Plusieurs aspects du modèle biopsychosocial promeuvent une approche humaniste en médecine. Cependant, Engel a explicitement rejeté un humanisme médical qui s’opposerait à la science. En adoptant une approche fondée sur la science des systèmes pour étudier les êtres humains, la santé et la maladie, Engel défend une approche scientifique pour améliorer la qualité des soins cliniques, ou autrement dit, une approche qui se prête à un examen scientifique de cette question.

Politics, Philosophy & Economics, Volume 21, Issue 2, Page 165-189, May 2022. It is generally acknowledged that a certain amount of state intervention in health and health care is needed to address the significant market failures in these sectors; however, it is also thought that the primary rationale for state involvement in health must lie elsewhere, for example in an egalitarian commitment to equalizing access to health care for all citizens. This paper argues that a complete theory of justice in (...) health can be derived from a commitment to correcting market failure, or in other words promoting Pareto-efficiency, in the domain of health. This approach can address familiar problems around access to care, as well as problems related to resource allocation and rationing, the control of health care costs, and the foundations of public health. Egalitarian theories of justice in health cannot make sense of the depth and pervasiveness of state involvement in health and health care; only a theory rooted in the need to correct market failure can. (shrink)

In a series of reflections published in the wake of the Covid-19 crisis, Giorgio Agamben expresses a number of concerns related to the way the pandemic has altered the very fabric of our societies, potentially changing it forever. While maintaining a certain scepticism towards the threat represented by the virus itself, Agamben claims that the response to the contagion shows how easy it is for authorities to limit individual freedoms in the name of public health, and how readily they are (...) willing to put such limitations in place. At the same time, the pandemic shows how easy it is for individuals to accept this situation as the new normal, and how readily they are willing to give up their freedoms and relationships. In this paper I offer a brief overview of Agamben’s worries, focussing on two issues in particular: the loss of individual freedom of movement and association, and the moral and political implications of social distancing. I then approach these issues from a different angle, making use of relational theory to propose an alternative framework which relies on the notion of vulnerability. While agreeing with Agamben that there is reason to worry about the state seizing the opportunity to exercise unchecked power over its citizens, I argue that we should pay attention to the ways in which social distancing measures can be grounded in solidarity and respect for the autonomy of vulnerable individuals. (shrink)

As scholars integrate empirical approaches to ethical questions in healthcare, relational autonomy theory must inform research design and change practice. Qualitative approaches are well suited to issues where patient values play a central role, and they can be combined with relational autonomy theory to investigate the factors influencing autonomy-rich experiences. This paper draws upon my experience conducting bioethics research related to clinical trial decision-making to develop a systematic method for applying relational autonomy as a theoretical lens to qualitative health research. (...) The resultant practical guide utilizes Susan Sherwin’s theory of relational autonomy and presents an empirical method responsive to autonomy-relevant questions. (shrink)

Key ethical challenges for healthcare workers arising from the COVID-19 pandemic are identified: isolation and social distancing, duty of care and fair access to treatment. The paper argues for a relational approach to ethics which includes solidarity, relational autonomy, duty, equity, trust and reciprocity as core values. The needs of the poor and socially disadvantaged are highlighted. Relational autonomy and solidarity are explored in relation to isolation and social distancing. Reciprocity is discussed with reference to healthcare workers’ duty of care (...) and its limits. Priority setting and access to treatment raise ethical issues of utility and equity. Difficult ethical dilemmas around triage, do not resuscitate decisions, and withholding and withdrawing treatment are discussed in the light of recently published guidelines. The paper concludes with the hope for a wider discussion of relational ethics and a glimpse of a future after the pandemic has subsided. (shrink)

Many healthcare practices expose people to risks of harmful outcomes. However, the major theories of moral philosophy struggle to assess whether, when and why it is ethically justifiable to expose individuals to risks, as opposed to actually harming them. Sven Ove Hansson has proposed an approach to the ethical assessment of risk imposition that encourages attention to factors including questions of justice in the distribution of advantage and risk, people’s acceptance or otherwise of risks, and the scope individuals have to (...) influence the practices that generate risk. This paper investigates the ethical justifiability of preventive healthcare practices that expose people to risks including overdiagnosis. We applied Hansson’s framework to three such practices: an ‘ideal’ breast screening service, a commercial personal genome testing service, and a guideline that lowers the diagnostic threshold for hypertension. The framework was challenging to apply, not least because healthcare has unclear boundaries and involves highly complex practices. Nonetheless, the framework encouraged attention to issues that would be widely recognised as morally pertinent. Our assessment supports the view that at least some preventive healthcare practices that impose risks including that of overdiagnosis are not ethically justifiable. Further work is however needed to develop and/or test refined assessment criteria and guidance for applying them. (shrink)

