What Does Public Health Ethics Tell (Or Not Tell) Us About Intervening in Non-Communicable Diseases?

Obesity has been described as pandemic and a public health crisis. It has been argued that concerted research efforts are needed to enhance our understanding and develop effective interventions for the complex and multiple dimensions of the health challenges posed by obesity. This would provide a secure evidence base in order to justify clinical interventions and public policy. This paper critically examines these claims through the examination of models of public health and public health ethics. I argue that the concept of an effective public health intervention is unclear and underdeveloped and, as a consequence, normative frameworks reliant on meeting the effectiveness criterion may miss morally salient dimensions of the problems. I conclude by arguing for the need to consider both an ecological model of public health and inclusion of a critical public health ethics perspective for an adequate account of the public health challenges posed by obesity.     

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.     

新冠肺炎时期公众对野生动物消费和贸易意愿的调查

新冠肺炎疫情的暴发, 使得对野生动物的消费与贸易中的公共健康安全问题引起广泛关注。为了给相关的立法和政策制定提供参考, 我们通过网络对于全国及部分海外华人发放问卷进行了调查, 共收回74,040份有效问卷。根据问卷调查结果, 本文对普通公众对于野生动物消费和贸易立法意愿及影响因素进行了分析。研究结果包括: (1)公众对全面取缔野味餐馆和集市、禁止消费野味、禁止野生动物及其制品的买卖以及禁止野生动物商业性活体展演的立法动议持赞成态度的比例均超过90%; (2)现有野生动物消费群体经历新冠肺炎疫情后倾向于停止消费行为; (3)曾经消费野生动物或周围有人从事野生动物相关产业的群体相比其他人群更有可能不支持全面禁止对野生动物的消费和贸易。结果表明, 全国人民代表大会常务委员会禁食野生动物的决定和修改野生动物保护法的动议在受高等教育者和城镇居民中有良好的公众基础。     

Health care and the principle of fair equality of opportunity: a report from The Netherlands

In The Netherlands, the public funding of a number of health care services is controversial. What can we learn from this about the moral concerns that underlie these judgements? And, if there is anything to learn, can we use this improved understanding to scrutinise the adequacy of particular decisions concerning the public funding of health care services? In the present paper, I will analyse three cases: corrective surgey, In Vitro Fertilisation and liver transplantation. I will summarise the arguments that have been used to support or to challenge the public funding of these services. I will then assess the merits of Daniels’fair equality of opportunity account of justice in health care. Can this account improve our understanding of the moral concerns underlying our judgements about the public funding of these services? Can it serve to scrutinise the adequacy of particular decisions that are made concerning the public funding of health care services? My answer to both questions will be a qualified yes. Daniels’account can provide guidance, but not because we can deductively infer from it what is right and what is wrong. Instead, I will argue for a more casuistic use of the concept of fair equality of opportunity.     

Digitally supported public health interventions through the lens of structural injustice: The case of mobile apps responding to violence against women and girls

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.     

基于禽流感发生风险的生态安全评价研究进展

禽流感是危害公共健康、社会经济和政治稳定重要的传染性疾病。近年来,禽流感引发的区域生态安全(公共卫生安全和生物安全)问题日益受到学界关注。为此,有必要从禽流感发生风险的角度来开展区域生态安全评价。根据1996—2017年发表的禽流感发生风险与生态安全评价英文文献,运用Citespace软件综合分析了禽流感与生态安全评价的最新研究进展。在阐述禽流感发生风险与生态安全评价关系基础上,结合生态安全评价理论框架,从数据来源、适用范围、优缺点等方面分别对禽流感发生风险评估方法以及基于禽流感发生风险的生态安全评价方法进行对比与总结。综述表明:禽流感发生风险对生物物种安全和公共卫生安全的威胁已经严重影响到区域生态安全,其引发的公共卫生危机和生物多样性减少是生态安全评价研究的重要内容,从禽流感发生风险视角评价区域生态安全具有其必要性和紧迫性,并迫切需要加强相关模型方法及其应用研究。目前,禽流感研究主要以病毒学、流行病学为主,与生态安全领域结合研究较为缺乏,在生态安全评价中有关禽流感发生风险内容的研究基本被忽视。既可为深入揭示禽流感发生与传播的动力学机制与防控和监测禽流感提供科学依据,亦可为未来开展基于禽流感发生风险的区域生态安全评价研究提供方法借鉴。     

The politics of recognition in culturally appropriate care

Over the last 20 years, the concept of culturally appropriate health care has been gradually gaining popularity in medicine and public health. In calling for health care that is culturally appropriate, minority groups seek political recognition of often racialized constructions of cultural difference as they intervene in health care planning and organization. Based on interview narratives from people involved in community organizing to establish a federally funded community health center in a mid-size New England city, I chart the emergence of a language of "culturally appropriate health care" in language used to justify the need for a health center. An identity model of recognition underlies the call for ethnic resemblance between patient and provider seen in many culturally appropriate care programs. I contrast this model of health care with earlier calls for community access and control by activists in the 1970s and explore the practical and theoretical implications of each approach.     

