Philosophy of epidemiology has recently emerged as a distinct branch of philosophy. The field will surely benefit from pluralism, reflected in the broad range of topics and perspectives in this special issue. Here, I argue that a healthy pluralistic field of philosophy of epidemiology has social responsibilities that require the field as a whole to engage actively with research on social determinants of health and health disparities. Practicing epidemiologists and the broader community of public health scientists have gradually acknowledged that (...) much of their attention ought to be paid to these, i.e. inequitable between-population health variations that largely reflect the world’s inequitable distribution of resources and social conditions. The paper illustrates how and why health disparities and social determinants of health, through no ill will, become de facto secondary concerns in Alex Broadbent’s field-defining Philosophy of Epidemiology, showing the ease with which these topics can be incidentally sidelined. As means for philosophy of epidemiology to meet its social responsibility obligations, I suggest philosophy of epidemiology expand its attention to two particular lines research. First, the paper discusses Geoffrey Rose’s concept of “causes of incidence”—causes of disparities between populations—and argues for the importance of engaging with these causes. Second, the paper argues for the value of engaging with Bruce Link and Jo Phelan’s “fundamental causes” model of how flexible social resources serve as buffers from harms, generating a plethora of shifting and locally-contingent health effects. (shrink)

Public deliberation about health policy in the United States often hinges on two untenable basic assumptions about political legitimacy. The first assumption, common in public debate throughout the United States, is that federal oversight of health care is justified under a federal compact binding all citizens. This assumption is false because the federal compact precludes such oversight. Indeed, the ascendancy of national government (and demise of federalism) over the past 70 years was engineered through the subversion of the federal compact, (...) creating an expansive legitimation gap. The second assumption—that political legitimacy can be established through appeals to expert consensus about fundamental conceptions of justice or human rights—is prevalent among bioethicists. I argue that this assumption is illicit because it hinges on a weak, rationalistic form of majoritarian democracy that conflates public acquiescence with public approval. If the public mission of academic bioethics involves protecting the integrity of public deliberation, then these two basic assumptions should be challenged. (shrink)

The “Father of the United States Constitution,” James Madison, once described justice as “the end” of both government and of civil society. Yet curiously, Madison said little about justice in elaborating the principles of American federalism in The Federalist Papers and elsewhere. His fundamental concerns, to the contrary, were in contriving a system of separated, countervailing powers and in establishing a first federal principle of enumerated powers — in which federal powers “are few, and defined.” This strategy, for Madison, was (...) the most feasible way of checking the innate tendency of political power to accumulate, centralize, and trample on citizens’ liberties. (shrink)

That liberalism requires governments to be agnostic to at least some deeply-held commitments of their citizens is uncontroversial. Much less agreed-upon is why....

In this article, I propose a novel characterization of sufficientarianism. I argue that sufficientarianism combines three claims: a priority claim that we have non-instrumental reasons to prioritize benefits in certain ranges over benefits in other ranges; a continuum claim that at least two of those ranges are on one continuum; and a deficiency claim that the lower a range on a continuum, the more priority benefits in that range have. This characterization of sufficientarianism sheds new light on two long-standing philosophical (...) debates, namely about the distinctiveness of sufficientarianism as a distributive principle and about the common objections to sufficientarianism. (shrink)

We live in an era where our health is linked to that of others across the globe, and nothing brings this home better than the specter of a pandemic. This paper explores the findings of town hall meetings associated with the Canadian Program of Research on Ethics in a Pandemic , in which focus groups met to discuss issues related to the global governance of an influenza pandemic. Two competing discourses were found to be at work: the first was based (...) upon an economic rationality and the second upon a humanitarian rationality. The implications for public support and the long-term sustainability of new global norms, networks, and regulations in global public health are discussed. (shrink)

This paper considers the morally relevant ways in which population-based research is a distinct type of human subjects research that have unique moral considerations relevant for public health practitioners and researchers. By defining population-based research, the authors distinguish it from public health practice and then consider, in more detail, the ways in which population-based research differs from clinical human subjects research. Based upon the distinctions between these types of research and practice, they identify five important issues that arise in the (...) design and conduct of certain kinds of population-based research. The authors hope that public health practitioners find these distinctions useful in determining when their work may actually be population-based research and that public health researchers use them to identify the areas where ethical issues in their research may arise. (shrink)

