This article sketches how liberal principles can be coherently set alongside the stewardship responsibilities of regulators. It indicates how this bears on the legitimacy of public health interventions in general and interventions of the kind associated with New York City’s public health programme in particular. The key idea is that stewardship responsibilities relate to the essential infrastructural conditions for human well-being; these conditions need to be protected because they are the staging for all human activity. Liberal (...) principles, by contrast, presuppose that the basic conditions for human well-being are in place; and, given this presupposition, they present a view about how humans should live, about how they should interact and transact and about how they should flourish. Where regulators are guided by a liberal ethic, they act illegitimately if they try to dictate how individuals should lead their lives; but, acting under their stewardship jurisdiction, regulators may legitimately intervene if they are trying to protect the conditions that are essential for any kind of human life. The article concludes by suggesting that while it is a good thing that New York City’s policies provoke debate about the legitimacy of public health interventions, it is the infrastructural conditions, and not the superstructural activities, that are the regulatory priority. (shrink)

This is a reply to Steve Latham's Article for the Republicanism special issue.

In the field of health technology assessment, there are several approaches that can be used for ethical analysis. However, there is a scarcity of literature that critically evaluates and compares the strength and weaknesses of these approaches when they are applied in practice. In this paper, we analyse the applicability of some selected approaches for addressing ethical issues in HTA in the field of complex health interventions. Complex health interventions have been the focus of methodological (...) attention in HTA. However, the potential methodological challenges for ethical analysis are as yet unknown.Six of the most frequently described and applied ethical approaches in HTA were critically assessed against a set of five characteristics of complex health interventions: multiple and changing perspectives, indeterminate phenomena, uncertain causality, unpredictable outcomes, and ethical complexity. The assessments are based on literature and the authors’ experiences of developing, applying and assessing the approaches.The Interactive, participatory HTA approach is by its nature and flexibility, applicable across most complexity characteristics. Wide Reflective Equilibrium is also flexible and its openness to different perspectives makes it better suited for complex health interventions than more rigid conventional approaches, such as Principlism and Casuistry. Approaches developed for HTA purposes are fairly applicable for complex health interventions, which one could expect because they include various ethical perspectives, such as the HTA Core Model® and the Socratic approach.This study shows how the applicability for addressing ethical issues in HTA of complex health interventions differs between the selected ethical approaches. Knowledge about these differences may be helpful when choosing and applying an approach for ethical analyses in HTA. We believe that the study contributes to increasing awareness and interest of the ethical aspects of complex health interventions in general. (shrink)

Mobile applications (apps) have gained significant popularity as a new intervention strategy responding to violence against women and girls. Despite their growing relevance, an assessment from the perspective of public health ethics is still lacking. Here, we base our discussion on the understanding of violence against women and girls as a multidimensional, global public health issue on structural, societal and individual levels and situate it within the theoretical framework of structural injustice, including epistemic injustice. Based on a systematic (...) app review we previously conducted, we evaluate the content and functions of apps through the lens of structural injustice. We argue that technological solutions such as apps may be a useful tool in the fight against violence against women and girls but have to be situated within the broader frame of public health that considers the structural dimensions of such violence. Ultimately, the concerns raised by structural injustice are—alongside key concerns of safety, data privacy, importance of human supportive contact, and so forth—crucial dimensions in the ethical assessment of such apps. However, research on the role and relevance of apps as strategies to address the structural and epistemic dimensions of violence remains scarce. This article aims to provide a foundation for further discussion in this area and could be applicable to other areas in public health policy and practice. (shrink)

Antimicrobial resistance (AMR) is increasingly recognised as a threat to human, animal and environmental health. In an effort to counter this threat, several intervention plans have been proposed and implemented by states and organisations such as the WHO. A One Health policy approach, which targets multiple domains (healthcare, animal husbandry and the environment), has been identified as useful for curbing AMR. Johnson and Matlock have recently argued that One Health policies in the AMR context require special ethical (...) justification because of the so-called least restrictive alternative principle. This article analyses and rejects two assumptions that this argument relies on. The first assumption is that One Health policies are generally more restrictive than their alternatives because they target more domains and impact more people. The second assumption is that the least restrictive alternative principle has a special normative importance in that it establishes a systematic presumption in favour of the least restrictive policy options. Once these assumptions are rejected, the use of One Health policies on AMR can be justified more easily than Johnson and Matlock argue. (shrink)

