Disproportional morbidity and mortality experienced by ethnic minorities in the UK have been highlighted by the COVID-19 pandemic. The ‘Black Lives Matter’ movement has exposed structural racism’s contribution to these health inequities. ‘Cultural Safety’, an antiracist, decolonising and educational innovation originating in New Zealand, has been adopted in Australia. Cultural Safety aims to dismantle barriers faced by colonised Indigenous peoples in mainstream healthcare by addressing systemic racism.This paper explores what it means to be ‘culturally safe’. The ways in which New (...) Zealand and Australia are incorporating Cultural Safety into educating healthcare professionals and in day-to-day practice in medicine are highlighted. We consider the ‘nuts and bolts’ of translating Cultural Safety into the UK to reduce racism within healthcare. Listening to the voices of black, Asian and minority ethnic National Health Service (NHS) consumers, education in reflexivity, both personal and organisational within the NHS are key. By listening to Indigenous colonised peoples, the ex-Empire may find solutions to health inequity. A decolonising feedback loop is required; however, we should take care not to culturally appropriate this valuable reverse innovation. (shrink)

Introduction Good quality of care is dependent on nurses’ strong clinical skills and moral competencies, as well. While most nurses work with high moral standards, the moral performance of some nurses in some organizations shows a deterioration in their moral sensitivity and actions. The study reported in this paper aimed to explore the experiences of nurses regarding negative changes in their moral practice. Materials and methods This was a qualitative study utilizing an inductive thematic analysis approach, which was conducted from (...) February 2017 to September 2019. Twenty-five nurses participated in semi-structured interviews. Results The main theme that emerged from our analysis was one of moral neutralization in the context of an unethical moral climate. We found five sub-themes, including: feeling discouraged; normalization; giving up; becoming a justifier; and moral indifference. Conclusions Unethical moral climates in health organizations can result in deterioration of morality in nurses which can harm both patients and health systems. Some unethical behaviors in nurses can be explained by this process. (shrink)

Experimental design is one aspect of a scientific method. A well-designed, properly conducted experiment aims to control variables in order to isolate and manipulate causal effects and thereby maximize internal validity, support causal inferences, and guarantee reliable results. Traditionally employed in the natural sciences, experimental design has become an important part of research in the social and behavioral sciences. Experimental methods are also endorsed as the most reliable guides to policy effectiveness. Through a discussion of some of the central concepts (...) associated with experimental design, including controlled variation and randomization, this chapter will provide a summary of key ethical issues that tend to arise in experimental contexts. In addition, by exploring assumptions about the nature of causation and by analyzing features of causal relationships, systems, and inferences in social contexts, this chapter will summarize the ways in which experimental design can undermine the integrity of not only social and behavioral research but policies implemented on the basis of such research. (shrink)

Background The COVID-19 pandemic posed many unprecedented challenges to health care systems and public health efforts worldwide. Policy making and science were deeply intertwined, in particular with regard to the justification of health policy measures. In this context, ethical considerations were often at the core of decision-making trade-offs. However, not much is known about the actual ethical challenges encountered by policy makers and scientists involved in policy advice. With this study, we therefore aim to explore the ethical challenges during COVID-19-related (...) political decision-making in Switzerland as perceived by policy makers and scientists involved in policy making. We also explore the role ethics advice had during the pandemic response and what can be learned for future public health crises. Methods We conducted thirteen qualitative expert interviews with policy makers and scientists involved in decision-making on COVID-19 policy responses in Switzerland on the regional and national level. We used inductive content analysis to analyse the interviews. Results Among the multitude of ethical challenges highlighted, interviewees perceived making trade-offs between the common good vs. the individual good and between economic welfare vs. health of the population, as well as proportionality of the policy measures, and the capacity of the public to accept uncertainty as central. Interviewees had diverging opinions on whether ethical considerations were sufficiently raised and discussed on the Swiss policy level during the COVID-19 pandemic. Among the reasons why ethics was not sufficiently discussed, they mentioned a lack of time in the fast-paced dynamic of the pandemic, ethics as a complex subject area, the interconnectedness between ethics and law, too much focus on few topics (mostly on vaccination-related ethical questions), and power relationships, such as dominance of medical professionals over ethicists. They evaluated ethics support to have been adequately present in the decision-making process, but wished for ethics training, involvement of the public in the discourse and for accompanying communication to build trust among the population for the future. Conclusions The study provides empirical insights into the ethical considerations of COVID-19 policy making in practice in Switzerland. It can help to develop ethics assistance for future crises and inform ethical health policy and decision-making not only in Switzerland, but also in other countries. (shrink)