Multiple scholars and institutions have asked what distinguishes public health research from public health practice. Most often, they ask in order to have a clear definition of what one does in various public health settings to assess oversight and/or regulation of human subjects research. More importantly, however, whether something is considered public health research or public health practice has real ethical implications in terms of the general moral considerations at stake and the obligations of public health researchers/practitioners to the populations (...) they serve or study.Numerous examples in recent history of research ethics, including the Kennedy Krieger Lead Abatement Study and EPA’s Children’s Environmental Exposure Research Study, suggest that an exploration of the ethics of public health, or more generally population-based research, may be warranted. Although we acknowledge that there are important ethical issues to consider in the implementation of public health practice, we leave that discussion for other authors. (shrink)

Courts are increasingly obliged to adjudicate upon challenges to allocative decisions in healthcare, but their involvement continues to be regarded with unease, imperilling the legitimacy of the judicial role in this context. A central reason for this is that judges are perceived to lack sufficient expertise to determine allocative questions. This article critically appraises the claim of lack of judicial expertise through an examination of the various components of a limit-setting decision. It is argued that the inexpertise argument is weak (...) when compared with other rationales for judicial restraint, such as the procedural unsuitability and lack of constitutional competence of courts. (shrink)

In this paper, I argue that disabled people have a right to assistive technology, but this right cannot be grounded simply in a broader right to health care or in a more comprehensive view like the capabilities approach to justice. Both of these options are plagued by issues that I refer to as the problem of constriction, where the theory does not justify enough of the AT that disabled people should have access to, and the problem of overextension, where the (...) theory cannot adequately identify an upper limit on the AT that people have a right to. As an alternative to these justificatory frameworks, I argue that disabled people are owed access to AT at the expense of nondisabled people as a matter of compensatory justice. That is, I defend the position that disabled people are owed AT as part of due compensation for the harms they experience from being disadvantaged by society’s dominant cooperative scheme and the violation of their right to equality of opportunity that such disadvantage entails. I also propose a method for identifying an upper limit to what this right to AT requires. In this way, I argue that compensatory justice avoids both the problem of constriction and the problem of overextension. (shrink)

The predominant influences on health are social or upstream factors. Poverty, inadequate education, insecure and toxic environments, and inferior opportunities for jobs and positions are inequitable disadvantages that adversely affect health across the globe. Many causal pathways are yet to be understood. However, elimination of these social inequalities is a moral imperative of the first order. Some physicians by word and deed argue that medical doctors should oppose the “structural violence” of social inequalities that greatly shorten lives and wreak so (...) much suffering. (shrink)

Sweatshop labor is often cited as an example of the worst and most pervasive form of exploitation today, yet understanding what is meant by the charge has proven surprisingly difficult for philosophers. I develop an account of what I call “Needs Exploitation,” grounded in a specification of the duty of beneficence. In the case of sweatshop labor, I argue that employers face a duty to extend to employees a wage sufficient to meet their basic needs. This duty is limited by (...) the degree of the employees’ dependence on the employer for basic needs and a reasonability standard where the employer may remain within a range of well-being between deficiency and luxury. (shrink)

Health equity is increasingly identified as a principal goal to be achieved through public health policies and activities. However, what is to be measured in the assessment of health equity and how inequities in health ought to be redressed are among the pressing questions that must be answered if health equity is to serve as a meaningful and consistent ethical guide for measurement and intervention in public health. In this article I argue that the concept of health equity, in the (...) form it is predominantly found in public health, suffers from normative indeterminacy and is therefore unlikely to provide actionable normative guidance to public health policy-makers, practitioners and researchers. I argue that the concept of health equity, as it is commonly defined in public health, ultimately rests upon assumptions of a more fundamental, yet tacit, conception of justice to do its normative work. In this vein, I expand upon a critique of Margaret Whitehead’s oft-cited definition of health equity made by James Wilson to raise additional reasons not explored by Wilson, or others, as to why Whitehead’s definition remains inadequate in providing normative guidance to policy-makers, practitioners and researchers in public health. (shrink)

