a recent Commonwealth Fund Commission on a High Performance Health Care System National Scorecard reports that the United States is lagging far behind other major industrialized countries — all of which provide universal health insurance — in (...) five key domains: healthy lives, access, quality, equity, and efficiency. U.S. national performance is well below benchmarks of top performance set by other countries or high performing states, hospitals, or health plans within the United States, with broad disparities in experience depending on geographic location, income, race/ethnicity, and insurance coverage. National leadership is required to manage the growing health care crisis in the United States and improve care for all Americans. (shrink)

Messaging from U.S. authorities about COVID-19 has been widely divergent. This research aims to clarify popular perceptions of the COVID-19 threat and its effects on victims. In four studies with over 4,100 U.S. participants, we consistently found that people perceive the threat of COVID-19 to be substantially greater than that of several other causes of death to which it has recently been compared, including the seasonal flu and automobile accidents. Participants were less willing to help COVID-19 victims, who they considered (...) riskier to help, more contaminated, and more responsible for their condition. Additionally, politics and demographic factors predicted attitudes about victims of COVID-19 above and beyond moral values; whereas attitudes about the other kinds of victims were primarily predicted by moral values. The results indicate that people perceive COVID-19 as an exceptionally severe disease threat, and despite prosocial inclinations, do not feel safe offering assistance to COVID-19 sufferers. This research has urgent applied significance: the findings are relevant to public health efforts and related marketing campaigns working to address extended damage to society and the economy from the pandemic. In particular, efforts to educate the public about the health impacts of COVID-19, encourage compliance with testing protocols and contact tracing, and support safe, prosocial decision-making and risk assessment, will all benefit from awareness of these findings. The results also suggest approaches, such as engaging people's stable values rather than their politicized perspectives on COVID-19, that may reduce stigma and promote cooperation in response to pandemic threats. (shrink)

BackgroundThe U.S. Food and Drug Administration traditionally has kept confidential significant amounts of information relevant to the approval or non-approval of specific drugs, devices, and biologics and about the regulatory status of such medical products in FDA’s pipeline.ObjectiveTo develop practical recommendations for FDA to improve its transparency to the public that FDA could implement by rulemaking or other regulatory processes without further congressional authorization. These recommendations would build on the work of FDA’s Transparency Task Force in 2010.MethodsIn 2016-2017, we convened (...) a team of academic faculty from Harvard Medical School, Brigham and Women’s Hospital, Yale Medical School, Yale Law School, and Johns Hopkins Bloomberg School of Public Health to develop recommendations through an iterative process of reviewing FDA’s practices, considering the legal and policy constraints on FDA in expanding transparency, and obtaining insights from independent observers of FDA.ResultsThe team developed 18 specific recommendations for improving FDA’s transparency to the public. FDA could adopt all these recommendations without further congressional action.FundingThe development of the Blueprint for Transparency at the U.S. Food and Drug Administration was funded by the Laura and John Arnold Foundation. (shrink)

Wage inequality, including the college/high school education premium, has increased substantially in the United States. A key part of the most widely accepted explanation for this is that skill-biased technological change accelerated during this time. This article suggests that the impact of skill-biased technological change was closer to constant in the second half of the twentieth century. This leaves a large unexplained decrease in the college/high school education premium in the 1940s and a large unexplained increase in the 1980s. (...) The current article provides evidence that the upsurge and decline in union power during those respective periods provide a good explanation for these unexplained wage inequality changes. (shrink)

Agricultural diversification in the Midwestern Corn Belt has the potential to improve socioeconomic and environmental outcomes by buffering farmers from environmental and economic shocks and improving soil, water, and air quality. However, complex barriers related to agricultural markets, individual behavior, social norms, and government policy constrain diversification in this region. This study examines farmer perspectives regarding the challenges and opportunities for both corn and soybean production and agricultural diversification strategies. We analyze data from 20 focus groups with 100 participants conducted (...) in Indiana, Illinois, and Iowa through a combined inductive and deductive approach, drawing upon interpretive grounded theory. Our results suggest that when identifying challenges and opportunities, participants center economics and market considerations, particularly income, productivity, and market access. These themes are emphasized both as benefits of the current corn-soybean system, as well as challenges for diversification. Additionally, logistical, resource and behavioral hurdles– including the comparative difficulty and time required to diversify, and constraints in accessing land, labor, and technical support– are emphasized by participants as key barriers to diversification. Agricultural policies shape these challenges, enhancing the comparative advantage and decreasing the risk of producing corn and soybeans as compared to diversified products. Meanwhile, alternative marketing arrangements, farmer networks, family relationships, and improved soil health are highlighted as important opportunities for diversification. We contextualize our findings within the theories of reasoned action and diffusion of innovation, and explore their implications for farmer engagement, markets, and agricultural policy, and the development of additional resources for business and technical support. (shrink)