Principialismo, bioética personalista y principios de acción en medicina y en servicios de salud Principialismo, bioética personalista e princípios de ação em medicina e serviços de saúde Since there is a gap and differences between bioethical concepts and other principles of action arising from the practice of modern medicine, their comparison is reasonable. Modern medicine has created principles of action based on evidence and principles of quality in medicine, and bioethical argumentation frequently resorts to principlism or personalist bioethics. This article (...) intends to illustrate the characteristics of the relationships between these concepts and their potential mutual enrichment. A simple, practical comparison matrix is proposed to compare the relationship between principles. These concepts have a significant overlap; however, both in the history of ideas and in their formulation, they are very dissimilar. Emphasis is placed on the contextual value of this analysis given by global health trends and some implications for medicine from personalist bioethics. Para citar este artículo / To reference this article / Para citar este artigo Insua JT. Principialismo, bioética personalista y principios de acción en medicina y en servicios de salud. pers. bioét. 2018; 22: 223-246. DOI: 10.5294/pebi.2018.22.2.3. (shrink)

Task shifting is increasingly used to address human resource shortages impacting HIV service delivery in low- and middle-income countries. By shifting basic tasks from higher- to lower-trained cadres, such as Community Health Workers, task shifting can reduce overhead costs, improve community outreach, and provide efficient scale-up of essential treatments like antiretroviral therapies. Although there is rich evidence outlining positive outcomes that CHWs bring into HIV programs, important questions remain over their place in service delivery. These challenges often reflect concerns over (...) whether CHWs can mitigate HIV through a means that does not overlook the ethical and practical constraints that undergird their work. Ethical and practical guidance thus needs to become the cornerstone of CHW deployment. This paper analyzes such challenges through the lens of Ethical Principlism. We examined papers identifying substantive and ethical challenges impacting CHWs as they provide HIV services in low- and middle-income contexts. To do this, we analyzed papers written in English and published from year 2000 or later. These articles were identified using MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar databases. In total, 465 articles were identified, 78 of which met our inclusion criteria. Article reference lists and grey literature were also examined. CHWs experience specific challenges while carrying out their duties, such as conducting emotionally- and physically-demanding tasks with often inadequate training, supervision and compensation. CHWs have also been poorly integrated into health systems, which not only impacts quality of care, but can hinder their prospects for promotion and lead to CHW disempowerment. As we argue, these challenges can be addressed if a set of ethical principles is prioritized, which specifically entail the principles of respect for persons, justice, beneficence, proportionality and cultural humility. CHWs play a crucial role in HIV service delivery, yet the ethical challenges that can accompany their work cannot be overlooked. By prioritizing ethical principles, policymakers and program implementers can better ensure that CHWs are combatting HIV through a means that does not exploit or take their critical role within service delivery for granted. (shrink)

Over the last decade there has been a noticeable increase in attention, on the part of public health scholars and professionals, to the important ethical challenges that arise in the context of public health policy, practice and research. This has arguably been a driver for the development of public health ethics as both a specialized field of study in bioethics and a subject for professional education. But how is PHE taught in public health programs and schools? Are current educational approaches (...) sufficient to provide future professionals with the necessary tools to address the diverse ethical challenges they will encounter? In this article, we examine the international public health and bioethics literatures regarding PHE education in public health programs and schools. Specifically, we 1) summarize the results from studies that describe PHE education in the United States, Europe, Canada and in some developing countries, 2) explore current attitudes and educational approaches toward ethics curricula in public health, and 3) identify and discuss reported barriers to PHE education. We conclude with some general recommendations and a research agenda to guide future work on implementing PHE into different public health programs. (shrink)