Epigenetics for the social sciences: justice,embodiment, and inheritance in the postgenomic age

In this paper, I firstly situate the current rise of interest in epigenetics in the broader history of attempts to go “beyond the gene” in twentieth-century biology. In the second part, after a summary of the main differences between epigenetic and genetic mutations, I consider what kind of implications the sui generis features of epigenetic mutations may have for the social sciences. I focus in particular on two sites of investigation: (a) the blurring of the boundaries between natural and social inequalities in theories of justice and their possible implications for public policy and public health and (b) a deepening of the notion that the constitution of the body is deeply dependent on its material and socially shaped surroundings (“embodied constructivism”). In conclusion, I advance some cautionary reflections on some of the (known and unprecedented) problems that the circulation of epigenetics in wider society may present.     

Identifying and evaluating layers of vulnerability – a way forward

“Vulnerability” is a key concept for research ethics and public health ethics. This term can be discussed from either a conceptual or a practical perspective. I previously proposed the metaphor of layers to understand how this concept functions from the conceptual perspective in human research. In this paper I will clarify how my analysis includes other definitions of vulnerability. Then, I will take the practical‐ethical perspective, rejecting the usefulness of taxonomies to analyze vulnerabilities. My proposal specifies two steps and provides a procedural guide to help rank layers. I introduce the notion of cascade vulnerability and outline the dispositional nature of layers of vulnerability to underscore the importance of identifying their stimulus condition. In addition, I identify three kinds of obligations and some strategies to implement them. This strategy outlines the normative force of harmful layers of vulnerability. It offers concrete guidance. It contributes substantial content to the practical sphere but it does not simplify or idealize research subjects, research context or public health challenges.     

同一个世界 同一个健康

随着工业化和城镇化水平的持续提高,人类的生活方式发生了翻天覆地的变化,在传统因素依然制约人类健康的同时,食源性疾病与营养结构不合理、畜禽养殖方式转变与宠物快速发展带来人与动物关系深刻变化、生态环境与居住环境变化等非传统因素,对人类健康的制约凸显。面对这些人类健康的新挑战,我们必须因应时代变化,在大力发展医疗卫生事业的同时,树立营养健康、动物健康、环境健康三位一体的现代健康新理念。努力提高营养健康水平,以宠物健康为新的关注点高度重视动物健康,以人居、社区环境为重点营造健康生态环境,建立起现代健康新模式。     

A historical synopsis of farm animal disease and public policy in twentieth century Britain

The diseases suffered by British livestock, and the ways in which they were perceived and managed by farmers, vets and the state, changed considerably over the course of the twentieth century. This paper documents and analyses these changes in relation to the development of public policy. It reveals that scientific knowledge and disease demographics cannot by themselves explain the shifting boundaries of state responsibility for animal health, the diseases targeted and the preferred modes of intervention. Policies were shaped also by concerns over food security and the public's health, the state of the national and livestock economy, the interests and expertise of the veterinary profession, and prevailing agricultural policy. This paper demonstrates how, by precipitating changes to farming and trading practices, public policy could sometimes actually undermine farm animal health. Animal disease can therefore be viewed both as a stimulus to, and a consequence of, twentieth century public policy.     

Defining risk: Normative considerations

The public thinks about (i.e., defines) environmental human health risks in different terms than the “experts.”; And because the manner in which we conceive of risk goes a long way in determining how risk management is conceived and carried out, any definition of risk has important normative elements. I argue that environmental policy based on the public's conception of risk fails to adequately protect fundamental human rights to health and liberty, by taking undue account of certain psychological factors that enter into the public's perception of risk. A survey of some of these factors is offered in an attempt to determine their policy relevance. The traditional scientific conception of risk, although not adequate to entirely define risk policy, serves as an important anchor for the protection of these rights by focusing on the probability or number of adverse health effects.     

Assisted Reproduction and Distributive Justice

The Canadian province of Quebec recently amended its Health Insurance Act to cover the costs of In Vitro Fertilization (IVF). The province of Ontario recently de‐insured IVF. Both provinces cited cost‐effectiveness as their grounds, but the question as to whether a public health insurance system ought to cover IVF raises the deeper question of how we should understand reproduction at the social level, and whether its costs should be a matter of individual or collective responsibility. In this article I examine three strategies for justifying collective provisions in a liberal society and assess whether public reproductive assistance can be defended on any of these accounts. I begin by considering, and rejecting, rights‐based and needs‐based approaches. I go on to argue that instead we ought to address assisted reproduction from the perspective of the contractarian insurance‐based model for public health coverage, according to which we select items for inclusion based on their unpredictability in nature and cost. I argue that infertility qualifies as an unpredictable incident against which rational agents would choose to insure under ideal conditions and that assisted reproduction is thereby a matter of collective responsibility, but only in cases of medical necessity or inability to pay. The policy I endorse by appeal to this approach is a means‐tested system of coverage resembling neither Ontario nor Quebec's, and I conclude that it constitutes a promising alternative worthy of serious consideration by bioethicists, political philosophers, and policy‐makers alike.     