In this paper, I want to scrutinise the value of utilising the concept of disease for a theory of distributive justice in health care. Although many people believe that the presence of a disease-related condition is a prerequisite of a justified claim on health care resources, the impact of the philosophical debate on the concept of disease is still relatively minor. This is surprising, because how we conceive of disease determines the amount of justified claims on health care resources. Therefore, (...) the severity of scarcity depends on our interpretation of the concept of disease. I want to defend a specific combination of a theory of disease with a theory of distributive justice. A naturalist account of disease, together with sufficientarianism, is able to perform a gate-keeping function regarding entitlements to medical treatment. Although this combination cannot solve all problems of justice in health care, it may inform rationing decisions as well. (shrink)

In her target article “Shared health governance” (AJOB 11(7): 32-45, 2011) and in her book Health and Social Justice (2009), Jennifer Prah Ruger defends an original model of governance dubbed “Shared Health Governance” (SHG). This model borrows elements from many other models of governance, and one may wonder what is the secret sauce that holds together these diverse ingredients. In response, Ruger would perhaps ultimately turn to public moral norms. My comment raises some concerns about the function and content of (...) these norms in her model and their connection to her claims about shared sovereignty within SHG. (shrink)

Surveillance plays a crucial role in public health, and for obvious reasons conflicts with individual privacy. This paper argues that the predominant approach to the conflict is problematic, and then offers an alternative. It outlines a Basic Interests Approach to public health measures, and the Unreasonable Exercise Argument, which sets forth conditions under which individuals may justifiably exercise individual privacy claims that conflict with public health goals. The view articulated is compatible with a broad range conceptions of the value of (...) health. (shrink)

Virtue ethics has a rich history; yet, its application in health ethics has been minimal compared to other major ethical frameworks. Even more, its application to health policy and population-level questions has been almost nonexistent. A new concept in moral theology, structures of virtue, provides impetus for ethicists to consider how virtue ethics can be a valuable addition to existing frameworks in public health ethics. This article offers a basic overview of virtue ethics and its value for analysis of social (...) structures in public health. It does so by explaining how virtue can be seen not only in the process of public health—the promotion of habituated behavior—but also in the content of public health—values such as temperance, fortitude and prudence. It concludes with two extended applications of virtue ethics: vaccination policy and healthy eating. (shrink)

Recent efforts by legislative officials and public health advocates to reform the US food stamp program, or Supplemental Nutrition Assistance Program, have focused on restricting the types of foods eligible for purchase with SNAP benefits, specifically sugar-sweetened beverages. We argue that it is, in principle, permissible for the US government to enact a SNAP-specific SSB ban prohibiting the purchase of SSBs with SNAP benefits. While the government has a duty to ensure that citizens meet their nutritional needs, since SSBs provide (...) negligible nutrition, it has no obligation to subsidize them. Additionally, there is good reason to think that a SNAP-specific SSB ban would enable the government to better fulfill two other duties—improving citizens’ health and providing public services like Medicaid and Medicare in a more cost-effective manner. Still, because the costs and benefits of such a ban remain uncertain, we argue that the government should conduct well-designed pilot projects to help determine the effects of an SSB ban. (shrink)

Various U.S. laws, such as the Clean Air Act and the Food Quality Protection Act, require additional protections for susceptible subpopulations who face greater environmental health risks. The main ethical rationale for providing these protections is to ensure that environmental health risks are distributed fairly. In this article, we (1) consider how several influential theories of justice deal with issues related to the distribution of environmental health risks; (2) show that these theories often fail to provide specific guidance concerning policy (...) choices; and (3) argue that an approach to public decision making known as accountability for reasonableness can complement theories of justice in establishing acceptable environmental health risks for the general population and susceptible subpopulations. Since accountability for reasonableness focuses on the fairness of the decision-making process, not the outcome, it does not guarantee that susceptible subpopulations will receive a maximum level of protection, regardless of costs or other morally relevant considerations. (shrink)