Value judgements in research and political decision-making that exclude evidence for the social determinants of suicide suggest that evidence is not sufficient on its own to guide policy and practice, and that there is a lack of conceptual clarity with regard to decisions relating to the prioritization of problems, the allocation of resources, the translation of research into practice, as well as questions of responsibility for suicide prevention. In this work I seek to broaden conventional ethical debate about suicide through (...) the use of public health ethics frameworks. I argue that despite espousing a public health approach, current suicide prevention strategies are based largely on individual-level theorizing. This emphasis on the individual works to responsibilize individuals and communities for suicide prevention and directs attention away from public policy and systemic inequities. Given continued high rates of suicide, especially among disadvantaged social groups and communities, comprehensive government action is required to address the social and political determinants of suicide. Normative justification for action in realizing these ends is critical. I conclude by proposing one practicable form of action to make values and value judgements in suicide prevention explicit so that alternative forms of ethical and political recognition and responsibility are acknowledged. (shrink)

In exploring the concept of vulnerability, we do not begin with a blank slate. In research involving human subjects, ethics guidelines typically provide a rough definition of the concept. For example, the commentary on Guideline 13 in the International Ethical Guidelines for Biomedical Research Involving Human Subjects, issued by the Council for International Organizations of Medical Sciences (CIOMS), says that "vulnerable persons are those who are relatively (or absolutely) incapable of protecting their own interests. More formally, they may have insufficient (...) power, intelligence, education, resources, strength, or other needed attributes to protect their own interests" (CIOMS 2002). Because the CIOMS guidelines .. (shrink)

This paper examines eight publicly available critical care triage protocols intended for use during an influenza pandemic. These protocols place an emphasis on objective measures of survivability as the primary criterion for assigning priority for lifesaving critical care during a pandemic. Triage would then be undertaken without consideration of the relational or social characteristics of patients who need critical care. We argue that enacting these protocols could result in the denial of lifesaving care to oppressed and disadvantaged groups. The lens (...) of relational theory reveals this ethical flaw in the triage protocols we examine, and suggests ways of improving these protocols. (shrink)

This article looks at how and why addiction should be understood as a ‘sociorelational’ disorder, and what this implies on a policy level in terms of the treatment and prevention of addiction. In light of scientific research, we argue that the neurobiological changes that underlie addiction are heavily influenced by sociorelational processes. We thereby advocate for a conceptual approach in which autonomy in addiction is a sociorelational concept, and social environments are considered autonomy undermining or autonomy promoting. We then discuss (...) the various implications this should have on policies. (shrink)

The evidence is overwhelming that members of particularly wealthy and industry-owning segments of Western societies have much larger carbon footprints than most other humans, and thereby contribute far more than their “fair share” to the enormous problem of climate change. Nonetheless, in this paper we shall counsel against a strategy focused primarily on blaming and shaming and propose, instead, a change in the ethical conversation about climate change. We recommend a shift in the ethical framework from a focus on the (...) role of individual agents and a conversation about guilt; in its place, we propose a relational approach to public health ethics that is centered around the idea of relational solidarity. We begin by briefly reviewing the most common—and woefully inadequate—approach in the West to reducing emissions and responding to the health-related impacts of climate change. We then go on to propose a relational approach to public health ethics as an alternative ethical framework that better fits the moral problems associated with climate change and holds promise for a more meaningful response. (shrink)

This chapter concerns the normativity of the concepts of paternalism and libertarian paternalism. The first concept is central in evaluating public health policy, but its meaning is controversial. The second concept is equally controversial and has received much attention recently. It may or may not shape the future evaluation of public health policy. In order to facilitate honest and fruitful debate, I consider three approaches to these concepts, in terms of their normativity. Concepts, I claim, may be considered nonnormative, normatively (...) charged, or normative in that they involve more complex relationships between values or duties. While the last approach is often best, other approaches may be appropriate depending on the context and purpose of discussion. The chapter’s conceptual investigation is illustrated by application to two public health policies: a tax on the consumption of fat and the encouragement of health-promoting food displays in restaurants and supermarkets. (shrink)

Recent articles published in this journal have highlighted the shortcomings of individualistic approaches to health promotion, and the potential contributions of relational analyses of autonomy to public health ethics. I argue that the latter helps to elucidate the former, by showing that an inadequate analysis of autonomy leads to misassignment of both forward-looking and backward-looking responsibility for health outcomes. Health promotion programmes predicated on such inadequate analyses are then ineffective, because they assign responsibility to agents whose social environment inhibits their (...) ability to act on such responsibilities; inequitable, because the social barriers to autonomous agency display a socio-economic gradient; and stigmatizing, because they license blaming of individuals for their own poor health without taking into account how reasonable it is to hold these individuals responsible, given the social barriers to autonomy they face. I further sketch how incorporating a relational understanding of autonomy could help to produce health promotion programmes that do not succumb to these difficulties, while avoiding coercive paternalism, exploring potential applications in ecological approaches to health promotion. (shrink)

n this paper, I argue that political solidarity is important to justice. At its core, political solidarity is a relational concept. To be in a relation of political solidarity, is to be in a relation of connection or unity with one’s fellow citizens. I argue that fellow citizens can be said to stand in such a relation when they have attitudes of collective identification, mutual respect, mutual trust, and mutual support and loyalty toward one another. I argue that political solidarity, (...) so conceived, is an integral element of a theory of justice. I argue that there are distinctly social bases for political solidarity and that justice requires that we promote these. Furthermore, as an example of the sort of social and political arrangements that might encourage political solidarity, I discuss Canada’s response to the recent H1N1 pandemic and the failings of this response with respect to members of the Aboriginal community within Canada. I argue that ensuring that members of the Aboriginal community had equal access to the goods they needed to protect themselves against H1N1 infection would have promoted relations of political solidarity and, in turn, would have promoted justice more effectively. (shrink)

