Disability Justice in Public Health Emergencies is the first book to highlight contributions from critical disability scholarship to the fields of public health ethics and disaster ethics. It takes up such contributions with the aim of charting a path forward for clinicians, bioethicists, public health experts, and anyone involved in emergency planning to better care for disabled people—and thereby for all people—in the future. Across 11 chapters, the contributors detail how existing public health emergency responses (...) have failed and still fail to address the multi-faceted needs of disabled people. They analyze complications in the context of epidemic and pandemic disease and emphasize that vulnerabilities imposed upon disabled people track and foster patterns of racial and class domination. -/- The central claim of the volume is that the ethical and political insights of disability theory and activism provide key resources for equitable disaster planning for all. The volume builds upon the existing efforts of disability communities to articulate emergency planning priorities and response measures that take into account the large body of qualitative and quantitative research on disabled people’s health, needs, and experiences. It is only by listening to disabled people’s voices that we will all fare better in future public health emergencies. (shrink)

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)

Recently, there has been a concerted effort to shift bioethics’ traditional focus from clinical and research settings to more robustly engage with issues of justice and health equity. This broader bioethics agenda seeks to embed health related issues in wider institutional and cultural contexts and to help develop fair policies. In this paper, we argue that bioethicists who ascribe to the broader bioethics’ agenda could gain valuable insights from the interdisciplinary field of environmental justice and transportation (...) justice, in particular. We then proceed to demonstrate the importance of adopting an intersectional approach to transportation and health. The paper concludes with the argument that intersectional gender inequality is of particular importance when studying both health equity and the unequal distribution of burdens associated with transportation systems in local contexts. This essay is meant to be the beginning of a robust conversation concerning health equity, transportation justice, and intersectional distributions of both benefits and burdens. (shrink)

This paper argues that societal duties of health promotion are underwritten (at least in large part) by a principle of beneficence. Further, this principle generates duties of justice that correlate with rights, not merely “imperfect” duties of charity or generosity. To support this argument, I draw on a useful distinction from bioethics and on a somewhat neglected approach to social obligation from political philosophy. The distinction is that between general and specific beneficence; and the approach from political philosophy (...) has at times been called equality of concern. After clarifying the distinction and setting out the basis of the equality of concern view, I argue that the result is a justice-based principle of “specific” beneficence that should be reflected in a society’s health policy. I then draw on this account to criticize, refine, and extend some prominent health care policy proposals from the bioethics literature. (shrink)

Universal health coverage (UHC) is at the center of current efforts to strengthen health systems and improve the level and distribution of health and health services. This document is the final report of the WHO Consultative Group on Equity and Universal Health Coverage. The report addresses the key issues of fairness and equity that arise on the path to UHC. As such, the report is relevant for every actor that affects that path and governments in (...) particular, as they are in charge of overseeing and guiding the progress toward UHC. (shrink)

New biotechnologies have the potential to both dramatically improve human well-being and dramatically widen inequalities in well-being. This paper addresses a question that lies squarely on the fault line of these two claims: When as a matter of justice are societies obligated to include a new biotechnology in a national healthcare system? This question is approached from the standpoint of a twin aim theory of justice, in which social structures, including nation-states, have double-barreled theoretical objectives with regard to (...) human well-being. The first aim is to achieve a sufficient level of well-being in each of six core dimensions. In the special case of healthcare systems, this aim is focally but not exclusively attentive to achieving health sufficiency as one of the core dimensions. The second aim is to combat the emergence and persistence of densely woven patterns of systematic disadvantage that tend to undermine the achievement of a sufficient level of health and the other core elements of well-being of some persons and groups. Judgments about entitlements to health related resources, including new biotechnologies, are made in light of a threshold notion of health sufficiency. What is enough or sufficient health? The answer that is defended here is that sufficient health is enough health for a decent human life, understood as enough health to live a full life course without preventable, significant functional disability or decrement in health, or treatable pain or suffering. When a state must include a new biotechnology in its national healthcare system is also influenced by ancillary concerns about the connection between health and other core dimensions of well-being. What counts as a significant functional impairment or health decrement is thus explicated, in part, in relation to the theory’s sufficiency aim for the other essential dimensions of well-being, and thus for a decent life, overall. Those elements of health that play a critical role in the experience of sufficient reasoning, affiliation, security, respect and self determination are especially important; any loss of health function or capacity that threatens the individual’s prospects for sufficiency in these other dimensions, including the relational egalitiarian concerns they entail, constitutes a significant functional impairment. Within national borders, individuals are thus entitled to those health-related goods and services that are essential for a sufficiency of each of the dimensions of well-being; with regard to self determination and respect, what is sufficient by way of guaranteed access to specific goods and services is going to depend on the implications of such access for where an individual stands in relation to her co-nationals. The content of any entitlement to health-related goods and services is also necessarily dynamic. What can be done for health and the other core dimensions of well-being as a function of technological innovation and diffusion is in constant flux. The paper concludes by considering the implications of this analysis for the conditions under which states are obligated to include access in their healthcare systems to one biotechnology, deep brain stimulation. (shrink)