Globally, the population is ageing, which has serious consequences for businesses. The prosperity of companies is crucially dependent on the ability to effectively manage their employees, including older workers. Best practice in age management is defined as those measures that combat age barriers and/or promote age diversity. These measures may entail specific initiatives aimed at particular dimensions of age management; they may also include more general employment or human resources policies that help to create an environment in which individual employees (...) can achieve their potential without being disadvantaged by their age. Promoting early retirement is generally not encouraged. Companies now have to encourage longer working lives. Much needs to be done to ensure that work remains a positive experience for workers throughout their career trajectories, and it does not damage their health. It has been found by studies that health is significantly related to retirement timing, influences work performance, and health-related organisational policies can positively influence employee retention. The major contemporary challenges to health at work are those associated with the way work, and work organisations are designed and managed. This is especially true for older workers. A comprehensive and effective approach towards age management can be very beneficial for them. How should companies implement age management? Some possible ways are set out in this policy brief below, which focuses on best practices in age management regarding ergonomic aspects and health interventions for older workers at an organisational level. The intention is to discuss the current situation and to illustrate some organisational techniques in selected countries. This policy brief can serve as an inspiration for, among others, companies and policymakers. Recommendations for successful practice are included. In total, this policy brief covers 8 COST member countries to give a glimpse of the current situation of best practice in age management and show how companies in various states deal with ergonomic aspects, health interventions and the ageing of their labour force. (shrink)

In order to support health interventions, biomedical and population health researchers need to collect solid evidence. This article asks what type of evidence this should be and expands on previous work that focused on etiological explanations, or causal-mechanical explanations of why and how illness occurs. The article proposes adding predictive evidence to the explanatory evidence, in order to form a joint evidence set, or JES = [A,B,C,D], which consists of four different types of evidence: association [A], biology (...) [B], confirmation [C], and difference-making [D]. The article discusses explanatory coherence as a backbone for this proposal, suggests criteria for each type of evidence, and offers a rubric for multi-evidence mapping. (shrink)

This paper argues that machine learning and epidemiology are on collision course over causation. The discipline of epidemiology lays great emphasis on causation, while ML research does not. Some epidemiologists have proposed imposing what amounts to a causal constraint on ML in epidemiology, requiring it either to engage in causal inference or restrict itself to mere projection. We whittle down the issues to the question of whether causal knowledge is necessary for underwriting predictions about the outcomes of public health (...) interventions. While there is great plausibility to the idea that it is, conviction that something is impossible does not by itself motivate a constraint to forbid trying. We disambiguate the possible motivations for such a constraint into definitional, metaphysical, epistemological, and pragmatic considerations and argue that “Proceed with caution” is the outcome of each. We then argue that there are positive reasons to proceed, albeit cautiously. Causal inference enforces existing classification schema prior to the testing of associational claims, but associations and classification schema are more plausibly discovered in a back-and-forth process of gaining reflective equilibrium. ML instantiates this kind of process, we argue, and thus offers the welcome prospect of uncovering meaningful new concepts in epidemiology and public health—provided it is not causally constrained. (shrink)

Is it possible to interfere with individual decision-making while preserving freedom of choice? The purpose of this article is to assess whether ‘libertarian paternalism’, a set of political and ethical principles derived from the observations of behavioural sciences, can form the basis of a viable framework for the ethical analysis of public health interventions. First, the article situates libertarian libertarianism within the broader context of the law and economics movement. The main tenets of the approach are then presented (...) and particular attention is given to its operationalization through the notion of a ‘nudge’. Essentially, a ‘nudge’ consists in an intervention, which aims to suggest one choice over another by gently steering individual choices in welfare-enhancing directions yet without imposing any significant limit on available choices. Finally, the article concludes that, while it fails as an overreaching framework of ethical analysis, libertarian paternalism nonetheless constitutes a valuable addition to the conceptual toolbox of public health ethics. (shrink)

