Is affordable and cost-effective assisted reproductive technology in low-income countries possible? What should we know to answer the question?

¹ Correspondence address. E-mail: j.d.f.habbema{at}erasmusmc.nl Decision making on infertility treatment in low-income countries(LIC) assumes answers to quite a few questions: how should theinfertility problem be defined? How often does infertility occur?What is the burden-of-disease of infertility? What is the incomein LIC, and what can be spend on health care? How cheap shouldIVF be in order to be accessible to a considerable part of thepopulation? With what alternative health interventions shouldinfertility treatment be compared? How cost-effective shouldIVF be in order to compete with those other interventions? Thesequestions will be discussed. The emphasis is on the situationin Sub-Saharan Africa (SSA). It is concluded that a place forART in a health care package is not straightforward. Many ofthe questions are not or only partially answered. Moreover,cheap and effective ART has yet to be developed and tested.From the limited evidence available for each of the questions,it could be calculated that an IVF cycle should cost between50 and 75 dollar in order to be a candidate for the inclusionin a health package in SSA. This estimate can easily changeconsiderably when in the future the calculations will be basedon thorough research. Thus, a targeted research programme foranswering the open questions, especially on quality-of-lifeimplications of infertility in different societies, is the preferredoption for facilitating the future evaluation of ART in LIC.     

Fertility effects of family planning programs: A methodological review

Abstract

Extensive effort over the last ten to fifteen years has been applied to questions of what family planning programs do to birth rates. Here we review this body of work, looking especially at the different methods used. First, attention is called to the diversity of the field, in its questions, its techniques, in the program types studied, and in assumptions as to modes of actions. Then clarifications are suggested regarding which program features can produce fertility change and which patterns in fertility trends can result from the net action of these factors. Each of the major methods used is then presented, with its advantages and disadvantages and with recent illustrations of its application. A matrix comparison of the methods is added to show their characteristics in relation to each other, and suggestions are made as to the appropriate circumstances for using each. Finally, recent work is described that promises partially to give more comparability of results across different methods and program settings.     

The ‘Obligation’ to Screen and its Effect on Autonomy

In the United States, disease screening is offered to the public as a consumer service. It has been proposed that the act of “consumption” is a manifestation of agency and that the decision to consume is an exercise of autonomy. The enthusiasm of the American public for disease screening and the expansion in the demand for all sorts of disease screening in recent years can be viewed as an expression of such autonomy. Here, we argue that the enthusiasm for disease screening witnessed in the American public today may be more a reflection of the constraint on autonomy than its facilitation. It is our opinion that the articulation of socio-historical processes has contributed to a moral imperative which is reflected in the decision making of individuals around disease screening. We suggest medical and health professionals have a responsibility to facilitate the exercise of individual autonomy in health care decision making as an integral component of professional obligation. These professionals need to problematise healthcare activities that constrain individual autonomy.     

Ethics consultation as moral engagement

I will begin by presenting some doubts about what might be called the "received view" of the role of the moral expert as a health care consultant. Then I will review the literature on moral experts and moral expertise and proceed to apply the results of that review to the notion that there are some who are expert in ethical decision making in health care. I will try to show that certain conclusions that can be drawn from this rather circumscribed topic have implications for the very conception of the relationship between moral theory and clinical ethics.     

A predictive diagnostic model for wild sheep (Ovis orientalis) habitat suitability in Iran

Wild sheep (Ovis orientalis) as the true ancestor of domestic sheep (Ovis aries) is currently listed as vulnerable (VU) by IUCN. Effective conservation of this species requires collecting all available ecological knowledge into a single framework that could be used for management decision making. Use of Bayesian Belief Networks for such purposes have been advocated over recent decades as this approach can integrate different sources of knowledge and perform comprehensive analyses. We built a decision support tool using BBN to assist in habitat management of wild sheep populations throughout the species’ geographical range. The behaviour of the model was tested using scenario and sensitivity analysis. Habitat security, food and water suitability, and thermal cover were recognised as the main habitat variables determining wild sheep habitat suitability. Integrating the complex interactions between variables, the model can be applied for both diagnostic and predictive analyses answering “what if” and “how” questions. This approach can assist wildlife conservationists for building similar models for other poorly-studied threatened species.     