In our recent article, together with more than 60 of our colleagues, we outlined a proposal for drug policy reform consisting of four specific yet interrelated strategies: (1) de jure decriminalization of all psychoactive substances currently deemed illicit for personal use or possession (so-called “recreational” drugs), accompanied by harm reduction policies and initiatives akin to the Portugal model; (2) expunging criminal convictions for nonviolent offenses pertaining to the use or possession of small quantities of such drugs (and releasing those serving (...) time for these offenses), while delivering retroactive ameliorative relief; (3) the ultimate legalization and careful regulation of currently illicit drugs; and (4) the delivery of a new “Marshall Plan” focused on community-building initiatives, expanded harm reduction programs, and social and health care support efforts (Earp et al. 2021). We were gratified to see so many thoughtful commentaries on our proposal, and we respond to them in part in this reply. (shrink)

According to the sufficiency theory of justice in health, justice requires that people have equal access to adequate health. In this article, I lay out the structure of this view and I assess its distributive implications for setting priority (i) between health needs across persons and (ii) between health care spending and other societal goods. I argue, first, that according to the sufficiency theory, deficiency in health cannot be completely offset by providing other (...) societal goods. And, second, that it can prevent the medicalization of societies by stressing that improvements beyond the level of adequate health have relatively little weight, if any, from the standpoint of justice. (shrink)

The future of health research will be characterised by three continuing trends: rising demand for health data; increasing impracticability of obtaining specific consent for secondary research; and decreasing capacity to effectively anonymise data. In this context, governments, clinicians and the research community must demonstrate that they can be responsible stewards of health data. IRBs and RECs sit at heart of this process because in many jurisdictions they have the capacity to grant consent waivers when research is judged (...) to be of particular value. However, several different terms are used to refer to this value, indicating a lack of conceptual clarity regarding the appropriate test for access to health data for research without consent. In this paper we do three things. First we describe the current confusion and instability in terminology relating to public interest in the context of consent waivers. Second we argue for harmonisation of terminology on the grounds of clarity, transparency and consistency. Third we argue that the term ‘public interest’ best reflects the normative work required to justify consent waivers because it is the broadest of the competing terms. ‘Public interest’ contains within its scope positive and negative implications of a study, as well as welfare, justice and rights considerations. In making this argument, we explain the normative basis for consent waivers, and provide a starting place for further discussion about the precise conditions in which a given study can be said to advance the public interest. Ipsos MORI study found that: … the public would be broadly happy with administrative data linking for research projects provided Those projects have social value, broadly defined. Data are de-identified. Data are kept secure. Businesses are not able to access the data for profit. (shrink)

This paper considers the obligation higher income countries have to lower and middle income countries during a global pandemic. Further considers which reforms are needed to the global supply-chain of medical resources. The short-comings in distribution and medical infrastructure have exacerbated the health crisis in developing countries. Global justice demands radical redistribution of medical resources in order to prevent mass casualties. This is argued first by highlighting that the COVID-19 pandemic should be acknowledged as an issue of global (...) justice, secondly, higher income countries ought to account for distribution inequity as a matter of rectifying past injustices, and thirdly argue for reform in distribution while considering the vaccine rollout as a prime example. We aim to show how the differences from country to country in response capabilities are a result of the economic foundation colonialism established and a direct result of cyclical poverty, which wealthy countries perpetuate to this day. (shrink)