Taking debates about the roles of structure and agency in health as a lens, this essay asks how Critical Realist and Feminist Intersectional approaches might inform health interventions research. Despite recognition of multiple determinants of health, health problems are often thought of as individual and interventions, in turn, target risky individual behaviours. Such approaches are rooted in a liberal model of personhood. This paper critiques enduring individualist assumptions linked to Western liberal underpinnings embedded in (...) health interventions. It posits the need to include a robust conception of the social world in which change depends on shifting power relations, and individual agency is shaped by power as well as individual will. We propose preliminary steps for undertaking critical realist intersectional interventions research. (shrink)

Measured against the gloomy pre-COVID-19 predictions, Africa has fared far better than most regions in managing the pandemic. This much, however, has received less attention. This paper answers the question: how have the new rituals of self determination in public health affected the successful management of COVID-19 in Africa, and how can the continent and the rest of the world build on such models/lessons in the post-pandemic era? I employ emancipatory theorising in reviewing literature on approaches to governance of (...) COVID-19. The rationale is to empower the grassroots and to accentuate the urgency for a decolonized local ownership of the governance of all public health crises. I argue that while traditional international cooperation is necessary for additional resource and expertise from the global North for sustainable health, the political will of Southern governments remains fundamental for any extraordinary success due to its grassroots/community orientation towards non-pharmaceutical interventions and initial pre-emptive rituals. The novelty in this paper is that it lays bare the ignored African responses and lessons and reveals how to harness protective communitarian ethos in solving future crises. The paper further provides population health as an ‘immune system’ policy framework for explaining and predicting how a scientific and human-centrered grassroots leadership can yield optimal outcomes in any future crisis. (shrink)

This paper develops a general approach to how society should compensate for losses that individuals incur due to public health interventions aimed at controlling the spread of infectious diseases. The paper falls in three parts. The first part provides an initial introduction to the issues and briefly outlines five different kinds of public health interventions that will be used as test cases. They are all directed at individuals and aimed at controlling the spread of infectious diseases (...) (1) isolation, (2) quarantine, (3) recommended voluntary social distancing, (4) changes in health care provision for asymptomatic carriers of multi-resistant microorganisms, and (5) vaccination. The interventions will be briefly described including the various risks, burdens and harms individuals who are subject to these interventions may incur. The second part briefly surveys current compensation mechanisms as far as any exist and argue that even where they exist they are clearly insufficient and do not provide adequate compensation. The third part will then develop a general framework for compensation for losses incurred due to public health interventions in the infectious disease context. This is the major analytical and constructive part of the paper. It first analyses pragmatic and ethical arguments supporting the existence of an obligation on the part of the state to compensate for such losses, and then considers whether this obligation can be defeated by (1) resource considerations, or (2) issues relating to personal responsibility. (shrink)

ABSTRACT Digital mental health interventions have emerged as a promising means of expanding access to mental healthcare. Prospective participants reporting severe symptoms or suicidal ideation are often excluded from DMHI trials and may struggle to access alternative treatments. However, evidence suggests that DMHIs are efficacious for people reporting these characteristics. We suggest that there are risks to both including and excluding people from DMHI trials, and we urge researchers to ensure that their eligibility criteria are designed in an (...) evidence-based and ethically conscious manner. We also make specific recommendations for those working in various other capacities within the academic community. (shrink)

This article draws on scientific explanations of obesity to motivate the creation of a system of paternalistic public health interventions into the obesity epidemic. Libertarian paternalists argue that paternalism is warranted in light of the cognitive limits of human decision-making abilities. There are further, specific biological limits on our capacity to choose and maintain a healthy diet. These biological facts strengthen the general motivation for libertarian paternalism. As a consequence, the creation of a system of paternalistic public (...) class='Hi'>health interventions into the obesity epidemic is warranted. (shrink)