Stigmatization and Denormalization as Public Health Policies: Some Kantian Thoughts

The stigmatization of some groups of people, whether for some characteristic they possess or some behavior they engage in, will initially strike most of us as wrong. For many years, academic work in public health, which focused mainly on the stigmatization of HIV‐positive individuals, reinforced this natural reaction to stigmatization, by pointing out the negative health effects of stigmatization. But more recently, the apparent success of anti‐smoking campaigns which employ stigmatization of smokers has raised questions about whether stigmatization may sometimes be justified, because of its positive effects on public health. Discussion of the issue so far has focused on consequences, and on some Kantian considerations regarding the status of the stigmatized. In this article, I argue that further Kantian considerations regarding the treatment of the general public (the potential stigmatizers) also count against any public health policy involving stigmatization. Attempts to encourage stigmatization are likely to fail to appeal to the rational decision‐making abilities of the general public, and the creation of stigmatized groups (even if they are stigmatized for their voluntary behavior) is an obstacle to the self‐improvement of members of the general public.     

Economic considerations for helminth control

The economic literature related to the control of helminths has grappled with three inter-related questions: is the control of helminths a priority health issue at a time of increasing resource scarcity, are any of the available options affordable and what is the most cost-effective control strategy? In this review of the recent literature, Helen Guyatt and David Evans reveal that the attempts to answer these questions have not been entirely successful, partly because they have sometimes focused on inappropriate issues and partly because some of the potentially valuable economic techniques are still being developed. However, the major current impediment to the provision of satisfactory answers is the lack of precise detail about the nature of the morbidity associated with helminth infections.     

Rational mate choice decisions vary with female age and multidimensional male signals in swordtails

Biologists have long been interested in intransitive preferences: circular preferences in which options cannot be ranked and no single option dominates, similar to a game of rock‐paper‐scissors. Intransitive preferences violate rational decision‐making, an assumption made by models of evolution by mate choice. Despite its potential importance in the study of sexual selection, few studies have tested for intransitive preferences. Even fewer have asked whether females differ in whether they choose mates transitively or intransitively and what factors might predict (in)transitive choice. Though intransitive choice is thought to be more common as options become more complex, this prediction is untested in animals. To fill this gap, we tested whether female Xiphophorus nigrensis swordtails can rank digitally animated males differing in size, courtship intensity, or both size and courtship intensity, and whether female responses were predicted by a female's age. Females choosing among males that varied only in size showed higher than expected levels of intransitivity, whereas females choosing among males that varied in their courtship or both properties did not. Older females were more likely to be irrational than younger females when evaluating male size, suggesting that experience modifies transitive decision‐making processes. These results show that mate choice irrationality may vary by a female's experience and the signal characteristics during decision‐making.     

The challenge of determining the need for remediation following a wide-area biological release

Recovering from a biological attack is a complex process requiring the successful resolution of numerous challenges. The Interagency Biological Restoration Demonstration program is one of the first multiagency efforts to develop strategies and tools that could be effective following a wide-area release of B. anthracis spores. Nevertheless, several key policy issues and associated science and technology issues still need to be addressed. For example, more refined risk assessment and management approaches are needed to help evaluate "true" public health risk. Once the risk is understood, that information can be considered along with the types of characterization activities deemed necessary to determine whether the cost and time of decontamination are actually warranted. This commentary offers 5 recommendations associated with decision making regarding decontamination and clearance options that should accompany a comprehensive risk analysis leading to more effective risk management decisions. It summarizes some of the most important technological gaps that still need to be addressed to help decision makers in their objective of reducing health risks to an acceptable level. The risk management approach described should enable decision makers to improve credibility and gain public acceptance, especially when an adequate science and technology base is available to support the required decisions.     

