STIGMATIZATION AND PUBLIC HEALTH ETHICS

Encouraged by the success of smoking denormalization strategies as a tobacco‐control measure, public health institutions are adopting a similar approach to other health behaviors. For example, a recent controversial ad campaign in New York explicitly aimed to denormalize HIV/AIDS amongst gay men. Authors such as Scott Burris have argued that efforts like this are tantamount to stigmatization and that such stigmatization is unethical because it is dehumanizing. Others have offered a limited endorsement of denormalization/stigmatization campaigns as being justified on consequentialist grounds; namely, that the potential public health benefits outweigh any stigmatizing side effects. In this paper, I examine and reject the blanket condemnation of stigmatization efforts in public health. I argue that the moral status of such efforts are best evaluated within a contractualist, as opposed to a consequentialist, framework. Contractualism in public health ethics asks whether a particular stigmatizing policy could be justified to reasonable individuals who do not know whether they will be affected by that policy. Using this approach, I argue that it is sometimes permissible for public health institutions to engage in health‐related stigmatization.     

Conceptual and Practical Problems of Moral Enhancement

Recently, the debate on human enhancement has shifted from familiar topics like cognitive enhancement and mood enhancement to a new and – to no one's surprise – controversial subject, namely moral enhancement. Some proponents from the transhumanist camp allude to the ‘urgent need’ of improving the moral conduct of humankind in the face of ever growing technological progress and the substantial dangers entailed in this enterprise. Other thinkers express more sceptical views about this proposal. As the debate has revealed so far, there is no shared opinion among philosophers (or scientists) about the meaning, prospects, and ethical evaluation of moral enhancement. In this article I will address several conceptual and practical problems of this issue, in order to encourage discussion about the prospects of (thinking about) moral enhancement in the future. My assumption is that (i) for the short term, there is little chance of arriving at an agreement on the proper understanding of morality and the appropriateness of one single (meta‐)ethical theory; (ii) apart from this, there are further philosophical puzzles loosely referred to in the debate which add to theoretical confusion; and (iii) even if these conceptual problems could be solved, there are still practical problems to be smoothed out if moral enhancement is ever to gain relevance apart from merely theoretical interest. My tentative conclusion, therefore, will be that moral enhancement is not very likely to be made sense of – let alone realized – in the medium‐term future.     

Community engagement in global health research that advances health equity

Community engagement is gaining prominence in global health research. So far, a philosophical rationale for why researchers should perform community engagement during such research has not been provided by ethics scholars. Its absence means that conducting community engagement is still often viewed as no more than a ‘good idea’ or ‘good practice’ rather than ethically required. In this article, we argue that shared health governance can establish grounds for requiring the engagement of low‐ and middle‐income country (LMIC) community members in global health research, where such research aims to help reduce health disparities. This philosophical basis has important implications for the ethical goals ascribed to engagement and the approach adopted to undertake it. We suggest the ethical goals of engagement in equity‐oriented global health research should include: (a) generating research topics and questions that reflect the key problems disadvantaged groups face in accessing healthcare, services and broader social determinants of health and (b) promoting the translation of research findings into policy and practice in ways that benefit the health of disadvantaged groups. We propose engagement practice should have the following features: deliberation with LMIC community members to make a range of project decisions, beginning with setting research topics and questions; inclusion of members of disadvantaged groups and those with the power to change policy and practice to benefit them; and purposeful structuring of deliberations to minimize the impact of power disparities between LMIC community members. Finally, we reflect on how these features differ from those typical of much current community engagement practice in LMICs.     

On the need to redress an inadequacy in animal welfare science: toward an internally coherent framework

The time is ripe for a greater interrogation of assumptions and commitments underlying an emerging common ground on the ethics of animal research as well on the 3 R (replacement, refinement, reduction) approach that parallels, and perhaps even further shapes, it. Recurring pressures to re-evaluate the moral status of some animals in research comes as much from within the relevant sciences as without. It seems incredible, in the light of what we now know of such animals as chimpanzees, to deny that these animals are properly accorded high moral status. Barring the requirement that they be human, it is difficult to see what more animals such as chimpanzees would have to possess to acquire it. If the grounds for ascribing high moral status are to be non-arbitrary and responsive to our best knowledge of those individuals who possess the relevant features, we should expect that a sound ethical experimental science will periodically reassess the moral status of their research subjects as the relevant knowledge demands. We already can observe this reassessment as scientists committed to humane experimental science incorporate discoveries of enrichment tools and techniques into their housing and use of captive research animals. No less should this reassessment include a critical reflection on the possible elevation of moral status of certain research animals in light of what is discovered regarding their morally significant properties, characteristics or capacities, or so I will argue. To do anything short of this threatens the social and moral legitimacy of animal research.     