The present proposal is an approach to the vision, cosmogony and philosophy of the Totonacapan people, and particularly with the inhabitants of the Totonacapan region in Veracruz Mexico, a town whose wisdom is manifested to this day, in the conservation of customs and traditions , as well as the hierarchy of collective desire that seeks health, well-being and peace in the region, are guides in the evolution of their cultural processes, where a closeness, respectful and deep with Mother Nature (...) stands out. This wisdom by the Council of Elders, transmitted to the new generations, by the Supreme Council of Totonacapan who seek share the basis to understand and conceive the current world, from the ancestral vision and cosmogony to identify their space, thought, spirituality and in the building your social context. In the Totonacapan region, the first pre-hispanic population concentrations were located around 1259 to 1311. Already by the year 1450, there is a record of incursions and the conquest of Totonaca territory, by the Mexica, establishing a relationship of domain and subordination. As a result of the presence of "Mexica" in the Totonaco territory, there was an imposition of customs and language, since in some areas they begin to speak in Nahuatl, resulting in the presence of a bilingualism (Nahuatl-Totonac) , situation that persists, until the encounter with the Spaniards in the year of 1519. At present, the Totonacapan region includes the area that extends from the Cazones River to the north, to the towns of Gutiérrez Zamora and Tecolutla, in the State of Veracruz in Mexico. 2 The importance of the document is that it constitutes an invitation to deepen and understand the vision of the inhabitants of Totonacapan, in the construction of their social context and their connection with nature, as part of an ancient culture, which creates and recreates their vision, in the search for the feeling of belonging and as an inheritance of the children of thunder (Tajin), as well as the need to preserve the benefits that nature itself offers them, seeking a peaceful and harmonious coexistence, in the social and environmental environment. However, the preservation of its history, tradition and philosophy of life, contrast with public policy strategies, particularly in the social sphere, and which are aimed at achieving economic development in the fight against multidimensional poverty and marginalization, all Once they have not incorporated into them, the feeling and living of the relationship between individual and nature, as the guiding axis, of the philosophy of the Totonacapan people. What is sustainability for the people of Totonacapan? What is social justice in the search for sustainability? And what is your concept of justice in sustainability and human development? From the vision and philosophy of the people of Totonacapan, as part of the history and tradition of the children of thunder "Tajin" and in whose worldview, he is responsible for regulating the rain, climate and life of the people of the region. How does the people of Totonacapan live and live in the face of the maelstrom of actions that, from public policy, that seek human development? How do you adjust, your way of life and how do you adapt to the requirements, which from the perspective of justice, are required to contribute to the objectives of the 2030 development agenda? This document is an effort to learn and recognize one of the most important millenary cultures in Mexico, in the construction of a more inclusive vision of the social development of the Totonacapan people, which invites us to reflect on the direction and scope of this response. (shrink)

As opposed to a ‘one size fits all’ approach, precision medicine uses relevant biological, medical, behavioural and environmental information about a person to further personalize their healthcare. This could mean better prediction of someone’s disease risk and more effective diagnosis and treatment if they have a condition. Big data allows for far more precision and tailoring than was ever before possible by linking together diverse datasets to reveal hitherto-unknown correlations and causal pathways. But it also raises ethical issues relating to (...) the balancing of interests, viability of anonymization, familial and group implications, as well as genetic discrimination. This article analyses these issues in light of the values of public benefit, justice, harm minimization, transparency, engagement and reflexivity and applies the deliberative balancing approach found in theEthical Framework for Big Data in Health and Research to a case study on clinical genomic data sharing. Please refer to that article for an explanation of how this framework is to be used, including a full explanation of the key values involved and the balancing approach used in the case study at the end. Our discussion is meant to be of use to those involved in the practice as well as governance and oversight of precision medicine to address ethical concerns that arise in a coherent and systematic manner. (shrink)

How can we allocate scarce health care resources justly? In particular, are markets the most efficient way to deliver health services? Much blood, sweat and ink has been shed over this issue, but rarely has either faction challenged the unspoken assumption behind the claim made by advocates of markets: that efficiency advances the interests of both individuals and society. Whether markets actually do increase efficiency is arguably a matter for economists, but the deeper ethical question is whether efficiency (...) is the correct criterion, in terms of social justice and individual needs. (shrink)

In this article, we suggest that the evidence regarding the social determinants of health calls for a deep re‐thinking of our understanding of distributive justice. Focusing on John Rawls's theory of distributive justice in particular, we argue that a full reckoning with the social determinants of health requires a re‐working of Rawls's principles of justice. We argue first that the social bases of health – a Rawlsian conception of the social determinants of health (...) – should be considered a social primary good. We argue second that including the social bases of health as a social primary good would lead the parties to the original position to choose an additional principle of justice and assign it lexical priority over Rawls's second principle. According to this principle, inequalities in people's share of the social bases of health are to be arranged so as to improve the health status of those least advantaged on the social health gradient. -/- . (shrink)