How should healthcare systems prepare to care for growing numbers and proportions of older people? Older people generally suffer worse health than younger people do. Should societies take steps to reduce age-related health inequalities? Some express concern that doing so would increase age-related inequalities in healthcare. This paper addresses this debate by presenting an argument in support of three principles for distributing scarce resources between age groups; framing these principles of age group justice in terms of life stages; (...) and indicating policy implications that merit further attention in light of rapidly aging societies. (shrink)

This article examines the uneven welfare support accorded to Black and white women at the end of the twentieth century. The author analyzes the generosity of Aid to Families with Dependent Children benefits in the 48 contiguous U.S. states in 1970, 1980, and 1990 to determine if the state is less supportive of Black than white women. The author argues that the race-biased policies and procedures implemented with the inception and expansion of the welfare state remained throughout the program, resulting (...) in uneven levels of support for Black and white families. More specifically, the author demonstrates that the generosity of AFDC is lower in states with a larger proportion of Black single mothers and higher in states with a larger proportion of white single mothers. These findings are relevant in the current period because such institutionalized race inequalities perpetuate white privilege and Black women's poverty. (shrink)

In this article I consider the common claim that the United States is the best country in the world. I examine the factors of freedom, literacy, health, happiness, and wealth, and conclude that the U.S. is 13th best, and that actually Norway is the best country in the world.

Policy officials often assert that the U.S. has the best health care system in the world, but a recent scorecard on U.S. health system performance finds that the U.S. achieves a score of only 65 out of a possible 100 points on key indicators of performance in five key domains: healthy lives, access, quality, equity, and efficiency, where 100 represents the best achieved performance in other countries or within the U.S. The U.S. should aim higher by adopting a (...) set of policies that will extend affordable health insurance to all; align financial incentives for health care providers to enhance value and achieve savings; organize the health care system around the patient to ensure that care is accessible and coordinated; meet and raise benchmarks for high-quality, efficient care; and ensure accountable national leadership and public-private collaboration. The incoming president and Congress should aspire to have the best health system in the world — not just assert it — and can do so by learning from examples of excellence within the U.S. and abroad. (shrink)

In 1997 President Clinton apologized to the survivors of the U.S. Public Health Service Syphilis Study. Since then, two of his recommendations have received little attention. First, he emphasized the need to remember the shameful past so we can build a better future for racial'ethnic minority populations. Second, he directed the creation in partnership with higher education to prepare training materials that would instruct biomedical researchers on the application of ethical principles to research with racial/ethnic minority populations. This article (...) proposes the inclusion of these issues in the implementation of the Affordable Care Act. It asks, What is the right or good thing to do? What are our obligations to one another? Two challenges are examined: (a) Conducting research with African Americans without knowledge of bioethics specific to this population, and (b) the ethical dilemma of conducting research that does not adequately take into account the diversity within the Black population that is a contributing factor in health disparities. Training and policy recommendations responsive to President Clinton's Apology are presented. (shrink)

This essay is a reflection on how ethical violations continue to have an impact across generations within families of vulnerable populations that have experienced significant breaches in biomedical research. The focus is on the surviving family members of the United States Public Health Service Syphilis Study at Tuskegee (USPHS). Emphasis will be on responsible ethical practices in research and the use of an unique approach narrative storytelling to address the needs of family descendents who have been impacted by the (...) USPHS Syphilis Study. (shrink)

There were two ways for the solicitor general of the United States to litigate the constitutional challenge to the Patient Protection and Affordable Care Act of 2010 brought by twenty‐six states and the National Federation of Independent Business. One path, which the solicitor general pursued, was to cautiously navigate judicial precedents, claim the barest increment of new congressional authority, and give the Supreme Court as many hooks as possible on which to hang a favorable decision.The road not traveled was to (...) offer a full‐throated defense of federal authority to comprehensively regulate the U.S. health care system, a multitrillion dollar commercial and social enterprise that represents the largest component of federal expenditure after national defense. The ACA has three cornerstones. First, make health insurance coverage as widespread as possible. Second, improve the quality and efficiency of health care delivery. Third, make individuals and communities healthier. The second and third pillars are sometimes overlooked because so much attention is paid to expanding coverage, but the hallmark of the ACA is that it combines major changes to health insurance, health care delivery, and health in a single piece of federal legislation.The Obama administration's timidity echoes what is strikingly absent from the new law. Although the ACA represents the successful culmination of a decades‐long struggle to universalize coverage, its structure and text never convey the intent that all Americans have a common stake in the health care system. This lack of shared national identity is the missing fourth pillar of the ACA. (shrink)