Soziale Faktoren haben einen starken Einfluss auf die Gesundheit und Lebenserwartung. Auch in Wohlfahrtsstaaten bestehen signifikante gesundheitliche Ungleichheiten zwischen besser und schlechter gestellten Bevölkerungsgruppen. Sie werden zunehmend als ein Problem der sozialen Gerechtigkeit wahrgenommen. Public Health dient dem Abbau gesundheitlicher Ungleichheiten und somit der Förderung der sozialen Gerechtigkeit. Obwohl Public Health-Maßnahmen effizienter zur Förderung und Angleichung der Bevölkerungsgesundheit beitragen können als viele medizinische Versorgungen, erhalten sie einen geringeren gesundheitspolitischen Stellenwert. Diese Prioritätensetzung zu Gunsten der Medizin kann als irrational kritisiert werden. (...) Allerdings ist zu beachten, dass die medizinische Versorgung eine hohe symbolische Bedeutung für die Fürsorge und soziale Anerkennung hat, die bei Public Health nicht in gleichem Maße gegeben ist. Gesundheitliche Ungleichheiten sind nicht per se sozial ungerecht, sondern dann, wenn sie auf einer ungerechten Verteilung sozialer Gesundheitsfaktoren beruhen. Diese Faktoren wie z. B. Einkommen und Bildung haben auch unabhängig von ihren gesundheitlichen Auswirkungen eine Bedeutung für die soziale Gerechtigkeit. Daher kann die Gesundheitsgerechtigkeit nicht isoliert, sondern nur im Kontext einer umfassenden Theorie der sozialen Gerechtigkeit bestimmt werden. (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)

Social justice has been identified as a foundational moral commitment for global health research ethics. Yet what a commitment to social justice means for community engagement in such research has not been critically examined. This paper draws on the rich social justice literature from political philosophy to explore the normative question: What should the ethical goals of community engagement be if it is to help connect global health research to social justice? Five ethical goals for community engagement are proposed that (...) promote well-being, agency, and self-development, particularly for those considered disadvantaged and marginalized. The paper also considers how key terms used in the proposed goals should be defined using existing theories of health and social justice. This analysis is done to give global health researchers and their partners a better idea of what the ethical goals mean. Patterns of convergence amongst different theories are identified that support relying on particular definitions of key terms. (shrink)

The COVID-19 pandemic is a global contagion of unprecedented proportions and health, economic, and social consequences. As with many health problems, its impact is uneven. This article argues the C...

Universal health coverage is often implemented within countries through several national insurance schemes that collectively cover their populations. Yet the extent of services and benefits available can vary substantially between different schemes. This paper argues that these variations in coverage comprise tiering and then reviews different accounts of health and social justice that consider whether and when a tiered health system is fair. Using these accounts, it shows that the fairness of tiering can be determined by assessing whether differences in (...) coverage mean enrolees under some national insurance schemes do not achieve sufficient health or normal functioning and/or feel inferior relative to those belonging to other national insurance schemes. The paper further contends that these determinations of fairness should involve the people covered by different insurance schemes. Key universal health coverage questions to involve the public in answering are: Do the sum of differences between the schemes in your country generate feelings of unequal moral worth and/or mean enrolees struggle to achieve sufficient health or normal functioning? Which specific differences between health insurance schemes generate the greatest feelings of unequal moral worth in individuals? Which specific differences generate the greatest barriers to individuals achieving sufficient health or normal functioning? Rather than identifying which services to extend coverage to first, answering these questions will identify which disparities in services and benefits are the most morally urgent to address. Finally, some initial thoughts are offered on who from the public should be involved in making these decisions and how they might be involved as a matter of justice. (shrink)

Global health research partnerships are increasingly taking the form of consortia of institutions from high-income countries and low- and middle-income countries that undertake programs of research. These partnerships differ from collaborations that carry out single projects in the multiplicity of their goals, scope of their activities, and nature of their management. Although such consortia typically aim to reduce health disparities between and within countries, what is required for them to do so has not been clearly defined. This article takes a (...) conceptual approach to explore how the governance of transnational global health research consortia should be structured to advance health equity. To do so, it applies an account called shared health governance to derive procedural and substantive guidance. A checklist based on this guidance is proposed to assist research consortia determine where their governance practices strongly promote equity and where they may fall short. (shrink)