Introduction: Probationers, offenders with less serious and non-violent offences, and under statutory supervision, have low levels of self-esteem and physical health, and high level of family conflict, and poorer quality of family relationships. This study examined the effectiveness of the existing probation service and the additional use of a positive family holistic health intervention to enhance physical, psychological, and family well-being in probationers and relationships with probation officers.Methods: Probationers under the care of the Hong Kong Social Welfare Department (...) were randomized into a care-as-usual control group, a brief intervention group receiving two 1-h individual sessions [of a brief theory-based positive family holistic health intervention integrating Zero-time Exercise and positive psychology themes of “Praise and Gratitude” in the existing probation service], or a combined intervention group receiving BI and a 1-day group activity with family members. The outcomes were physical activity, fitness performance, self-esteem, happiness, anxiety and depression symptoms, life satisfaction, quality of life, family communication and well-being, and relationships with probation officers. Self-administered questionnaires and simple fitness tests were used at baseline, 1-month and 3-month follow-up. Linear mixed model analysis was used to compare difference in the changes of outcome variables among groups, adjusted of sex, age, and baseline values. Focus group interviews were conducted. Thematic content analysis was used.Results: 318 probationers were randomized into CAU, BI, or CI group. CAU showed enhanced physical activity, fitness performance and psychological health, and family communication with small effect sizes. BI and CI showed further improved physical activity, family communication and family well-being. Additionally, CI reported greater improvements in the relationships with probation officers than CAU with a small effect size. CI also reported greater increases in physical activity and family communication than BI with small to moderate effect sizes. Qualitative feedbacks corroborated the quantitative findings.Conclusion: Our trial provided the first evidence of the effectiveness of probation service and the additional use of an innovative, relatively low-cost, theory-based brief positive family holistic health intervention. This intervention may offer a new model for enhancing probation service.Trial Registration: The research protocol was registered at the National Institutes of Health. (shrink)

Interventions to decrease acquisition and transmission of sexually transmitted diseases among African American women using text messages versus small-group delivery modalities pose distinct research risks and benefits. Determining the relative risk–benefit ratio of studies using these different modalities has relied on the expertise of investigators and their institutional review boards. In this study, African American women participated in focus groups and surveys to elicit and compare risks and benefits inherent in these two intervention delivery modalities, focusing on issues such (...) as convenience, privacy, and stigma of participation. Some risk/benefit variables were implicated in willingness to participate the two intervention modalities. (shrink)

Background: This article describes the types of community‐wide benefits provided by investigators conducting public health research in South Asia as well as their self‐reported reasons for providing such benefits.Methods: We conducted 52 in‐depth interviews to explore how public health investigators in low‐resource settings make decisions about the delivery of ancillary care to research subjects. In 39 of the interviews respondents described providing benefits to members of the community in which they conducted their study. We returned to our narrative (...) dataset to find answers to two questions: What types of community‐wide benefits do researchers provide when conducting public health intervention studies in the community setting, and what reasons do researchers give when asked why they provided community‐wide benefits?Findings: The types of community‐wide benefits delivered were directed to the health and well‐being of the population. The most common types of benefits delivered were the facilitation of access to health care for individuals in acute medical need and emergency response to natural disasters. Respondents' self‐reported reasons when asked why they provided such benefits fell into 2 general categories: intrinsic importance and instrumental importance. (shrink)

Community consultation is increasingly recommended, and in some cases, required by ethical review boards for research that involves higher levels of ethical risk such as international research and research with vulnerable populations. In designing a randomised control trial of a mental health intervention using a wait list control, we consulted the community where the research would be undertaken prior to finalising the study protocol. The study sites were two conflict-affected locations: Grozny in the Chechen Republic and Kitchanga in eastern (...) Democratic Republic of Congo. (shrink)