The public purse is responsible for funding almost all autism spectrum disorders (ASD) research in Canada (as per Canadian Institutes of Health Research [CIHR]) and for providing some of the existing services and supports for this population. In this article, we consider various reasons why Canada should be concerned to ensure a more equitable distribution of relevant public funding for ASD research than is currently the case to meet the express needs and interests of the diversity of autism stakeholders. As (...) such, we report data to show that CIHR-supported ASD research from the period of 2000–2010 demonstrates a bias focussed on the aetiology of the condition revealing a disproportionate emphasis on only two (Biomedical and Clinical) out of the four research pillars avowed by CIHR, with a comparative lack of fiscal resources committed to Health Systems and Services and Population and Public Health research. We advance certain normative and prudential reasons for funding more Health Systems and Services and Population and Public Health ASD research in Canada. In our view, this would seem to follow from CIHR’s official mandate ‘as a flexible mechanism that will continually align health research funding with changes in the manner in which health problems and opportunities are identified, understood and addressed’. (shrink)

Many legal scholars well recognize that, in some instances, support for a law or policy may be primarily because of its expressive function, i.e. the statements it makes about underlying values. In these cases, the expressive content of a law or policy may actually overshadow its central purpose. Examples of this phenomenon, according to Cass Sunstein, include, for example, regulations against hate speech in the USA. He suggests that achieving the consequence (prohibiting hateful speech against certain groups) may not be (...) the real focus (central purpose) of the law. Rather, the real focus is on the social meaning of these regulations—that bigotry is unacceptable in a liberal society. In this way, a particular law or policy can operate on many levels—while aiming to achieve a particular objective or behavior, it can also be a valuable tool for achieving other important social goals through its expressive function. This article applies this insight to the realm of public health policy, with particular attention to the case of pandemic planning, and suggests that public health policy and its overall goals may be well-served by deliberate regard for, and appropriate utilization of, the expressive function. (shrink)

Worldwide, there is renewed public and political attention focused on public health fueled by the globally explosive H1N1 pandemic. Pandemic planning emerged as a major area for public action in the absence of an overarching ethics framework appropriate for the community and population focus of public health. Baylis, Sherwin, and Kenny propose relational personhood and relational solidarity as core values for a public health ethics. The Catholic faith tradition makes three useful contributions in support of a relational ethic: first, a (...) religious ontology that aligns with the view that human persons are inherently relational; second, a coherent account of the requisite social and communal ideals and structures that this belief demands; and third, inspiration and motivation for the attitudes and actions that are required in response to a relational ontology. (shrink)

Obesity is a public health problem influenced by behavioral patterns that span an ecological spectrum of individual-level factors, social network factors and environmental factors. Both individual and environmental approaches necessarily include significant influences from social networks, but how and under what conditions social networks influence behavior change is often not clearly mapped out either in the obesity literature or in many intervention designs. In this paper, we provide an analysis of recent empirical work in obesity research that explicates social network (...) influences on eating behaviors. We argue that a relational rather than individualistic view of personhood should help us better understand the content and context of social network relations that inform health behavior choices. We introduce the concept of ‘identity-constitutive affiliations’ as the glue that binds these social relationships together. Finally, we outline the implications for public health ethics in the development of effective interventions to address overweight and obesity, leveraging the content and context of social network ties to reinforce healthy (or alter unhealthy) eating. More complex treatment of positive and negative behaviors stemming from social network connections should lead to more comprehensive theoretical models of health behavior change and more effective public health interventions. (shrink)

The portrayal of novel neurotechnologies in Steven Spielberg’s Minority Report serves to inoculate viewers from important moral considerations that are displaced by the film’s somewhat singular emphasis on the question of how to reintroduce freedom of choice into an otherwise technology driven world. This sets up a crisis mentality and presents a false dilemma regarding the appropriate use, and regulation, of neurotechnologies. On the one hand, it seems that centralized power is required to both control and effectively implement such technologies (...) and, on the other hand, individual heroic resistance is required to protect citizens from the invasions of personal privacy and state control made possible through neurotechnologies. While Minority Report, as a dystopic vision of emergent neurotechnologies, engages surface ethical issues it risks cheapening them through its rather simplistic, dichotomous analysis. Most conspicuously absent from this approach is a sense of the social matrices that work to circumscribe or augment expressions of human freedom, privacy, control and power that are all implicated in our engagement with novel neurotechnologies. Were Minority Report unique in this respect it would have little interest, but we think this type of cheapening of ethical discourse about novel technologies is common. Because science fiction film informs the social imaginary in which ethical considerations and ultimately policy decisions take place, such cheapening risks subverting pervasive and tangible ethical issues by focusing on the sensationalistic and simplistic. (shrink)

In this paper I use normative analysis to explore the curious and seemingly singular phenomenon whereby some dog owners deny the physical and moral facts about a situation where it is claimed their dog harmed or irritated others. I define these as epistemic and ethical denial, respectively, and offer a tentative exploration of their implications in terms of relational autonomy and responsible behaviour in public spaces.