Cluster randomization and political philosophy

In this paper, I will argue that, while the ethical issues raised by cluster randomization can be challenging, they are not new. My thesis divides neatly into two parts. In the first, easier part I argue that many of the ethical challenges posed by cluster randomized human subjects research are clearly present in other types of human subjects research, and so are not novel. In the second, more difficult part I discuss the thorniest ethical challenge for cluster randomized research--cases where consent is genuinely impractical to obtain. I argue that once again these cases require no new analytic insight; instead, we should look to political philosophy for guidance. In other words, the most serious ethical problem that arises in cluster randomized research also arises in political philosophy.     

Public consultation in ethics an experiment in representative ethics

Genome Canada has funded a research project to evaluate the usefulness of different forms of ethical analysis for assessing the moral weight of public opinion in the governance of genomics. This paper will describe a role of public consultation for ethical analysis and a contribution of ethical analysis to public consultation and the governance of genomics/biotechnology. Public consultation increases the robustness of ethical analysis with a more diverse set of moral experiences. Consultation must be carefully and respectfully designed to generate sufficiently diverse and rich accounts of moral experiences. Since dominant groups tend to define ethical or policy issues in a manner that excludes some interests or perspectives, it is important to identify the range of interests that diverse publics hold before defining the issue and scope of the discussion and the premature foreclosure of ethical dialogue. Consequently, a significant contribution of ethical dialogue strengthened by social analysis is to consider the context and non-policy use of power to govern genomics and to sustain social debate on enduring ethical issues.     

Ethics and Embryo/Foetus Research

Research with embryos and foetuses raise moral problems. In this article the origins of these moral intuitions are analyzed and discussed at four levels: moral problems regarding the treatment of the foetus and the mother animal; ethical problems experienced by the moral actor (researcher); ethical problems related to a justification based upon a balance between means and goals; and ethical problems raised by society.     

Ethics and Embryo/Foetus Research

Research with embryos and foetuses raise moral problems. In this article the origins of these moral intuitions are analyzed and discussed at four levels: moral problems regarding the treatment of the foetus and the mother animal; ethical problems experienced by the moral actor (researcher); ethical problems related to a justification based upon a balance between means and goals; and ethical problems raised by society.     

Will technology trample peer review in ecology? Ongoing issues and potential solutions

The classical view of peer review is that it is our primary process for assessing and judging whether research results should be published in a scholarly journal. However, the increased pressure to publish and technological developments are transforming peer review such that it is becoming a system that judges where work is published rather than whether the research is publishable (a ‘where rather than if’ process). Ecology is a field in which publication numbers puts a particular pressure on the review system. In this forum piece, I summarize the issues with the current publication system and discuss how technology is changing it, while suggesting solutions for important prior and ongoing issues with the peer review system. The view explored here is that technological developments (e.g. ease of creating journals, internet sites, storage, data generation, sharing of data and analytical code) will not eliminate peer review per se but will allow for a new set of parameters in which ethics and the optimal use of public funding will play a vital role in the evolution of the review process. Synthesis The number of papers and journals in Ecology has increased dramatically in the past decade. I present a critical overview of our review system and proposes that pressure to publish and technological developments have transformed peer review into a system that decides “where rather than if” papers are publishable. While reviewing the current pressures and factors playing a vital role in the evolution of the review and publication systems, I propose potential solutions to deal with current and future challenges to the peer review and publication systems.     

Protecting Future Children from In‐Utero Harm

The actions of pregnant women can cause harm to their future children. However, even if the possible harm is serious and likely to occur, the law will generally not intervene. A pregnant woman is an autonomous person who is entitled to make her own decisions. A fetus in‐utero has no legal right to protection. In striking contrast, the child, if born alive, may sue for injury in‐utero; and the child is entitled to be protected by being removed from her parents if necessary for her protection. Indeed, there is a legal obligation for health professionals to report suspected harm, and for authorities to protect the child's wellbeing. We ask whether such contradictory responses are justified. Should the law intervene where a pregnant woman's actions risk serious and preventable fetal injury? The argument for legal intervention to protect a fetus is sometimes linked to the concept of ‘fetal personhood’ and the moral status of the fetus. In this article we will suggest that even if the fetus is not regarded as a separate person, and does not have the legal or moral status of a child, indeed, even if the fetus is regarded as having no legal or moral status, there is an ethical and legal case for intervening to prevent serious harm to a future child. We examine the arguments for and against intervention on behalf of the future child, drawing on the example of excessive maternal alcohol intake.     