Public health scholars and public health officials increasingly worry about health-related misinformation online, and they are searching for ways to mitigate it. Some have suggested that the tools of digital influence are themselves a possible answer: we can use targeted, automated digital messaging to counter health-related misinformation and promote accurate information. In this commentary, I raise a number of ethical questions prompted by such proposals—and familiar from the ethics of influence and ethics of AI—highlighting hidden costs (...) of targeted digital messaging that ought to be weighed against the health benefits they promise. (shrink)

Background: This article describes the types of community-wide benefits provided by investigators conducting public health research in South Asia as well as their self-reported reasons for providing such benefits. Methods: We conducted 52 in-depth interviews to explore how public health investigators in low-resource settings make decisions about the delivery of ancillary care to research subjects. In 39 of the interviews respondents described providing benefits to members of the community in which they conducted their study. We returned to our (...) narrative dataset to find answers to two questions: What types of community-wide benefits do researchers provide when conducting public health intervention studies in the community setting, and what reasons do researchers give when asked why they provided community-wide benefits? Findings: The types of community-wide benefits delivered were directed to the health and well-being of the population. The most common types of benefits delivered were the facilitation of access to health care for individuals in acute medical need and emergency response to natural disasters. Respondents' self-reported reasons when asked why they provided such benefits fell into 2 general categories: intrinsic importance and instrumental importance. (shrink)

Marketing restrictions to promote public health invoke competing rights, including the right to free commercial speech which for-profit entities use to protect their freedom to market products without undue regulation. The right to free commercial speech in South Africa has been developed through case law since the adoption of the first democratic constitution in South Africa in 1996. This article examines the impact of this recent judgment and the lessons for policy makers to ensure effective regulation of marketing practices (...) in South Africa. (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)

Médecins Sans Frontières is not morally required to continue providing the same therapeutic and preventative interventions for lead poisoning in Nigeria in the face of conditions that negatively impact on the achievement of their objectives. Nevertheless, Médecins Sans Frontières may have reasons to revise their objectives and adopt different interventions or methods.

ABSTRACT The technological revolution has created enormous opportunities for the provision of affordable, accessible, and flexible mental healthcare. Yet it also creates complexities and ethical challenges. While some of these challenges may be similar to face-to-face care, their nuance in the online milieu is different, as relationships, identities and boundaries in this setting are fluid, and there is an absence of physical presence. In this paper we consider the specific ethical complexities involved in the provision of a social networking intervention (...) for depression and problematic alcohol use involving providers and peers. We present a case in which clinicians encountered a participant who repeatedly expressed suicidal thoughts in this online forum, and reflect on how this situation was managed. In analyzing this case, we use relational ethics—which proposes that interpersonal relationships are the fulcrum for ethical decision-making and action—together with actor-network theory—which highlights the power of technology to transform and mediate social and ethical relationships. Our analysis demonstrates the need to move beyond human-centric approaches, to recognize the role of both human and non-human actors in shaping moral decisions and behavior in the provision of e-mental healthcare. (shrink)

Researchers conducting large community-based studies among underserved populations may collect data on health conditions that are little-acknowledged in the local setting, and for which there are few if any services for referral of participants who need follow-up diagnosis and care. In the design and planning of studies for such settings, investigators and research ethics committees may struggle to determine what constitutes effective referral and whether it is reasonably available. We offer a guiding framework for referral planning, informed by our (...) experiences of research in the field and of service on research ethics committees, to support evaluation of local referral resources and consideration of the benefits, burdens and risks of referral in the local setting. The framework addresses both the impact of referral on the well-being of the people who would be referred and the impact that referral of study participants would have on local people outside the study. We use a sustained discussion of three field-based case examples to illustrate the ethical concerns at issue and to demonstrate the use of the referral planning framework. (shrink)

Journal of Philosophy of Education, Volume 56, Issue 1, Page 41-50, February 2022.