Uncertainty is inherent in new and unexpected viral outbreaks such as the current COVID-19 pandemic. It imposes challenges for health officials in soliciting cooperative behavioural changes based on incomplete information. In this paper, we use evolving mask recommendations in the United States as an example to analyse the ethical importance and practical demonstration of trustworthiness in pandemic messaging and decision-making. We argue that responsible public health interventions in the time of uncertainties requires explicit intersecting ethical considerations both in action and (...) in communication to promote trustworthiness. First, as public health decisions have to be made in the face of incomplete and evolving data, health officials need to exhibit competence while committing to epistemic humility. They can explain the methods used in making and updating mask recommendations as well as explicitly acknowledge the need to incorporate sociocultural and other contextual considerations in translating scientific data into mask recommendations. Second, officials and agencies must uphold and communicate decisional transparency as part of their effort to demonstrate accountability and promote the public’s understanding of the evolving pandemic. Third, especially since both the pandemic and mask recommendations may have disparate impact on different populations, officials should start with the fair implementation of the least restrictive measures that can help reduce harm. (shrink)

COVID-19 deeply affects many spheres of life. Lockdown measures implemented worldwide have accentuated mental wellbeing changes in the population from the perspectives of space and social relations. These changes leave lasting imprints on individuals and communities. This article draws upon solidarity and care ethics in exploring their role in rebuilding mental wellbeing in the light of constraints arising from lockdown. The diversity of responses to physical and social isolation during the pandemic illuminates the distinctly relational nature of human beings, offering (...) the opportunity for care and solidarity to respond to mental wellbeing challenges in an inclusive and context-sensitive way. (shrink)

Nossa seleção de verbetes parte do interesse de cada pesquisador e os dispomos de maneira histórico-cronológica e, ao mesmo tempo, temática. O verbete de Melissa Lane, “Filosofia Política Antiga” vai da abrangência da política entre os gregos até a república e o império, às portas da cristianização. A “Filosofia Política Medieval”, de John Kilcullen e Jonathan Robinson, é o tópico que mais demanda espaço na nossa seleção em virtude das disputas intrínsecas ao período, da recepção de Aristóteles pelo medievo e (...) da tensão entre poder Papal e Civil. No verbete “Liberalismo”, de Gerald Gaus, Shane Courtland e David Schmidtz, vemos as fontes fundantes da Filosofia Política da modernidade. As ideias de liberdade negativa e positiva se coadunam com a Ética Liberal e sua influência sobre a abrangência do valor fundamental da liberdade individual diante das políticas públicas. O texto de Ian Carter, “Liberdade Positiva e Liberdade Negativa”, expõe o paradoxo da liberdade em suas concepções valorativas e neutra, muito úteis para compreender os problemas políticos que enfrentamos hoje. Por fim, Bas Van Der Vossen no texto “Libertarianismo” trata das noções tensas entre Estado e indivíduos. A concepção de “liberdade de si”, genuinamente negativa, ganha destaque justificatório. Jackie Scully, no verbete Bioética Feminista, exemplifica o valor da influência dessas correntes no âmago de todos os contemporâneos. Sua escrita homenageia postumamente Anne Donchin com um apanhado histórico da luta de inserção de políticas feministas na pesquisa acadêmica global. No verbete “Democracia”, os professores brasileiros Gustavo Dalaqua e Alberto Ribeiro Barros acrescentaram tópicos importantes ao tema geral, respectivamente: “Construtivismo Representativo vs. Representação Descritiva” e “Democracia Contestatória de Philip Pettit”. O texto de Thomas Christiano perpassa os principais argumentos de justificação política contra e a favor da democracia ocidental, com foco central nas concepções de liberdade e igualdade. Os verbetes dispostos nessa seleção de textos são tendenciosos na medida que expressam o interesse genuíno de cada pesquisador com os assuntos relevantes em suas pesquisas. Em virtude disso, a escolha “adota um lado” em detrimento de outros – mais especificamente: de outro que poderia ser mais “progressista”. Por si só, o livro já nasce reclamando um segundo volume, que será providenciado. Colocamos de lado qualquer exigência de “imparcialidade”, algo que não existe na Filosofia, muito menos na Filosofia Política. Sobressai, nesse aspecto, o caráter reflexivo que o assunto exige e a importância do assunto, sem o qual não teríamos a modernas concepções de representatividade, as teorias da justiça ou mesmo as ciências sociais. Um outro volume, portanto, se faz imperativo, por conta da abrangência da própria SEP e do respeito a seu projeto inicial, genuinamente um plano plural. (shrink)