This chapter discusses how justice applies to public health. It begins by outlining three different metrics employed in discussions of justice: resources, capabilities, and welfare. It then discusses different accounts of justice in distribution, reviewing utilitarianism, egalitarianism, prioritarianism, and sufficientarianism, as well as desert-based theories, and applies these distributive approaches to public health examples. Next, it examines the interplay between distributive justice and individual rights, such as religious rights, property rights, and rights against discrimination, (...) by discussing examples such as mandatory treatment and screening. The chapter also examines the nexus between public health and debates concerning whose interests matter to justice (the “scope of justice”), including global justice, intergenerational justice, and environmental justice, as well as debates concerning whether justice applies to individual choices or only to institutional structures (the “site of justice”). The chapter closes with a discussion of strategies, including deliberative and aggregative democracy, for adjudicating disagreements about justice. (shrink)

In this chapter, I propose that conceptions of justice in bioethics must be feminist, meaning they must be able to capture how the domains of health, healthcare and medicine exacerbate the subordination of those perceived to be women and girls and how injustice impacts their health. After providing context in the first section, I identify three problems with conceptions of justice in the bioethics literature that interfere with their potential to be feminist. They tend to adopt (...) the ahistoricism and distributivism characteristic of theories of justice that have been dominant in political philosophy, and they often rely on gendered conceptions of health that result in troubling comparisons of men and women’s health. My argument is primarily “negative”: it is a critique of generalist conceptions of justice in bioethics. However, in the final section I present characteristics of what a feminist conception of justice needs to look like and indicate how feminist bioethicists are using such a conception in assessing issues of injustice in bioethics. I emphasize the centrality of actual structural injustices, relational egalitarianism, and the assessment of values in conceptions of health and the health sciences. (shrink)

The paper discusses the possibility that the benefits of pharmacogenomics will not be distributed equally and will create orphan populations. I argue that since these inequalities are not substantially different from those produced by ‘traditional’ drugs and are not generated with the intention to discriminate, their production needs not be unethical. Still, the final result is going against deep-seated moral feelings and intuitions, as well as broadly accepted principles of just distribution of health outcomes and healthcare. I thus propose (...) two provisos that would prevent the most offensive outcomes and moderate the scope of the produced inequalities. The first proviso rejects pharmacogenomics innovations that worsen existing group inequalities and aggravate the disadvantage of communities with a history of discrimination. The second proviso requires that there is a strategy in place to even out as much as possible the distribution of benefits in the future and that a system of compensations is in place for pharmacogenomic orphans. Given that only one moral problem generated by pharmacogenomics has been tackled, the list of provisos might be expanded when other issues are considered. (shrink)

The purpose of this article is to explore the concept and scope of public health and to argue that particularly in low-income contexts, where social injustice and poverty often impact significantly on the overall health of the population, the link between public health and social justice should be a very firm one. Furthermore, social justice in these contexts must be understood as not simply a matter for local communities and nation-states, but in so far as (...) public health is concerned, as a matter of global concern and responsibility. The interpretation of the scope of public health by any particular nation is I believe contingent on the current socio-political context and the conception of social or distributive justice that underpins this context. Furthermore I will argue here that the link between public health and social justice ought to be founded on a conception of social justice that adequately addresses issues of social injustice, and patterns of systematic disadvantage, that contribute to ill health and that so commonly prevail in many low- and middle-income social contexts. (shrink)

Many social gradients in health appear steeper for men than for women. I refer to this as the “Steepness Puzzle.” This paper explores the ethical implications of this Puzzle. First, it identifies potential explanations for the Steepness Puzzle, including methodological problems. Second, it highlights two harms associated with the methodological explanation: the consequences of biased epistemic practices and the marginalization of women. It also demonstrates how attempts to flatten the gradients in health could disproportionately favor men or reinforce (...) troubling gendered norms. Finally, I suggest ways to address the methodological problems underlying the Puzzle. (shrink)

The paper presents the outlines of an ontology of plans and guidelines, which is then used as the basis for a framework for implementing guideline-based systems for the management of workflow in health care organizations. The framework has a number of special features, above all in that it enables us to represent in formal terms assignments of work-items both to individuals and to teams and to tailor guideline to specific contexts of application in health care organizations. It is (...) designed also to enable implementations to do justice to the fact that the processes carried out in health care organizations may deviate in different ways from the norms set forth in corresponding guideline definitions. This means that implementations built in conformity with the framework will be marked by a type of flexibility that might make them more likely to be accepted by healthcare professionals than are standard guideline-based management systems. (shrink)