Thus far, little work in bioethics has specifically focused on global health research priority-setting. Yet features of global health research priority-setting raise ethical considerations and concerns related to health justice. For example, such processes are often exclusively disease-driven, meaning they rely heavily on burden of disease considerations. They, therefore, tend to undervalue non-biomedical research topics, which have been identified as essential to helping reduce health disparities. In recognition of these ethical concerns and the limited scholarship and dialogue addressing them, we (...) convened an international workshop in September 2015. The workshop aimed to initiate discussion on the appropriate relationship between global and national levels of health research priority-setting and to begin exploring what might be ethically required for priority-setting at each of those levels. This paper comprises our reflections following the workshop. Its main objective is to launch a research agenda for the ethics of global health research priority-setting. We identify three domains of global health research priority-setting—scope, underlying values and substantive requirements, and procedural considerations. For each domain, specific research questions are highlighted and why they need to be explored is explained. Some preliminary thoughts and normative arguments as to how the research questions might be answered are also offered. For example, we provide initial ideas about the appropriate relationship between different priority-setting levels and what values and substantive considerations should guide or underpin global health research priority-setting as a matter of justice. We anticipate that framing a new research agenda for the ethics of global health research priority-setting will spur ethicists, researchers, and policymakers to refocus their efforts on developing more rigorous and ethically sound approaches to priority-setting. (shrink)

In this article, we address the relevance of J.S. Mill’s political philosophy for a framework of public health ethics. In contrast to some readings of Mill, we reject the view that in the formulation of public policies liberties of all kinds enjoy an equal presumption in their favor. We argue that Mill also rejects this view and discuss the distinction that Mill makes between three kinds of liberty interests: interests that are immune from state interference; interests that enjoy a presumption (...) in favor of liberty; and interests that enjoy no such presumption. We argue that what is of focal importance for Mill in protecting liberty is captured by the essential role that the value of self-determination plays in human well-being. Finally, we make the case for the plausibility of a more complex and nuanced Millian framework for public health ethics that would modify how the balancing of some liberty and public health interests should proceed by taking the thumb off the liberty end of the scale. Mill’s arguments and the legacy of liberalism support certain forms of state interference with marketplace liberties for the sake of public health objectives without any presumption in favor of liberty. (shrink)

The main aim of this paper is to investigate the views of healthcare professionals in Portugal about healthcare rationing, and compare them with the views of college students. A self-administered questionnaire was used to collect data from a sample of 60 healthcare professionals and 180 college students. Respondents faced a hypothetical rationing dilemma where they had to order four patients and justify their choices. Multinomial logistic regressions were used to test for differences in orderings, and content analysis to categorize the (...) written justifications. The findings suggest that both groups appeared to support three main rationing principles: health maximization, priority to the severely ill and priority to the young. However, professionals seemed to give less weight to the latter principle. In conclusion, professionals have similar views to students about healthcare rationing, though may be slightly less inclined to give priority to the young. (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)

When it comes to improving the health of the general population, mHealth technologies with self-monitoring and intervention components hold a lot of promise. We argue, however, that due to various factors such as access, targeting, personal resources or incentives, self-monitoring applications run the risk of increasing health inequalities, thereby creating a problem of social justice. We review empirical evidence for “intervention-generated” inequalities, present arguments that self-monitoring applications are still morally acceptable, and develop approaches to avoid the promotion of health inequalities (...) through self-monitoring applications. (shrink)

In modern representative democracies, much healthcare is publicly funded or provided and so the question of what healthcare systems should do is a matter of public policy. Given that public resources are inevitably limited, what should be done and who should benefit from healthcare? It is a dilemma for policymakers and a subject of debate within several disciplines, but rarely across disciplines. In this paper, I draw on thinking from several disciplines and especially philosophy, economics, and systems theory. I conclude (...) that economist and philosopher John Broome’s writing provides the framework for an answer: a healthcare system in a democracy should do as much good as possible, although sometimes we should sacrifice some overall good for the sake of fairness. This leaves open some detailed questions about what in practice we consider to be good and fair, and about when some good should be traded off in order to be fair. The answers to these questions depend on our values, or as explained by systems theory, our weltanschauung. How policy decisions should be made when citizens’ values differ is a subject of extensive academic debate. However, it is a separate question. Representative democracies have mechanisms for resolving such debates. (shrink)

This article presents a critique of the health promotion policy of Japan, which is based on an examination of the social importance of and justification for health promotion. This is done to suggest the proper direction that the future Japanese policy could take, and to question the adequacy of the term of ‘health promotion’. We find the ‘social progress’ characterization of the ‘Second Term of National Health Promotion Movement in the Twenty-First Century - Health Japan 21 ’ to be problematic. (...) While there are clear restraints found in terms of social costs related to the policy, the aims toward social justice provided by the policy are not clear. Considering the social importance and justification of health promotion, and the present conditions seen in Japan, we believe that it is necessary clearly to position health promotion as a form of social justice. Having said this, the term ‘health promotion’ is in itself misleading and can belie the range of activities required to action these policies. Therefore, we propose considering the selection of a different and more appropriate term for health promotion that concretely defines policies that actively work toward definitive health equity. (shrink)