In "Public Health and Precarity," Michael Doan and Ami Harbin have done important work extending Sherwin's concept of relational autonomy to encompass relational agency—including agents such as communities and states. This opens up new ways of thinking about responsibility for public health in long-standing debates about the role of the state in public health.The case studies Doan and Harbin analyze are also important for thinking of the account of relational solidarity that Sherwin developed together with Baylis and Kenny, one element (...) of relational public health. The discussion may even open the space for a reformulation of relational solidarity. I will use the... (shrink)

Modern health data practices come with many practical uncertainties. In this paper, I argue that data subjects’ trust in the institutions and organizations that control their data, and their ability to know their own moral obligations in relation to their data, are undermined by significant uncertainties regarding the what, how, and who of mass data collection and analysis. I conclude by considering how proposals for managing situations of high uncertainty might be applied to this problem. These emphasize increasing organizational flexibility, (...) knowledge, and capacity, and reducing hazard. (shrink)

Concern for human vulnerability seems to be at the heart of bioethical inquiry, but the concept of vulnerability is under-theorized in the bioethical literature. The aim of this article is to show why bioethics needs an adequately theorized and nuanced conception of vulnerability. We first review approaches to vulnerability in research ethics and public health ethics, and show that the bioethical literature associates vulnerability with risk of harm and exploitation, and limited capacity for autonomy. We identify some of the challenges (...) emerging from this literature: in particular, how to reconcile universal human vulnerability with a context-sensitive analysis of specific kinds and sources of vulnerability; and how to reconcile obligations to protect vulnerable persons with obligations to respect autonomy. We then briefly survey some of the theoretical resources available within the philosophical literature to address these challenges, and to assist in understanding the conceptual connections between vulnerability and related concepts such as harm, exploitation, needs, and autonomy. We also sketch out a taxonomy of sources and kinds of vulnerability. Finally, we consider the implications for policy evaluation of making vulnerability an explicit and central focus of bioethics. Our investigation is in the form of a broad survey motivating a research agenda rather than a detailed analysis. (shrink)

Philosophical arguments stemming from the public health ethics arena suggest that public health interventions ought to be subject to normative inquiry that considers relational values, including concepts such as solidarity, reciprocity and health equity. As yet, however, the extent to which ‘public’ values influence the ‘autonomous’ decisions of the public remains largely unexplored. Drawing on interviews with 50 men in Vancouver, Canada, this study employs a critical discourse analysis to examine participants’ decisions and motivations to voluntarily access HIV testing and/or (...) to accept a routine HIV test offer. Within a sub-set of interviews, a transactional discourse emerged in which the decision to test features an arrangement of ‘giving and receiving’. Discourses related to notions of solidarity emphasize considerations of justice and positions testing as a ‘public’ act. Lastly, ‘individualistic’ discourses focused on individual-level considerations, with less concern for the broader public ‘good’. These findings underscore how normative dimensions pertaining to men’s decisions to test are dialectically interrelated with the broader social and structural influences on individual and collective health-related behaviour, thereby suggesting a need to advance an explicit empirical-normative research agenda related to population and public health intervention research. (shrink)

While the effects of COVID-19 are being felt globally, the pandemic disproportionately affects lower- and middle-income countries (LMICs) by exacerbating existing global health disparities. In this article, we illustrate how intersecting upstream social determinants of global health form a disparity pathway that compromises LMICs’ ability to respond to the pandemic. We consider pre-existing disease burden and baseline susceptibility, limited disease prevention resources, and unequal access to basic and specialized health care, essential drugs, and clinical trials. Recognizing that ongoing and underlying (...) disparity issues will require long-term correction efforts, this pathway approach is nonetheless helpful to inform ethical responses to this global pandemic. It can facilitate international cooperation during the pandemic to reduce the disparate burdens among different regions without imposing significant burden on any particular contributor. The pathway approach allows international stakeholders in various social positions to respond to different components of the pathway based on their respective strengths and resources to help break the cycle of global health inequity. Guided by the ethical principles of relational and pragmatic solidarity, we argue for a coordinated global division of labor such that different stakeholders can collaborate to foster equitable healthcare access during this pandemic. (shrink)

This paper focuses on an emergency basic income as a tool for avoiding financial insecurity during the time of pandemic. The authors argue that paying each resident a monthly cash amount for the duration of the crisis would serve to protect them from the economic fallout.They suggest three reasons why the EBI proposal is particularly well-suited to play an important role in a comprehensive public health response to COVID-19: it offers an immediate and agile response; it prioritizes the most vulnerable (...) in the affected population; and it promotes a solidaristic response to the pandemic crisis. To go beyond the need to shut down and restart an EBI assistance scheme each time a pandemic hits, the authors propose considering turning the program into a permanent feature. (shrink)