MORAL EXPERTISE: A PROBLEM IN THE PROFESSIONAL ETHICS OF PROFESSIONAL ETHICISTS

Philosophers, particularly moral philosophers, are increasingly being involved in public decision-making in areas which are seen to raise ethical issues. For example, Dame Mary Warnock chaired the ‘Committee of Inquiry into Human Fertilization and Embryology’ in the UK in 1982–4; the Philosophy Department at Auckland was commissioned by the Auckland Regional Authority to report on the ethical aspects of fluoridating the public water supply in 1990; and many of us are serving on ethics committees of various sorts. Not only are philosophers actually being called on or consulted, but many of us would argue that a philosophical contribution in such areas is essential. The involvement of moral philosophers in public policy decisions raises a question of professional ethics, viz, what role should a philosopher's own moral perspective or judgements play in the advice s/he gives, or contribution s/he makes, to public decision-making on ethical issues. Like most problems in professional ethics, this prompts reflection on the nature of the profession, and in particular on the expertise we take moral philosophy to offer. It also prompts reflection on how processes of public decision making in ethically problematic areas should be understood. I explore these issues in this paper.     

Moral expertise: a problem in the professional ethics of professional ethicists

Philosophers, particularly moral philosophers, are increasingly being involved in public decision-making in areas which are seen to raise ethical issues. For example, Dame Mary Warnock chaired the 'Committee of Inquiry into Human Fertilization and Embryology' in the UK in 1982-4; the Philosophy Department at Auckland was commissioned by the Auckland Regional Authority to report on the ethical aspects of fluoridating the public water supply in 1990; and many of us are serving on ethics committees of various sorts. Not only are philosophers actually being called on or consulted, but many of us would argue that a philosophical contribution in such areas is essential. The involvement of moral philosophers in public policy decisions raises a question of professional ethics, viz, what role should a philosopher's own moral perspective or judgements play in the advice s/he gives, or contribution s/he makes, to public decision-making on ethical issues. Like most problems in professional ethics, this prompts reflection on the nature of the profession, and in particular on the expertise we take moral philosophy to offer. It also prompts reflection on how processes of public decision making in ethically problematic areas should be understood. I explore these issues in this paper.     

Within a Range of Possibilities: Morality and Ethics in Social Life

Despite its now common currency the anthropological concept of morality remains underdeveloped. One anthropologist who has made several important attempts to work out a more precise theoretical concept of morality is Joel Robbins. In his most recent contribution to this endeavor Robbins addresses the tension in anthropology between what he calls the morality of reproduction and the morality of freedom. In this article, I suggest an alternative solution to the problem of conceiving the distinction between a nonconsciously enacted morality and the conscious awareness of ethical dilemmas and moral questioning. I will support this distinction with ethnographic and life-historical material from my research on the moral lives of some Muscovites.     

Stem cell therapy: medical advance or moral challenge?Thérapie cellulaire : avance médicale ou défi moral ?

My professional lifetime has seen progress in the biomedical sciences that beggars belief. This has lead to astonishing advances in the ability to prevent and treat disease and, in the developed world at least, people live longer and healthier lives than ever before. Paradoxically, this has gone hand in hand with the growth of a vocal and influential anti-science lobby that not only rejects much modern science but is also deeply suspicious of new medical interventions. The prospect of cell therapy in the near or middle future is their current target especially where the use of embryonic stem cells or of cell nuclear transfer techniques is concerned. The prospect of cell therapy is welcomed with enthusiasm by patients with genetic and degenerative diseases who hope to benefit from them. On the other hand the whole idea is regarded as repugnant by the anti-science lobby. While some of this opposition is essentially luddite in nature, there are some more persuasive arguments raised particularly to any research than uses embryonic or foetal materials. These arguments will be examined critically. The moral problems of denying the sick the hope of effective treatments have to be weighed against those seen in the development of such treatments. (This article is closely based on an already published paper. P. Lachmann, Stem cell research: why is it regarded as a threat? An investigation of the economic and ethical arguments made against research with human embryonic stem cells. EMBO Rep. 2 (3) (2001) 165–168.)     