The proposition that digital innovations can put people in charge of their health has been accompanied by prolific talk of empowerment. In this paper we consider ethical challenges and opportunities of trying to achieve justice and empowerment using digital health initiatives. The language of empowerment can misleadingly suggest that by using technology, people can control their health and take responsibility for health outcomes to a greater degree than is realistic or fair. Also, digital health (...) empowerment often primarily reaches people who already have high technological and health literacy, leaving others behind. We critically investigate whether the concept of health empowerment could be re-engineered to mean something different, namely the process of improving the health literacy and access of those who least possess it, in line with recent proposals for conceptual engineering in the service of justice. We settle on the weaker conclusion that underlying ethical values including justice should be used to interpret the existing concept of empowerment. To conclude, we take a high-level view of various strategies for achieving the ethical value associated with digital health empowerment. (shrink)

Environmental health research produces scientific knowledge about environmental hazards crucial for public health and environmental justice movements that seek to prevent or reduce exposure to these hazards. The environment in environmental health research is conceptualized as the range of possible social, biological, chemical, and/or physical hazards or risks to human health, some of which merit study due to factors such as their probability and severity, the feasibility of their remediation, and injustice in their distribution. This (...) paper explores the ethics of identifying the relevant environment for environmental health research, as judgments involved in defining an environmental hazard or risk, judgments of that hazard or risk's probability, severity, and/ or injustice, as well as the feasibility of its remediation, all ought to appeal to non-epistemic as well as epistemic values. I illustrate by discussing the case of environmental lead, a housing-related hazard that remains unjustly distributed by race and class and is particularly dangerous to children. Examining a controversy in environmental health research ethics where researchers tested multiple levels of lead abatement in lead-contaminated households, I argue that the broader perspective on the ethics of environmental health research provided in the first part of this paper may have helped prevent this controversy. (shrink)

Several attempts have been made to apply the choice-sensitive theory of distributive justice, luck egalitarianism, in the context of health and healthcare. This article presents a framework for this discussion by highlighting different normative decisions to be made in such an application, some of the objections to which luck egalitarians must provide answers and some of the practical implications associated with applying such an approach in the real world. It is argued that luck egalitarians should address distributions of (...) health rather than healthcare, endorse an integrationist theory that combines health concerns with general distributive concerns and be pluralist in their approach. It further suggests that choice-sensitive policies need not be the result of applying luck egalitarianism in this context. (shrink)

Many people in the developing world access essential health services either partially or primarily through programs run by international non-governmental organizations (INGOs). Given that such programs are typically designed and run by Westerners, and funded by Western countries and their citizens, it is not surprising that such programs are regarded by many as vehicles for Western cultural imperialism. In this chapter, I consider this phenomenon as it emerges in the context of development and humanitarian aid programs, particularly those delivering (...) medical treatment, nutrition and access to clean water. I argue that in order to avoid contributing to cultural imperialism, INGOs have a duty to ensure that they do not offer services in a way that requires their beneficiaries to choose between accessing essential health services and violating or otherwise undermining traditional norms and practices which have significance for their beneficiaries. Following Onora O'Neill, I argue that offers requiring such a choice are effectively “unrefuseable” and so coercive. INGOs therefore, must avoid making such offers, and can accomplish this by means of an iterated process of reciprocal negotiation under conditions of equality, in which both the INGOs’ and the beneficiaries’ deep values and concerns play a role. In essence, I claim that employing such a process is a requirement of procedural justice, given the non-ideal conditions in which INGOs must operate. (shrink)

This article proposes that, in line with moral-cosmopolitan theorists, affluent nations have an obligation, founded in justice and not merely altruism or beneficence, to share the responsibility of the burden of public health implementation in low-income contexts. The current Ebola epidemic highlights the fact that countries with under-developed health systems and limited resources cannot cope with a significant and sudden health threat. The link between burden of disease, adverse factors in the social environment and poverty is (...) well established and confirmed by the 2008 World Health Organization (WHO)’s Social Determinants of Health Commission report. Well-resourced nations generally consider that they have some humanitarian obligation to assist where possible, but this obligation is limited. The following questions are considered: Is reliance on the principle of beneficence to address the global disparities in the social determinants of health and life expectancy at birth good enough? Do well-resourced nations have some obligation from justice, which is stronger than from beneficence, and which cannot be as easily cast aside or diminished, to address these issues? In a globalised world, shaped by centuries of historical injustice and where first-world economies are now so intertwined and reliant on third-world labour, beneficence is not a strong enough principle on which to base an obligation to achieve the WHO vision of ‘health equity through action on the social determinants of health’. (shrink)