In the popular folklore three-score-years-and-ten is treated as a fair innings for people, and thereby serves as an informal reference point for judgements about distributive justice within a community. But length of life alone is an insufficient basis for such judgements - a person's health-related quality-of-life also needs to be taken into account. If one of the objectives of public policy is to reduce inequalities in lifetime health, it will be demonstrated that this is very likely to require (...) systematic discrimination against the older members of a community. The notion of community solidatity will also be tested, because a decision will need to be made as to whether the same fair innings applies to all members of the community, or whether some are entitled to more than others. The strength of the fair innings principle is that it brings these issues to the fore in a systematic way which should ais their resolition in a practical context. (shrink)

Using the infamous research studies in Tuskegee and Guatemala, the article examines the difference between victims and bystanders. The victims can include families, sexual partners, and children not just the participants. There are also the bystanders in the populations who are affected, even vaguely, decades after the initial studies took place. Differing reparations for victims and bystanders through lawsuits and historical acknowledgments has to be part of broader discussions of historical justice, and the weighing of the impact of racism and (...) imperial research endeavors. (shrink)

This article asserts that traditionally dominant models of health promotion in the US are fairly characterized by methodological individualism. This schema produces a focus on the individual as the node of intervention. Such emphasis results in a number of scientific and ethical problems. I identify three principal ethical deficiencies: first, the health promotions used are generally ineffective, which violates canons of distributive justice because scarce health resources are expended on interventions that are unlikely to produce health (...) benefits. Second, the health promotions used tend to expand health inequalities between the affluent and the least well-off. Third, the health promotions used are likely to intensify stigma against the least well-off, a deficiency that itself may exacerbate the ‘densely-woven patterns of disadvantage’ that characterize life on the tail of the social gradient. Because Powers and Faden’s health sufficiency model of social justice argues that the amelioration of such clusters of disadvantage should be the primary ethical goal of public health policy, methodologically individualist models of health promotion are ethically deficient and should not stand as primary approaches for health promotion in a just social order. (shrink)

Much media attention has been given to the potentially shifting voting patterns of the U.S. Hispanic population in the 2020 election. However, far less attention has been given to the implications...

We report on an effort to characterize (changes in) teachers’ and school and district leaders’ race consciousness within their visions of equitable mathematics instruction. We analyzed interviews conducted over multiple years within a project in an urban school district in the U.S. that focused on racism and racial equity in secondary mathematics and included multi-week professional learning opportunities for teachers during the months between school years. Our analysis yielded a 4-level trajectory modelling the development of race consciousness in participants’ discourse. (...) Distinctions across levels pertain to the presence of race in individuals’ discourse, the directness with which they talk about race, and the extent to which they locate sources of an historical accumulation of racial inequity within systems. (shrink)

Technology has provided state and federal governments with huge collections of DNA samples and identifying profiles stored in databanks. That information can be used to solve crimes by matching samples from convicted felons to unsolved crimes, and has aided law enforcement in investigating and convicting suspects, and exonerating innocent felons, even after lengthy incarceration. Rights surrounding the provision of DNA samples, however, remain unclear in light of the constitutional guarantee against unreasonable searches and seizures and privacy concerns. The courts have (...) just begun to consider this issue, and have provided little guidance. It is unclear whether the laws governing protected health information are applicable to the instant situation, and if so, the degree to which they apply. DNA databanks are not uniformly regulated, and it is possible that DNA samples contained in them may be used for purposes unintended by donors of the samples. As people live their lives, they leave bits of their DNA behind. They cannot be assured that these tiny specimens will not be taken or used against their will or without their knowledge for activities such as profiling to measure tendencies such as thrill-seeking, aggressiveness, or crimes with threatening behavior. Existing racial or ethnic discrimination and profiling may also encompass genetic discrimination and profiling, creating societal class distinctions. This article will explore the constitutionality of collecting genetic materials, the ethics of such activities, and balance the social good in solving crime and deterrence against the individual's security, liberty, and privacy. (shrink)