Systems thinking has emerged as a means of conceptualizing and addressing complex public health problems, thereby challenging more commonplace understanding of problems and corresponding solutions as straightforward explanations of cause and effect. Systems thinking tries to address the complexity of problems through qualitative and quantitative modeling based on a variety of systems theories, each with their own assumptions and, more importantly, implicit and unexamined values. To date, however, there has been little engagement between systems scientists and those working in bioethics (...) and public health ethics. The goal of this paper is to begin to consider what it might mean to combine systems thinking with public health ethics to solve public health challenges. We argue that there is a role for ethics in systems thinking in public health as a means of elucidating implicit assumptions and facilitating ethics debate and dialogue with key stakeholders. (shrink)

In this paper, I ask what is wrong with sufficiency. I formulate a generic sufficiency principle in relation to which I discuss possible problems for sufficientarianism. I argue against the arbitrariness–concern, that sufficiency theory need only to identify a possible space for determining a plausible threshold, and I argue against the high–low threshold dilemma concern, that multiple-threshold views can solve this dilemma. I then distinguish between currency-pluralist and currency-monist multiple-threshold views and test them against two different versions of the widely (...) shared ‘ignorance of inequality objection’ to sufficientarianism—a benefit-driven and a burden-driven version. I argue that currency-pluralist sufficiency views are better capable of responding to the former than currency-monist views. However, I show that no existing sufficiency view can provide a plausible response to the burden-driven version. Hence, I conclude that the problem of unequal distribution of burdens above the thresholds represents an overlooked threat to the sufficiency view, in any version. (shrink)

Public reason demands that policies are justified to all reasonable citizens. Public health aims at protecting or improving aggregated health outcomes. Since health is not an uncontroversial value, an insurmountable chasm between public reason and public health seems to preclude any viable synthesis between the two outlooks. For any given public health policy, some reasonable citizen seems to have a reason to support ‘no policy’ over ‘some policy’, meaning that the policy cannot be justified to all. The paper first spells (...) out what exactly this conflict is about. Then, using smoking as a case, the paper outlines a model of reconciliation between public reason and public health that should give us some optimism if we want to have public health policies that are compatible with treating citizens as free and equal in the public reason sense. (shrink)

Watson begins with two questions: “Should the need for abortion care be considered a health disparity? and, “If yes, would framing it this way increase the ability of poor women and women of color...

We sought to assess formally the extent to which different control and elimination strategies for human African trypanosomiasis Trypanosoma brucei gambiense would exacerbate or alleviate experiences of societal disadvantage that traditional economic evaluation does not take into account. Justice-enhanced cost-effectiveness analysis is a normative approach under development to address social justice considerations in public health decision-making alongside other types of analyses. It aims to assess how public health interventions under analysis in comparative evaluation would be expected to influence the clustering (...) of disadvantage across three core dimensions of well-being: agency, association and respect. As a case study to test the approach, we applied it to five strategies for Gambiense HAT control and elimination, in combination with two different other evaluations: a cost-effectiveness analysis and a probability of elimination analysis. We have demonstrated how JE-CEA highlights the ethical importance of adverse social justice impacts of otherwise attractive options and how it indicates specific modifications to policy options to mitigate such impacts. JE-CEA holds promise as an approach to help decision makers and other stakeholders consider social justice more fully, explicitly and systematically in evaluating public health programs. (shrink)

Several feminist philosophers of science have argued that social and political values are compatible with, and may even enhance, scientific objectivity. A variety of normative recommendations have emerged regarding how to identify, manage, and critically evaluate social values in science. In particular, several feminist theorists have argued that scientific communities ought to: 1) include researchers with diverse experiences, interests, and values, with equal opportunity and authority to scrutinize research; 2) investigate or "study up" scientific phenomena from the perspectives, interests, and (...) conditions of marginalized stakeholders potentially affected by the research; and 3) make gender, ethnicity, class, and geographical location "visible," or use them as categories of analysis when appropriate. Yet, more work is needed to determine what exactly these recommendations would require, and the benefits they would yield, in specific research contexts. Using the recent development of the human papillomavirus (HPV) vaccines, we examine how these three feminist recommendations would have applied. We argue that these principles would have yielded several epistemic and social benefits in the HPV case, as well as in biomedical research more generally. That is, biomedical research guided by these principles would not only be epistemically superior, but also more socially responsible. (shrink)