The application of Artificial Intelligence (AI) in healthcare and epidemiology undoubtedly has many benefits for the population. However, due to its environmental impact, the use of AI can produce social inequalities and long-term environmental damages that may not be thoroughly contemplated. In this paper, we propose to consider the impacts of AI applications in medical care from the One Health paradigm and long-term global health. From health and environmental justice, rather than settling for a short and (...) fleeting green honeymoon between health and sustainability caused by AI, it should aim for a lasting marriage. To this end, we conclude by proposing that, in the upcoming years, it could be valuable and necessary to promote more interconnected health, call for environmental cost transparency, and increase green responsibility. (shrink)

On January 30, 2020, the World Health Organization declared a Public Health Emergency of International Concern (PHEIC) over what would quickly become known as SARS-CoV- 2 or COVID- 19. This emergency status was officially ended in the United States in May 2023 amidst much dissent and debate. Although emergency conditions resulting from COVID- 19 will likely wax and wane over the coming years, there is good reason to think that the incidence of severe global pandemics will increase over (...) the next century, as will declarations of emergency. The declaration of an emergency calls for urgent action, but it just as urgently demands careful reflection. Official “emergency” status licenses unparalleled executive intervention, completely reorganizing the lives of those who live under its decree. Such official recognition, however, is heavily dependent on the social context in and from which the emergency arises. Highlighting which circumstances rise to the level of an official emergency clarifies our reigning assumptions about what threshold of active harm—and in relation to which groups of people—demands immediate intervention. (shrink)

The guiding premise from which this special report begins is the conviction and hope that justice is at the normative heart of medicine and that it is the perpetual task of bioethics to bring concerns of justice to bear on medical practice. On such an account, justice is medicine's lifeblood, that by which it contributes to life as opposed to diminishing it. It is in this larger, historical, intersectional, critical, and ethically minded context that we must approach (...) pressing questions facing medicine, including the question of the import and role of genomic knowledge for human life. The second premise is that, at least in principle, the knowledge generated by genomics can be a gift or a weight, or both at the same time. That is to say that, on the one hand, genomic knowledge is a gift, creating novel insights into the genetic drivers of disease and into the geographical paths of our ancestors. And on the other hand, it is a weight, creating new obligations, new forms of social classification, and new forms of surveillance. Because it is in many ways the “common sense” of the day that genomic knowledge is a gift, this special report, which contains nine essays, concentrates on the ways in which such knowledge can be a weight, a weight that has the potential to thwart—and historically has thwarted—medicine from genuinely advancing justice . (shrink)

This paper endeavors to provide an explanation of health and the make-up of healthcare through distributive justice theories and access to the development of capabilities as the basis of a just healthcare structure. It also looks at matters around first level attention in healthcare as fundamental in the development of capabilities and access to functional diversity. It amounts, therefore, to a redefinition of bioethical contractualism, applied at the structure as basis of justice and the capability development.

There are a number of important links and similarities between public health and safety. In this extended essay, Gregg D. Caruso defends and expands his public health-quarantine model, which is a non-retributive alternative for addressing criminal behavior that draws on the public health framework and prioritizes prevention and social justice. In developing his account, he explores the relationship between public health and safety, focusing on how social inequalities and systemic injustices affect health outcomes and (...) crime rates, how poverty affects brain development, how offenders often have pre-existing medical conditions (especially mental health issues), how involvement in the criminal justice system itself can lead to or worsen health and cognitive problems, how treatment and rehabilitation methods can best be employed to reduce recidivism and reintegrate offenders back into society, and how a public health approach could be successfully applied within the criminal justice system. Caruso's approach draws on research from the health sciences, social sciences, public policy, law, psychiatry, medical ethics, neuroscience, and philosophy, and he delivers a set of ethically defensible and practically workable proposals for implementing the public health-quarantine model. The essay begins by discussing recent empirical findings in psychology, neuroscience, and the social sciences that provide us with an increased understanding of the social and neurological determinants of health and criminal behavior. It then turns to Caruso's public health-quarantine model and argues that the model provides the most justified, humane, and effective approach for addressing criminal behavior. Caruso concludes by proposing a capability approach to social justice grounded in six key features of human well-being. He argues that we cannot successfully address concerns over public health and safety without simultaneously addressing issues of social justice—including the social determinants of health (SDH) and the social determinants of criminal behavior (SDCB)—and he recommends eight general policy proposals consistent with his model. (shrink)