Spreading disease: a controversy concerning the metaphysics of disease.

This article concerns the metaphysics of disease. Is disease a fixed feature of the world or a social value or preference? I argue that disease is not a value-laden concept and thus debates concerning it differ fundamentally from debates concerning health, harm, or suffering where evaluative judgements are central. I show how the so-called social constructionist view of disease has been motivated both by ethical concerns with medical practices and general theoretical doubts about scientific naturalism. If I can show that ethical concerns about medical treatment can be answered without adopting social constructionism, that leaves only the broader theoretical question of naturalism. I cannot completely answer those theoretical doubts, but I show that the theoretical motivation is less convincing when it is separated from the moral challenge often accompanying it. I conclude that a convincing defense of the non-naturalistic conception of disease is rarely attempted and proves more difficult and counter-intuitive than its proponents assume.     

FURTHERING INJUSTICES AGAINST WOMEN: GENETIC INFORMATION, MORAL OBLIGATIONS, AND GENDER

The purpose of this paper is to show that a decontextualized approach to ethical issues is not just unhelpful for the decision making process of real, situated human beings, but dangerous. This is so, because by neglecting the context in which people make moral decisions we run the risk of reinforcing or furthering injustices against already disadvantaged groups. To show this, I evaluate three moral obligations that our ability to obtain genetic information has made salient: the duty to obtain genetic information about ourselves, the obligation to inform family members about genetic risks and the duty not to reproduce when we know that there is a high risk of transmitting a serious disease or defect. I will argue here that in ignoring the context in which these moral obligations are put into practice, and in particular the situation of women in our society, those who defend these moral duties might be furthering injustices against women.     

Medicine and the Gulag.

The nature of the medical treatment of prisoners in the Gulag has emerged from accounts published by survivors. Over a period of 70 years some doctors entrusted with the medical care of prisoners failed to discharge their ethical duties, contributing to the prisoners'' neglect and suffering. The medical profession must carefully examine what occurred and properly assign responsibility for ethical as well as unethical medical acts. Understanding the history of these ominous events will alert doctors worldwide to the importance of medical autonomy in the support of imprisoned patients.     

Responsible choices: situating pregnancy intention among Haitians in South Florida

In this article, I focus on unintended pregnancy as a means to interrogate the intersections of abortion and prenatal discourses in the United States, and the ways in which these discourses assume certain kinds of moral, liberal subjects. Using media material, congressional legislation, public health policy, and ethnographic data from South Florida (2004-06), I trace how these discourses assume that women will behave in "rational," "responsible" ways to plan their reproductive futures, and how these assumptions intersect with Haitian women migrants' lived experiences in South Florida. My research illustrates how decisions about family planning are situated within particular local moral worlds, where gender relations, religion, power, and desires for children inform women's everyday lives.     

Antibiotic resistance as a tragedy of the commons: An ethical argument for a tax on antibiotic use in humans

To the extent that antibiotic resistance (ABR) is accelerated by antibiotic consumption and that it represents a serious public health emergency, it is imperative to drastically reduce antibiotic consumption, particularly in high‐income countries. I present the problem of ABR as an instance of the collective action problem known as ‘tragedy of the commons’. I propose that there is a strong ethical justification for taxing certain uses of antibiotics, namely when antibiotics are required to treat minor and self‐limiting infections, such as respiratory tract infections, in otherwise healthy individuals. Taxation would allow a reduction in consumption (given certain behavioural economics assumptions) and/or ensure that individuals internalize or compensate for their contribution to the erosion of the common good of antibiotic effectiveness. I suggest that revenue from the tax could be used to fund conservation and innovation strategies. Taxation might be a coercive policy, especially for certain individuals, but the ethical case for coercive policies is very strong when the good to be preserved is important enough and when they force individuals to do something they have a moral obligation to do anyway. I argue that, in the case of mild and self‐limiting infections, individuals have a moral duty of easy rescue and a moral duty of fairness to make their contribution to the preservation of the common good of antibiotic effectiveness by foregoing antibiotics. I also suggest that taxing antibiotics in such cases is an all things considered ethically justified policy even if it would introduce inequalities in access to healthcare.