This article challenges a key tacit assumption underpinning legal and ethical instruments in health care, namely, that people are ideally bounded, independent, and often also strategically rational individuals. Such an understanding of personhood has been criticized within feminist and other critical scholarship as being unfit to capture the deeply relational nature of human beings. In the field of medicine, however, it also causes tangible problems. I propose that a solidarity-based perspective entails a relational approach and as such helps to formulate (...) new solutions to complex ethical and regulatory questions, ranging from caring for people at the end of their lives to improving policies for organ donation and better governance of health data. It also underscores the importance of universal health care. Although a solidarity-based perspective does not require health to be seen as an individually enforceable right, it does influence our understanding of individual rights: it draws attention to how their meaning is shaped by shared social practices. I conclude by arguing that, in light of current pressures for medicine to become more personalized, using a relational understanding of personhood to shape policies and practices is a much needed endeavor. (shrink)

In this paper, I attend to a current strand in bioethics that forwards solidarity as a promising direction for bioethics theory and health-promoting practices. Drawing on resources from social and political philosophy, I argue that we can gain useful insight in bioethics if we understand solidarity as a political relation grounded not on shared social location but rather on shared visions for the sorts of worlds in which collective health and dignity proliferate. I consider what traction this conception of solidarity (...) might give for thinking about social justice issues in the context of political movements for “reproductive justice.”. (shrink)

Healthcare user fees present an important barrier for accessing services for the poorest (indigents) in Burkina Faso and selective removal of fees has been incorporated in national healthcare planning. However, establishing fair, effective and sustainable mechanisms for the removal of user fees presents important challenges. A participatory action-research project was conducted in Ouargaye, Burkina Faso, to test mechanisms for identifying those who are indigents, and funding and implementing user fee removal. In this paper, we explore stakeholder perceptions of ethical considerations (...) relating to participation and partnership arising in the action-research. (shrink)

In this article, we present an ethics framework for health practice in humanitarian and development work: the ethics of engaged presence. The ethics of engaged presence framework aims to articulate in a systematic fashion approaches and orientations that support the engagement of expatriate health care professionals in ways that align with diverse obligations and responsibilities, and promote respectful and effective action and relationships. Drawn from a range of sources, the framework provides a vocabulary and narrative structure for examining the moral (...) dimensions of providing development or humanitarian health assistance to individuals and communities, and working with and alongside local and international actors. The elements also help minimize or avoid certain miscalculations and harms. Emphasis is placed on the shared humanity of those who provide and those who receive assistance, acknowledgement of limits and risks related to the contributions of expatriate health care professionals, and the importance of providing skillful and relevant assistance. These elements articulate a moral posture for expatriate health care professionals that contributes to orienting the practice of clinicians in ways that reflect respect, humility, and solidarity. Health care professionals whose understanding and actions are consistent with the ethics of engaged presence will be oriented toward introspection and reflective practice and toward developing, sustaining and promoting collaborative partnerships. (shrink)

In this paper, we explore the role of reciprocity in the employment of restrictive measures in contexts of contagion. Reciprocity should be understood as a substantive value that governs the use, level and extent of restrictive measures. We also argue that independent of the role reciprocity plays in the legitimisation the use of restrictive measures, reciprocity can also motivate support and compliance with legitimate restrictive measures. The importance of reciprocity has implications for how restrictive measures should be undertaken when preparing (...) and evaluating public health responses to contagion. (shrink)

Contemporary critical approaches to bioethics increasingly present themselves as “relational,” though the meaning of relationality and its implications for bioethics seem to be many and varying. I argue that this confusion is due to a multiplicity of relational approaches originating from distinct theoretical lineages. In this article, I identify four key differences among commonly referenced relational approaches: the scope and nature of relationships considered, the extent of the determining influence on individual selfhood, and the integrity of individual selfhood. Importantly, these (...) four differences carry consequences for the usage of relational approaches within academic and clinical bioethics. I show that these differences attach to multiple objects of critique within mainstream bioethics and imply distinct metaethical commitments. Although I issue a cautionary note about combining relational approaches from distinct lineages, I close by suggesting that many such approaches may have their use, drawing on Susan Sherwin's sense of bioethical theories as lenses. (shrink)

Developed in the past two decades, the clustered regularly interspaced short palindromic repeats‐associated protein 9 (CRISPR‐Cas9) technique offers greater accessibility and efficiency in editing genes. Its immediate success has transformed medical research and treatment in productive ways, but has also left questions about ethical consequences in its wake. These are questions familiar to bioethical inquiry. How do we balance short‐term and long‐term benefits and risks? How do we promote just and equitable access to new medical interventions? How do we protect (...) respect for individual autonomy? These questions require a balance between protecting individuals' liberties and the good of the communities in which they live. In this essay, I am interested in how the principle of respect for autonomy can be interpreted in light of CRISPR‐Cas9. I argue that a relational autonomy framework forges a middle ground between the need to respect individual freedom to pursue genetic treatments and the need to acknowledge the networks of dependence that define our moral worlds. I identify three thematic areas that relational autonomy brings into greater focus: the importance of trust, the acknowledgment of vulnerability/dependence, and the promotion of justice. Autonomy understood relationally allows us to see individual freedom as tethered to communal well‐being. (shrink)