Background: Transgender health care is a subject of much debate among clinicians, political commentators, and policy-makers. While the World Professional Association of Transgender Health (WPATH) Standards of Care (SOC) establish clinical standards, these standards contain implied ethics but lack explicit focused discussion of ethical considerations in providing care. An ethics chapter in the SOC would enhance clinical guidelines. Aims: We aim to provide a valuable guide for healthcare professionals, and anyone interested in the ethical aspects of clinical support (...) for gender diverse and transgender people of all ages. Recognizing that the WPATH is a global association, we address broad challenges. We offer a reflection on general ethical principles, providing conceptual tools for healthcare providers, patients, and families to navigate the specific challenges they might encounter in transgender health care, in line with WPATH’s worldwide mission and scope. Method: This article employs a descriptive analysis, and our framework of reference is the four principles of biomedical ethics: respect for autonomy, beneficence, nonmaleficence, and justice. Results: The article presents a discussion on the four ethical principles as applied to transgender health care. We address issues such as respect for patient autonomy in decision-making, the role of beneficence and nonmaleficence in clinical interventions, and the importance of justice in equitable treatment and access to care. Some of the ethical concerns we address in this article pertain to the current sociopolitical climate, where there has been increasing legal interference, internationally, for transgender and nonbinary people, particularly youth, seeking medical care. Discussion: We highlight the interplay between ethical principles and clinical practice, underscoring the need for ethical guidance in addressing the diverse challenges faced by healthcare providers and patients in transgender health care. We advocate for continuous refinement of ethical thinking to ensure that transgender health care is not only medically effective but also ethically sound. (shrink)

Child health inequalities violate children’s rights to optimal wellbeing. Different issues worldwide affect children’s physical and mental health as well as their development, influencing their future as adults. Inequities are avoidable inequalities. Despite improvements in the past two decades, the ambitious goals of global agendas have, for the most part, remained as expectations with regard to childhood rights, social justice, and health equity in practice. The concept of social determinants of health has become part of (...) the common language in certain settings, but this is still too little to improve health in practice on a global scale, particularly for underprivileged subgroups of the community, as children and adolescents often are. Pediatric health professionals and their organizations are also responsible for guaranteeing children’s and adolescents’ right to health and better wellbeing, helping to reduce health inequalities. (shrink)

Palliative care serves both as an integrated part of treatment and as a last effort to care for those we cannot cure. The extent to which palliative care should be provided and our reasons for doing so have been curiously overlooked in the debate about distributive justice in health and healthcare. We argue that one prominent approach, the Rawlsian approach developed by Norman Daniels, is unable to provide such reasons and such care. This is because of a central (...) feature in Daniels' account, namely that care should be provided to restore people's opportunities. Daniels' view is both unable to provide pain relief to those who need it as a supplement to treatment and, without justice-based reasons to provide palliative care to those whose opportunities cannot be restored. We conclude that this makes Daniels' framework much less attractive. (shrink)

Luck egalitarianism provides a reason to object to conditionality in health incentive programmes in some cases when conditionality undermines political values such as solidarity or inclusiveness. This is the case with incentive programmes that aim to restrict access to essential healthcare services. Such programmes undermine solidarity. Yet, most people's lives are objectively worse, in one respect, in non-solidary societies, because solidarity contributes both instrumentally and directly to individuals' well-being. Because solidarity is non-excludable, undermining it will deprive both the prudent (...) and the imprudent citizens of its goods. Thereby, undermining solidarity can make prudent citizens worse off than they would have otherwise been, out of no fault or choice of their own, but rather as a result of somebody else's imprudent choice. This goes against the spirit of luck egalitarianism. Therefore (luck egalitarian) justice can require us to save the imprudent and avoid conditionality in access to essential healthcare services. (shrink)

Should we grant a fresh start to those who come to regret their past lifestyle choices? A negative response to this question can be located in the luck egalitarian literature. As a responsibility-sensitive theory of justice, luck egalitarianism considers it just that people’s relative positions reflect their past choices, including those they regret. In a recent article, Vansteenkiste, Devooght and Schokkaert argue against the luck egalitarian view, maintaining instead that those who regret their past choices in health are (...) disadvantaged in a relevant way and should receive compensation. Employing the ideal that people should be made equal as measured by equivalent resources, they purport to show the fairness of such an arrangement through a hypothetical scenario. Relaxing the implicit assumptions of this scenario brings forth several unattractive consequences of the fresh-start idea. The main problem is that in striving to ensure that people’s past choices do not affect their own opportunities, the authors must accept that these choices put heavy strains on the opportunities available to other people. Furthermore, the luck egalitarian position is more compelling than they admit. (shrink)