The idea that the degree of infringement public health interventions have on individual rights should be proportional to the degree of expected benefits has emerged as an influential principle in public health ethics and policy. While proportionality makes sense in theory, it may be difficult to implement in practice, due to the inherent conflict between individual rights and the common good underlying the principle. To apply the proportionality principle to a decision of policy, one must still find a reasonable way (...) of balancing these competing values in light of the available options and empirical evidence. In this article, I consider how the proportionality principle applies to the regulation of dietary supplements and examine some critiques of the current oversight system. I argue that it may be difficult maintain proportional oversight because the risks of dietary supplements vary considerably. Strengthening the regulations may therefore promote an appropriate level of regulation in some cases but lead to overregulation in others. (shrink)

The administration of pro re nata medications is the responsibility of the nurse. However, ethical uncertainties often happen due to the inability of incapacitated patients to collaborate with the nurse in the process of decision making for pro re nata medication administration. There is a lack of integrative knowledge and insufficient understanding regarding ethical considerations surrounding the administration of pro re nata medications to incapacitated patients. Therefore, they have been discussed in this paper and practical strategies to avoid unethical practices (...) have been suggested. The complicated caring situation surrounding the administration of pro re nata medications is intertwined with ethical issues affecting the consideration of the patient's wishes and interventions that override them. The patient's right of autonomy and treatment refusal, surrogacy role, paternalism, and coercion are the main ethos of ethical pro re nata medication administration. Education and training can help nurses avoid legal and ethical issues in pro re nata medicines management and improve the quality and safety of healthcare. Empirical research is needed to improve our understanding of this phenomenon in the multidisciplinary environment of medicines management. (shrink)

The Arab and Islamic world is in cultural, political and ethical flux. Pressures of globalisation contend with ancient ideas and concepts that permeate cultural frameworks. Health professionals are among the many groups battling to accommodate the rapidly changing conditions. In many predominantly Muslim countries intense debates are underway among clinicians about the impact of the forces of change on their practices. To help understand these forces we conducted a study of the experiences of clinicians in the Hashemite Kingdom of Jordan, (...) a Middle Eastern nation state where the overwhelming majority of the population is Muslim. The sample contained 508 doctors and doctors-in-training, of whom 63% were male and 80% were younger than 40 years of age. It included both a quantitative survey, covering a wide range of issues, and qualitative, free-text written responses. Our results demonstrated high levels of disquiet related to the overall organisation and administration of the health care system, the specific content of ethical decisionmaking, and the impact of changing social, cultural and religious factors. Concerns included overcrowding, widespread corruption and hierarchical, non- democratic, management practices, and tensions relating to traditional and modern approaches to ethics, especially in relation to consent, organ donation, confidentiality, privacy, abortion, and the role of women. The roles of religion and religious authorities, the relative importance of the family, and community and tribal obligations were also areas of contention. The study exposes profound divisions and widely differing perspectives among Jordanian doctors and an abiding sense of uncertainty and instability within the profession. Many doctors express ambivalence in relation to both modern trends and traditional precepts. Three main axes of ethical contention were demonstrated, relating to the tensions between: "conservative" and "pragmatic" styles of decision-making; "traditional" approaches and internationalised standards of ethics; and the role of Islam and pressures to disengage ethical decision- making from religious authority. We speculate that these issues and divisions, and the deep sense of disquiet revealed by our data reflect large-scale forces to which Jordanian society is exposed and to a substantial degree may provide a way to understand the ethical predicament of many other countries in the contemporary Arab world. (shrink)