Many publicly-funded health systems apply cost-benefit frameworks in response to the moral dilemma of how best to allocate scarce healthcare resources. However, implementation of recommendations based on costs and benefit calculations and subsequent challenges have led to ‘special cases’ with certain types of health benefits considered more valuable than others. Recent debate and research has focused on the relative value of life extensions for people with terminal illnesses. This research investigates societal perspectives in relation to this issue, in the UK.

Steven Soderbergh’s Contagion positions the vaccine as the end point of the arc of ​pandemic, marking both the containment of an elusive virus and ​the resumption of a life not fundamentally different from ​before the disease outbreak. ​The film reinforces the ​assumption that a pandemic will awaken ​all of us to the urgency of vaccination​, persuading us to put aside our reservations and anxieties ​and the idea that compliance is the inevitable outcome of quarantine. This article explores how pro-vaccination cultural (...) products ​such as Contagion might in fact undermine public health efforts by promoting a false narrative, which simplifies the kind of vaccination campaign necessary for herd immunity to develop. An ethic of sacrifice and selflessness drives the public health messaging of the film but leaves intact certain individualistic tropes and plague narrative scapegoating tendencies, while the framing of the vaccine as “gift” takes it out of the realm of medical science altogether. (shrink)

There have been calls for some time for a new approach to public health in the United Kingdom and beyond. This is consequent on the recognition and acceptance that health problems often have a complex and multi-faceted aetiology. At the same time, policies which utilise insights from research in behavioural economics and psychology have gained prominence on the political agenda. The relationship between the social determinants of health and behavioural science in health policy has not hitherto been explored. Given the (...) on-going presence of strategies based on findings from behavioural science in policy-making on the political agenda, an examination of this is warranted. This paper begins by looking at the place of the SDoH within public health, before outlining, in brief, the recent drive towards utilising behavioural science to formulate law and public policy. We then examine the relationship between this and the SDoH. We argue that behavioural public health policy is, to a certain extent, blind to the social and other determinants of health. In section three, we examine ways in which such policies may perpetuate and/or exacerbate health inequities and social injustices. We argue that problems in this respect may be compounded by assumptions and practices which are built into some behavioural science methodologies. We also argue that incremental individual gains may not be enough. As such, population-level measures are sometimes necessary. In section four we defend this contention, arguing that an equitable and justifiable public health requires such measures. (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)

Recent epidemiological reports of associations between socioeconomic status and epigenetic markers that predict vulnerability to diseases are bringing to light substantial biological effects of social inequalities. Here, we start the discussion of the moral consequences of these findings. We firstly highlight their explanatory importance in the context of the research program on the Developmental Origins of Health and Disease (DOHaD) and the social determinants of health. In the second section, we review some theories of the moral status of health inequalities. (...) Rather than a complete outline of the debate, we single out those theories that rest on the principle of equality of opportunity and analyze the consequences of DOHaD and epigenetics for these particular conceptions of justice. We argue that DOHaD and epigenetics reshape the conceptual distinction between natural and acquired traits on which these theories rely and might provide important policy tools to tackle unjust distributions of health. (shrink)

In this paper, we provide a state-of-the-art overview of the ethical challenges that arise in the context of antimicrobial resistance, which includes an introduction to the contributions to the symposium in this issue. We begin by discussing why AMR is a distinct ethical issue, and should not be viewed purely as a technical or medical problem. In the second section, we expand on some of these arguments and argue that AMR presents us with a broad range of ethical problems that (...) must be addressed as part of a successful policy response to emerging drug resistance. In the third section, we discuss how some of these ethical challenges should be addressed, and we argue that this requires contributions from citizens, ethicists, policy makers, practitioners and industry. We conclude with an overview of steps that should be taken in moving forward and addressing the ethical problems of AMR. (shrink)