Health has been a focal point in sustainable development policies. Seventeen new goals of sustainable development contribute directly or indirectly to people’s health. Particular emphasis should be laid on health, along with saving lives of poor people. This can be done by effectively creating healthier society for individuals around the world. Sustainable development goals perceive significance value—that is to concentrate on the needs of hindered groups, children, women, and the poorest of poor to attain sustainable development of human ambitions and (...) to confirm a healthier life for all. This paper analyses the issues of public health and sustainable development from an ethical point of view. As ethics deals with what is good or bad, right or wrong, the paper examines the normative aspects of sustainable development with respect to public health. (shrink)

Background The world is threatened by future pandemics. Vaccines can play a key role in preventing harm, but there will inevitably be shortages because there is no possibility of advance stockpiling. We therefore need some method of prioritising access. Main text This paper reports a critical interpretative review of the published literature that discusses ethical arguments used to justify how we could prioritise vaccine during an influenza pandemic. We found that the focus of the literature was often on proposing different (...) groups as priorities. Different reasons were often suggested as a means of justifying such priority groupings. We suggest that much of the literature, wrongly, assumes that we are able to plan priority groups prior to the time of a particular pandemic and development of a particular vaccine. We also point out the surprising absence of various issues from the literature. Conclusions The literature proposes a wide range of ways to prioritise vaccines, focusing on different groups and ‘principles’. Any plan to use pandemic vaccine must provide justifications for its prioritisation. The focus of this review was influenza pandemic vaccines, but lessons can be learnt for future allocations of coronavirus vaccine, if one becomes available. (shrink)

Vaccine hesitancy is a growing threat to public health. The reasons are complex but linked inextricably to a lack of trust in vaccines, expertise and traditional sources of authority. Efforts to increase immunization uptake in children in many countries that have seen a fall in vaccination rates are two-fold: addressing hesitancy by improving healthcare professional-parent exchange and information provision in the clinic; and, secondly, public health strategies that can override parental concerns and values with coercive measures such as mandatory and (...) presumptive vaccination. It is argued that such conflicting, parallel approaches seriously risk undermining trust that is crucial for sustaining herd immunity. Although public health strategies can be ethically justified in limiting freedoms, a parent-centered approach seldom acknowledges how it is impacted by contemporaneous coercive measures. In addition, the clinical encounter is not well suited to helping parents consider the public dimensions of vaccination, despite these being important for trust formation and informed decision-making. Efforts to address vaccine hesitancy require more consistent engagement of parental and citizen views. Along with evidence-based information, debates need to be informed by ethical support that equips parents and professionals to respond to the private and public dimensions of vaccination in a more even-handed, transparent manner. Efforts to address vaccine hesitancy need to avoid simple reliance on either parental values or coercive public policies. To do this effectively requires increasing citizen engagement on vaccination to help inform a parent-centered approach and legitimize public policy measures. In addition, cultivating a more ethically consistent strategy means moving beyond the current silos of health ethics - clinical and public health ethics. (shrink)

Newborn screening involves the collection of blood from the heel of a newborn baby and testing it for a list of rare and inheritable disorders. New biochemical screening technologies led to expansions of NBS programs in the first decade of the 21st century. It is expected that they will in time be replaced by genetic sequencing technologies. These developments have raised a lot of ethical debate. We reviewed the ethical literature on NBS, analyzed the issues and values that emerged, and (...) paid particular interest to the type of impacts authors think NBS should have on the lives of children and their families. Our review shows that most authors keep their ethical reflection confined to policy decisions, about for instance the purpose of the program, and its voluntary or mandatory nature. While some authors show appreciation of how NBS information empowers parents to care for their children, most authors consider these aspects to be ‘private’ and leave their evaluation up to parents themselves. While this division of moral labor fits with the liberal conviction to leave individuals free to decide how they want to live their private lives, it also silences the ethical debate about these issues. Given the present and future capacity of NBS to offer an abundance of health-related information, we argue that there is good reason to develop a more substantive perspective to whether and how NBS can contribute to parents’ good care for children. (shrink)