As a result of the coronavirus (COVID‐19) pandemic, health professionals are faced with situations they have not previously encountered and are being forced to make difficult ethical decisions. As the first group to experience challenges of caring for patients with coronavirus, Chinese nurses endure heartbreak and face stressful moral dilemmas. In this opinion piece, we examine three related critical questions: Whether society has the right to require health professionals to risk their lives caring for patients; whether health professionals have the (...) right to refuse to care for patients during the coronavirus pandemic; and what obligations there are to protect health professionals? Value of care, community expectations, legal obligations, professional and codes of practice may compel health professionals to put themselves at risks in emergency situations. The bioethical principles of autonomy, justice, beneficence and non‐maleficence, as well as public health ethics, guide nurses to justify their decisions as to whether they are entitled to refuse to treat COVID‐19 patients during the pandemic. We hope that the open discussion would support the international society in addressing similar ethical challenges in their respective situations during this public health crisis. (shrink)

Food fortification and water fluoridation are two public health initiatives that involve the passive consumption of nutrients through food and water supplies. While ethical analyses of food fortification and water fluoridation have been done separately, none have been done together. In this paper, we will consider whether the similarities between food fortification and water fluoridation override their differences and thus what ethical conclusions can be cross-pollinated between the two interventions. This study does three things: first, we review the origin, reasoning (...) and mechanisms behind food fortification and water fluoridation. From there, we deduce the primary ethical dilemma that overshadows food fortification and water fluoridation – they both require a form of deception and are consumed passively without the need for informed consent. Finally, we look at various approaches ethicists have taken to understand the ethical issues surrounding the programs. Two key ethical models appear in this discussion: the justificatory approach and the stewardship model. Beyond these two frameworks, one ethical analysis deduces from the Nuremberg Code that water fluoridation is unethical based on the definition of consent. As recent scientific papers and the general public have started discussing and debating the passive consumption of various drugs via public water supplies, it is prudent that we revisit the ethics behind food fortification and water fluoridation programs; this will ultimately allow us to better navigate complex problems in nutritional ethics and passive delivery. (shrink)

Health research ethics training is highly variable, with some researchers receiving little to none, which is why ethical frameworks represent critical tools for ethical deliberation and guiding responsible practice. However, these documents' voluntary and abstract nature can leave health researchers seeking more operationalised guidance, such as in the form of checklists, even though this approach does not support reflection on the meaning of principles nor their implications. In search of more reflective and participatory practices in a pandemic context with distance (...) learning, this study explored whether co-design could support engagement and reflection on ethical principles amongst early-stage health researchers. In a pilot test using the Swiss Personalized Health Network's ethical framework for Responsible Usage of Personal Data in Health Research as a case study, we engaged health researchers to design visuals of four ethical principles. In two online workshops, participants (N = 10, N = 8) completed activities such as individual reflection, collaborative ideation, sketching, prototyping, discussion, and feedback. Our analysis shows that the co-design process helped foster in-depth engagement and reflection on the meaning and relevance of the SPHN ethical principles. Participants reported enjoying the experience, and most felt that visuals could motivate engagement with ethical frameworks. This study demonstrates the feasibility of a participatory, design-oriented approach to promote engagement with research ethics among early-career health researchers and highlights key challenges and lessons learned. In doing so, it lays the foundation for future research to investigate the impact of design-oriented, participatory learning to foster reflection and deliberation in ethics education. (shrink)

Disability is one of the key public health issues in India and the burden will increase given the trend of an aging population. People with disabilities experience greater vulnerability as they may develop secondary health issues. They face various barriers while accessing health services. This is a major ethical concern. In this article, we frame the barriers to healthcare provision to persons with disabilities and propose an ethical framework to address these barriers. This ethical framework is derived from the basic (...) ethical principles of justice, fairness, trust, solidarity, stewardship, proportionality, and responsiveness. The framework proposes strategies to address these barriers to healthcare service delivery for persons with disabilities in India. (shrink)