Incorporating Science,Technology, Fairness,and Accountability in Environmental,Health, and Safety Decisions

The Precautionary Principle is in sharp political focus today because (1) the nature of scientific uncertainty is changing and (2) there is increasing pressure to base governmental action on more “rational” schemes, such as cost-benefit analysis and quantitative risk assessment, the former being an embodiment of ‘rational choice theory’ promoted by the Chicago school of law and economics. The Precautionary Principle has been criticized as being both too vague and too arbitrary to form a basis for rational decision making. The assumption underlying this criticism is that any scheme not based on cost-benefit analysis and risk assessment is both irrational and without secure foundation in either science or economics. This paper contests that view and makes explicit the rational tenets of the Precautionary Principle within an analytical framework as rigorous as uncertainties permit, and one that mirrors democratic values embodied in regulatory, compensatory, and common law. Unlike other formulations that reject risk assessment, this paper argues that risk assessment can be used within the formalism of tradeoff analysis—a more appropriate alternative to traditional cost-benefit analysis and one that satisfies the need for well-grounded public policy decision making. This paper will argue that the precautionary approach is the most appropriate basis for policy, even when large uncertainties do not exist, especially where the fairness of the distributions of costs and benefits of hazardous activities and products are a concern. Furthermore, it will offer an approach to making decisions within an analytic framework, based on equity and justice, to replace the economic paradigm of utilitarian cost-benefit analysis.     

Effects of feedback of information on clinical practice: a review.

OBJECTIVE--To establish what is known about the role of feedback of statistical information in changing clinical practice. DESIGN--Review of 36 studies of interventions entailing the use of statistical information for audit or practice review, which used a formal research design. SUBJECTS--Papers identified from computer searches of medical and health service management publications, of which 36 describing studies of interventions designed to influence clinical care and including information feedback from clinical or administrative data systems were reviewed. MAIN OUTCOME MEASURES--Evidence for effect of information feedback on change in clinical practice. RESULTS--Information feedback was most likely to influence clinical practice if it was part of strategy to target decision makers who had already agreed to review their practice. A more direct effect was discernable if the information was presented close to the time of decision making. The questions of the optimum layout and quantity of information were not addressed; the 36 papers were insufficient for defining good formats for information to be used for audit or quality assurance. CONCLUSIONS--Given the cost of information processing and the current emphasis on closing the audit loop in the health services, it is important that the use of information in the audit process should be critically evaluated.     

Cellular and molecular basis of decision‐making

People think they are in control of their own decisions: what to eat or drink, whom to marry or pick a fight with, where to live, what to buy. Behavioural economists and neurophysiologists have long studied decision‐making behaviours. However, these behaviours have only recently been studied through the light of molecular genetics. Here, we review recent research in mice, Drosophila melanogaster and Caenorhabditis elegans, that analyses the molecular and cellular mechanisms underlying decision‐making. These studies interrogate decision‐making about food, sexual behaviour, aggression or foraging strategies, and add molecular and cell biology understanding onto the consilience of brain and decision.     

Linking reductionist science and holistic policy using systematic reviews: unpacking environmental policy questions to construct an evidence-based framework

1. There is a mismatch between broad holistic questions typically posed in policy formation and narrow reductionist questions that are susceptible to scientific method. This inhibits the two-way flow of information at the science-policy interface and weakens the impact of applied ecology on environmental policy.
2. We investigate the approaches to building policy in the health services as a model to help establish a framework in applied ecology and environmental management by which reductionist science can underpin decision making at the policy level.
3. A comparison of policy documents in the health and environmental sectors reveals many similarities in identifying approaches and specific interventions that might achieve policy objectives. The difference is that in the health services, information on the effectiveness of potential interventions is far more readily available through the collaborative process of systematic review.
4. Synthesis and applications . Decision makers are increasingly looking to produce policies that are shaped by evidence through evidence-based policy making. The approach that we outline here provides a framework for structuring systematic reviews to deliver the evidence on key policy issues in a way that will see a faster return and provide better use of the systematic review methodology in environmental management.     

Functional neuroimaging of the vegetative state

A number of recent studies have demonstrated a role for state-of-the-art neuroimaging methods in the assessment of patients in the vegetative state and other so-called 'disorders of consciousness'. In several cases, functional MRI has been used to show that aspects of speech perception, emotional processing, language comprehension and even conscious awareness might be retained in some patients who behaviourally meet all of the criteria that define the vegetative state. This work has profound implications for clinical care, diagnosis, prognosis and medical-legal decision making (relating to the prolongation, or otherwise, of life after severe brain injury), as well as for more basic scientific questions about the nature of consciousness and the neural representation of our own thoughts and intentions.     