The ethical dimensions of health communicators' interventions and campaigns are brought into question in this thought-provoking book. Examining the efforts to effect behavior change, the author questions how far health communication can and should go in changing people's values. The author broadens the current analysis of interventions and presents conceptual frameworks that help identify values and justifications that are embedded in health communication goals, strategies, and evaluation criteria. This critical approach helps explain how and why (...) choices are made in design and implementation, and provides constructs and frameworks to examine them. It also widens the criteria for program evaluation and policymaking, and provides practitioners, planners, policy-makers, researchers, and students with practice-oriented questions. (shrink)

The information contained in this teaching module and the accompanying PowerPoint slides is appropriate for use in a survey public health law course or seminar. The purpose of this lesson is two-fold. The first objective is to provide law students with an overview of the authority public health agencies have to set and enforce policies necessary to keep the population healthy. The second objective is to inform law students about the legal constraints courts have placed upon the actions (...) of those agencies. The module ends with a project designed to give law students the opportunity to apply the law to a “real world” situation. (shrink)

We consider the implications for the ethical evaluation of research programs of two fundamental changes in the revised research ethical guideline of the Council for International Organizations of Medical Sciences. The first is the extension of scope that follows from exchanging “biomedical” for “health‐related” research, and the second is the new evaluative basis of “social value,” which implies new ethical requirements of research. We use the example of antibiotic resistance interventions to explore the need to consider the instances (...) of what we term the pragmatic risks of such interventions to evaluate the social value of certain kinds of health‐related research. These (pragmatic) risks severely threaten the social value of interventions in every area where human and social responses significantly impact on their effectiveness. Thus, the social value of health‐related research needed to demonstrate its effectiveness depends on the extent and successful management of such risks. Research designed to take into account the management of pragmatic risks also gives rise to similar types of risks, and the potential for social value in light of those risks needs to be considered in ethical reviews based on the new guidelines. We argue that, to handle this new expanded task, the international system of research ethical review addressed by the guidelines needs institutional development. (shrink)

Health‐related Quality of Life measures have recently been attacked from two directions, both of which criticize the preference‐based method of evaluating health states they typically incorporate. One attack, based on work by Daniel Kahneman and others, argues that ‘experience’ is a better basis for evaluation. The other, inspired by Amartya Sen, argues that ‘capability’ should be the guiding concept. In addition, opinion differs as to whether health evaluation measures are best derived from consultations with the general public, (...) with patients, or with health professionals. And there is disagreement about whether these opinions should be solicited individually and aggregated, or derived instead from a process of collective deliberation. These distinctions yield a wide variety of possible approaches, with potentially differing policy implications. We consider some areas of disagreement between some of these approaches. We show that many of the perspectives seem to capture something important, such that it may be a mistake to reject any of them. Instead we suggest that some of the existing ‘instruments’ designed to measure HR QoLs may in fact successfully already combine these attributes, and with further refinement such instruments may be able to provide a reasonable reconciliation between the perspectives. (shrink)

Health-related Quality of Life measures have recently been attacked from two directions, both of which criticize the preference-based method of evaluating health states they typically incorporate. One attack, based on work by Daniel Kahneman and others, argues that ‘experience’ is a better basis for evaluation. The other, inspired by Amartya Sen, argues that ‘capability’ should be the guiding concept. In addition, opinion differs as to whether health evaluation measures are best derived from consultations with the general public, (...) with patients, or with health professionals. And there is disagreement about whether these opinions should be solicited individually and aggregated, or derived instead from a process of collective deliberation. These distinctions yield a wide variety of possible approaches, with potentially differing policy implications. We consider some areas of disagreement between some of these approaches. We show that many of the perspectives seem to capture something important, such that it may be a mistake to reject any of them. Instead we suggest that some of the existing ‘instruments’ designed to measure HR QoLs may in fact successfully already combine these attributes, and with further refinement such instruments may be able to provide a reasonable reconciliation between the perspectives. (shrink)