Standard of Care,Institutional Obligations,and Distributive Justice

The problem of standard of care in clinical research concerns the level of treatment that investigators must provide to subjects in clinical trials. Commentators often formulate answers to this problem by appealing to two distinct types of obligations: professional obligations and natural duties. In this article, I investigate whether investigators also possess institutional obligations that are directly relevant to the problem of standard of care, that is, those obligations a person has because she occupies a particular institutional role. I examine two types of institutional contexts: (1) public research agencies – agencies or departments of states that fund or conduct clinical research in the public interest; and (2) private‐for‐profit corporations. I argue that investigators who are employed or have their research sponsored by the former have a distinctive institutional obligation to conduct their research in a way that is consistent with the state's duty of distributive justice to provide its citizens with access to basic health care, and its duty to aid citizens of lower income countries. By contrast, I argue that investigators who are employed or have their research sponsored by private‐for‐profit corporations do not possess this obligation nor any other institutional obligation that is directly relevant to the ethics of RCTs. My account of the institutional obligations of investigators aims to contribute to the development of a reasonable, distributive justice‐based account of standard of care.     

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.     

Multilocus sequence typing

Numerous computer-based statistical packages have been developed in recent years and it has become easier to analyze nucleotide sequence data and gather subsequent information that would not normally be available. Multilocus sequence typing (MLST) is used for characterizing isolates of bacterial and fungal species and uses nucleotide sequences of internal fragments of housekeeping genes. This method is finding a place in clinical microbiology and public health by providing data for epidemiological surveillance and development of vaccine policy. It adds greatly to our knowledge of the genetic variation that can occur within a species and has therefore been used for studies of population biology. Analysis requires the detailed interpretation of nucleotide sequence data obtained from housekeeping and nonhousekeeping genes. This is due to the amount of data generated from nucleotide sequencing and the information generated from an array of analytical tools improves our understanding of bacterial pathogens. This can benefit public health interventions and the development of enhanced therapies and vaccines. This review concentrates on the analytical tools used in MLST and their use in the clinical microbiology and public health fields.     

Evaluating interventions in health: a reconciliatory approach

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.     

Global Health Care Justice,Delivery Doctors and Assisted Reproduction: Taking a Note From Catholic Social Teachings

This article will examine the Catholic concept of global justice within a health care framework as it relates to women's needs for delivery doctors in the developing world and women's demands for assisted reproduction in the developed world. I will first discuss justice as a theory, situating it within Catholic social teachings. The Catholic perspective on global justice in health care demands that everyone have access to basic needs before elective treatments are offered to the wealthy. After exploring specific discrepancies in global health care justice, I will point to the need for delivery doctors in the developing world to provide basic assistance to women who hazard many pregnancies as a priority before offering assisted reproduction to women in the developed world. The wide disparities between maternal health in the developing world and elective fertility treatments in the developed world are clearly unjust within Catholic social teachings. I conclude this article by offering policy suggestions for moving closer to health care justice via doctor distribution.     

Improving the dialogue between public health and ecosystem science on antimicrobial resistance

The concept of health has evolved markedly from a bio-medical, mechanistic model to include an interdisciplinary perspective where human, animal and ecosystem health are integrated. One Health, EcoHealth and Planetary Health are examples of approaches to health advocating collaboration and interdisciplinarity at multiple levels. In practice, successful integration has been challenging and in particular, understanding of the ecosystem component of health lags behind the human and animal components. Antimicrobial resistance is an important threat to human health, which develops, is maintained and transmitted at the human–animal–environment interface. While the human and livestock components of resistance are well understood, this is not the case for the ecosystem component. This gap in knowledge leads to a poor representation of the environmental dimension of antimicrobial resistance in key policy documents and in interdisciplinary work around this issue. We interviewed a group of leading researchers in public health and ecology to explore their perceptions on the integration of ecosystem and public health research in the context of antimicrobial resistance. Experts from both fields considered that research on antimicrobial resistance is only beginning to consider ecosystems. They highlighted various barriers that have contributed to limited integration, such as conceptual barriers, and a lack of knowledge translators as facilitators. Better interdisciplinary integration is needed to address the challenge of antimicrobial resistance. Improving the dialogues between the disciplines is a necessary first step in this process. Greater engagement of ecologists is needed to build a more complete understanding of the role of ecosystems in human health, and identify how human interactions with ecosystems can both contribute to, and restrict, the development of antimicrobial resistance.