Fair Resource Allocation to Health Research: Priority Topics for Bioethics Scholarship

This article draws attention to the limited amount of scholarship on what constitutes fairness and equity in resource allocation to health research by individual funders. It identifies three key decisions of ethical significance about resource allocation that research funders make regularly and calls for prioritizing scholarship on those topics – namely, how health resources should be fairly apportioned amongst public health and health care delivery versus health research, how health research resources should be fairly allocated between health problems experienced domestically versus other health problems typically experienced by disadvantaged populations outside the funder's country, and how domestic and non‐domestic health research funding should be further apportioned to different areas, e.g. types of research and recipients. These three topics should be priorities for bioethics research because their outcomes have a substantial bearing on the achievement of health justice. The proposed agenda aims to move discussion on the ethics of health research funding beyond its current focus on the mismatch between worldwide basic and clinical research investment and the global burden of disease. Individual funders’ decision‐making on whether and to what extent to allocate resources to non‐domestic health research, health systems research, research on the social determinants of health, capacity development, and recipients in certain countries should also be the focus of ethical scrutiny.     

WHY DOES A METHOD THAT FAILS CONTINUE TO BE USED?

As a critical framework for addressing a diversity of evolutionary and ecological questions, any method that provides accurate and detailed phylogeographic inference would be embraced. What is difficult to understand is the continued use of a method that not only fails, but also has never been shown to work--nested clade analysis is applied widely even though the conditions under which the method will provide reliable results have not yet been demonstrated. This contradiction between performance and popularity is even more perplexing given the recent methodological and computational advances for making historical inferences, which include estimating population genetic parameters and testing different biogeographic scenarios. Here I briefly review the history of criticisms and rebuttals that focus specifically on the high rate of incorrect phylogeographic inference of nested-clade analysis, with the goal of understanding what drives its unfettered popularity. In this case, the appeal of what nested-clade analysis claims to do--not what the method actually achieves--appears to explain its paradoxical status as a favorite method that fails. What a method promises, as opposed to how it performs, must be considered separately when evaluating whether the method represents a valuable tool for historical inference.     

医疗机构合理用药评价模型的构建研究

目的 针对医疗机构的合理用药水平进行评价研究。方法 根据医疗机构合理用药的具体要求,构建医疗机构合理用药评价指标体系,采用基于模糊群决策的方法和多指标评价分析法构建医疗机构合理用药评价模型。结果 构建了基于模糊群决策的医疗机构合理用药评价模型,并通过实例分析证明了评价模型的可行性。结论 建立的基于模糊群决策的医疗机构合理用药评价模型能够对医疗机构的合理用药水平进行科学评价,为提高医疗机构合理用药水平奠定基础。     

Risk communication and decision tools for children's health protection

Scientific discovery linking the environment to beneficial and adverse health children's health outcomes is rapidly expanding, leading scientists and health professionals to call for timely action to prevent harm and secure benefits. A robust method to synthesize what is known about the environmental drivers of health is a foundational step to making the science actionable by individuals and decision‐makers. To meet this need, a methodology called the Navigation Guide was crafted by a collaboration of 22 clinical and environmental health scientists. The Navigation Guide proceeds from methods of research synthesis used in clinical settings but accounts for differences between environmental and clinical health sciences related to the evidence‐base and decision‐context. The methodology can be used to develop evidence profiles that provide simple, transparent summaries, such as practice guidelines or other evidence‐based recommendations for prevention. Establishing proof‐of‐concept of the method is underway. Development of the Navigation Guide is extremely timely as it coincides with growing recognition of the need for updated methods in risk assessment. The costs in 2008 to the US healthcare system for treatment of childhood illnesses linked to toxic environmental exposures is conservatively estimated to be over $76 billion, and it is anticipated that US healthcare policy decisions will increasingly rely on systematic reviews of the evidence. The Navigation Guide is poised to provide a methodological bridge to link healthcare decision‐making to efforts to reduce toxic environmental exposures. The institutionalization of the Navigation Guide would provide a concrete mechanism for linking science to action to protect children's health. Birth Defects Research (Part C) 99:45–49, 2013. © 2013 Wiley Periodicals, Inc.