The judiciary is a key policy actor that is involved in deciding health rights and policy by intervening in the policy process through a variety of judicial mechanisms, yet the appropriate extent of its involvement remains contentious. Taking the competence objection seriously requires understanding it as an epistemic problem about how courts assess empirical and scientific evidence in order to competently adjudicate controversial health claims. This paper examines recent advances in social epistemology to develop insights for the epistemic (...) competence of the judiciary from a system‐oriented approach. I outline three epistemic features that set the judiciary and the judicial decision‐making process apart from other types of decision‐makers in health policy: the distribution of epistemic power, the epistemic authority of a justified believer, and the principle of disinterestedness. Finally, I relate these insights back to the judicial decision‐making process with a specific focus on recent court decisions in health rights and health policy in Chile. (shrink)

The aim of this systematic review was to summarize and assess the quality of asthma intervention health economic studies from 2002 to 2007, compare the study findings with clinical management guidelines, and suggest avenues for future improvement of asthma health economic studies. Forty of the 177 studies met our inclusion criteria. We assessed the quality of studies using The Quality of Health Economic Studies validated instrument (total score range: 0-100). Six studies (15%) had quality category 2, 26 (...) studies (65%) achieved quality category 3, and the remaining eight (20%) studies were scored as the highest quality level, category 4. Overall, the findings from this review are in line with the Global Initiative for Asthma clinical guidelines. Many asthma health economic studies lacked appropriate long term time horizons to match the chronic nature of the disease and suffered from using effectiveness measures that did not capture all disease related risks and benefits. We recommend that new asthma simulation models: be flexible to allow for long term time horizons, focus on using levels of asthma control in their structure, and estimate both long term asthma specific outcomes like well-controlled time as well as generic outcomes such as quality adjusted survival. (shrink)

The widely cited Nuffield Council on Bioethics ‘Intervention Ladder’ structurally embodies the assumption that personal autonomy is maximized by non-intervention. Consequently, the Intervention Ladder encourages an extreme ‘negative liberty’ view of autonomy. Yet there are several alternative accounts of autonomy that are both arguably superior as accounts of autonomy and better suited to the issues facing public health ethics. We propose to replace the one-sided ladder, which has any intervention coming at a cost to autonomy, with a two-sided ‘Balanced (...) Intervention Ladder,’ where intervention can either enhance or diminish autonomy. We show that not only the alternative, richer accounts of autonomy but even Mill’s classic version of negative liberty puts some interventions on the positive side of the ladder. (shrink)

According to various accounts, intervention in pediatric decisions is justified either by the best interests standard or by the harm principle. While these principles have various nuances that distinguish them from each other, they are similar in the sense that both focus primarily on the features of parental decisions that justify intervention, rather than on the competency or authority of the parties that intervene. Accounts of these principles effectively suggest that intervention in pediatric decision making is warranted for both physicians (...) and the state under precisely the same circumstances. This essay argues that there are substantial differences in the competencies and authorities of physicians and the state, and that the principles that guide their interventions should also be conceived differently. While both the best interests standard and the harm principle effectively incorporate important aspects of physicians’ ethical obligations, neither adequately reflects the state’s ethical obligations. In contrast to physicians, the state has major obligations of distributive justice and neutrality that should form an integral part of any proposed ethical principles guiding state intervention in pediatric decision making. The differences are illustrated by examining recent cases involving parental refusal of chemotherapy in aboriginal Canadian communities and parental refusal of blood transfusions by Jehovah’s Witnesses. (shrink)

This paper attempts a critical discussion of the possibilities for mental health nurses to claim a particular right of conscientious objection to their involvement in enforced pharmaceutical interventions. We nest this within a more general critique of perceived shortcomings of psychiatric services, and injustices therein. Our intention is to consider the philosophical and practical complexities of making demands for this conscientious objection before arriving at a speculative appraisal of the potential this may hold for broader aspirations for a (...) transformed or alternative mental health care system, more grounded in consent than coercion. We consider a range of ethical and practical dimensions of how to realize this right to conscientious objection. We also rely upon an abolition democracy lens to move beyond individual ethical frameworks to consider a broader politics for framing these arguments. (shrink)