Given the evolution of the public health (PH) and the changes from the phenomenon of globalization, this area has encountered new ethical challenges. In order to find a coherent approach to address ethical issues in PH policy, this study aimed to identify the evolution of public health ethics (PHE) frameworks and the main moral values and norms in PH practice and policy. According to the research questions, a systematic search of the literature, in English, with no time limit was performed (...) using the main keywords in databases Web of Science (ISI) and PubMed. Finally, the full text of 56 papers was analyzed. Most of the frameworks have common underpinning assumptions and beliefs, and the need to balance PH moral obligation to prevent harm and health promotion with respect for individual autonomy has been specified. As such, a clear shift from liberal values in biomedical ethics is seen toward the community’s collective values in PHE. The main moral norms in PH practice and policy included protecting the population against harm and improving PH benefits, utility and evidenced-based effectiveness, distributive justice and fairness, respect for all, privacy and confidentiality, solidarity, social responsibility, community empowerment and participation, transparency, accountability and trust. Systematic review of PHE frameworks indicates utilization of the aforementioned moral norms through an practical framework as an ethical guide for action in the PH policy. The validity of this process requires a systematic approach including procedural conditions. (shrink)

The dominant, individualistic understanding of autonomy that features in clinical practice and research is underpinned by the idea that people are, in their ideal form, independent, self-interested and rational gain-maximising decision-makers. In recent decades, this paradigm has been challenged from various disciplinary and intellectual directions. Proponents of ‘relational autonomy’ in particular have argued that people’s identities, needs, interests – and indeed autonomy – are always also shaped by their relations to others. Yet, despite the pronounced and nuanced critique directed at (...) an individualistic understanding of autonomy, this critique has had very little effect on ethical and legal instruments in clinical practice and research so far. In this article, we use four case studies to explore to what extent, if at all, relational autonomy can provide solutions to ethical and practical problems in clinical practice and research. We conclude that certain forms of relational autonomy can have a tangibl... (shrink)

In this article, we present an ethics framework for health practice in humanitarian and development work: the ethics of engaged presence. The ethics of engaged presence framework aims to articulate in a systematic fashion approaches and orientations that support the engagement of expatriate health care professionals in ways that align with diverse obligations and responsibilities, and promote respectful and effective action and relationships. Drawn from a range of sources, the framework provides a vocabulary and narrative structure for examining the moral (...) dimensions of providing development or humanitarian health assistance to individuals and communities, and working with and alongside local and international actors. The elements also help minimize or avoid certain miscalculations and harms. Emphasis is placed on the shared humanity of those who provide and those who receive assistance, acknowledgement of limits and risks related to the contributions of expatriate health care professionals, and the importance of providing skillful and relevant assistance. These elements articulate a moral posture for expatriate health care professionals that contributes to orienting the practice of clinicians in ways that reflect respect, humility, and solidarity. Health care professionals whose understanding and actions are consistent with the ethics of engaged presence will be oriented toward introspection and reflective practice and toward developing, sustaining and promoting collaborative partnerships. (shrink)

This article reflects on the work of feminist bioethicists over the past ten years, reviewing how effective feminists have been in using relational theory to reorient bioethics and where we hope it will go from here. Feminist bioethicists have made significant achievements using relational theory to shape the notion of autonomy, bringing to light the relevance of patients' social circumstances and where they are situated within systems of privilege and oppression. But there is much work to be done to reorient (...) bioethics so that it is capable of addressing some current public health challenges. We argue that relational theory holds promise for beginning this work. (shrink)

Transnational reproductive travel is symptomatic of insufficient supplies of reproductive resources, including donor gametes and gestational surrogacy services, and inequities in access to these within domestic health-care jurisdictions. Here, we argue that an innovative approach to domestic policy making using the framework of the National Self-Sufficiency paradigm represents the best solution to domestic challenges and the ethical hazards of the global marketplace in reproductive resources.

BackgroundPregnant people have been overlooked or excluded from clinical research, resulting in a lack of scientific knowledge on medication safety and efficacy during pregnancy. Thus far, both the opportunities to generate evidence-based knowledge beyond clinical trials and the role of pregnant people in changing their status quo have not been discussed. Some scholars have argued that for rare disease patients, for whom, just like pregnant people, a poor evidence base exists regarding treatments, solidarity has played an important role in addressing (...) the evidence gap. This paper explores whether and how the enactment of solidarity among pregnant people can be stimulated to help address the poor evidence base on medications used during pregnancy.MethodWe use the concept of solidarity formulated by Prainsack and Buyx and enrich their concept by providing an account for stimulating the enactment of solidarity. Then we apply this account to the case of pregnant people who use medication.ResultsSolidarity means enacted commitment on the part of an individual to assisting others with whom the person recognizes a similarity in a relevant respect. Although solidarity cannot be imposed, we argue that the empowerment of people is a crucial concept in understanding how solidarity can be stimulated. Empowerment in the context of pregnant people means creating awareness about their status quo, explaining how scientific research can help close the knowledge gap, and how pregnant people can themselves contribute. In particular, how pregnant people can contribute to the collection of health data to strengthen the evidence base for medications used during pregnancy.ConclusionsWe conclude that acting in solidarity can help change the status quo for pregnant people. Furthermore, we argue that the empowerment of pregnant people and other relevant stakeholders is a way to stimulate the enactment of solidarity. The process of empowerment starts by raising awareness about the lack of evidence on medications used during prengnacy and by explaining to pregnant people how they can contribute to changing the way knowledge is being generated by, for example, sharing data on the health effects of medications. (shrink)