Chile has achieved great success in terms of growth and development. However, growing inequalities exist in relation to income and health status. The previous Chilean government began to reform the healthcare system with the aim of reducing health inequities. What is meant by “equity” in this context? What is the extent of the equity aimed for? A normative framework is required for public policy-makers to consider ideas about fairness in their decisions about healthcare reform. This paper aims to (...) discuss the main features of the Chilean healthcare reform and their implications for such a normative framework. (shrink)

Historically, laws and policies to criminalize drug use or possession were rooted in explicit racism, and they continue to wreak havoc on certain racialized communities. We are a group of bioethicists, drug experts, legal scholars, criminal justice researchers, sociologists, psychologists, and other allied professionals who have come together in support of a policy proposal that is evidence-based and ethically recommended. We call for the immediate decriminalization of all so-called recreational drugs and, ultimately, for their timely and appropriate legal regulation. (...) We also call for criminal convictions for nonviolent offenses pertaining to the use or possession of small quantities of such drugs to be expunged, and for those currently serving time for these offenses to be released. In effect, we call for an end to the “war on drugs.”. (shrink)

Recent epidemiological research on the social determinants of health has been used to attack an important framework, associated with Norman Daniels, that depicts healthcare as special. My aim is to rescue the idea that healthcare has special importance in society, although specialness will turn out to be mainly limited to clinical care. I build upon the link between Daniels's theory and the work of John Rawls to develop a conception of public justification liberalism that is suitable to the field (...) of justice and health. I argue that, from the perspective of public justification liberalism, (clinical) healthcare deserves special status. (shrink)

Taking into consideration the extremely harsh public health conditions faced by the majority of the world population, the Health Impact Fund (HIF) proposal seeks to make the intellectual property regimes more in line with human rights obligations. While prioritizing access to medicines and research on neglected diseases, the HIF makes many compromises in order to be conceived as politically feasible and to retain a compensation character that makes its implementation justified solely on basis of negative duties. Despite that (...) current global health realities make such steps reasonable, the paper looks up the negative effects on one overlooked human right: the right to participate in scientific advancement. (shrink)

Religion and culture are interwoven and this can be seen among the Oron people in their use of the shrine as a socio-cultural and ethical institution. The shrine is an embodiment and the symbol of the very traditional religion of the people. As such, the shrine serves as a medium through which the norms, values, ethics, taboos, and morals are taught and enforced. There is also a great relationship between religion and justice as the shrine (Afi/Obio) as an ethical (...) institution serves as a tribunal of justice by the deities, divinities, and ancestors under the guidance and administration of the priest in tackling and resolving criminal activities, disputes as well as restoring social order and justice in Oron traditional society. The Oron Afi/Obio (Shrine) method of administering justice is beyond the Empirical application of the modern judiciary system that relies on physical facts and shreds of evidence, while the shrine, also, uses spiritual methods that involve Oath taking, incantation and necromancy. Globalization rather than modifying the lapses and loopholes of this system in the parlance of morality, ethics, and health has led to its abolition and break down. This work adopts the qualitative method. This work as primary research uses the conflict theory, phenomenological and Historical method. It identifies globalization as a threat to the traditional justice system and recommends that the shrine is a multi-faceted institution whose function can be adopted and applied to the Nigerian legal system where there is no or little evidence and oath swearing for politicians in our contemporary society. (shrink)

This chapter explores two questions in detail: How should we determine the threshold for costs that individuals are asked to bear through insurance premiums or care-related out-of-pocket costs, including user fees and copayments? and What is an adequate relationship between costs and benefits? This chapter argues that preventing impoverishment is a morally more urgent priority than protecting households against income fluctuations, and that many health insurance plans may not adequately protect individuals from health care costs that threaten to (...) drop their financial status below a decent minimum. A design that places greater emphasis on preventing impoverishment and finances the achievement of that goal by reducing unnecessary subsidies to better-off households would better accord with a sufficientarian approach to health care. -/- . (shrink)

People’s health is hugely affected by where they live, their occupational status and their socio-economic position. It has been widely argued that the presence of such social determinants in health provides good reasons to reject luck egalitarianism as a theory of distributive justice in health. The literature provides different reasons why this responsibility-sensitive theory of distributive justice should not be applied to health. The critiques submit that the social circumstances undermine or remove people’s responsibility (...) for their health; responsibility sensitive health policies would adversely affect those who are worst off and; the luck egalitarian approach to health distracts from the important task of rectifying socio-economic influences on people's health and provides individualistic solutions to collective problems. But for each of these variants of the critique luck egalitarianism provides suitable answers. The literature on social determinants is no detriment to the project of applying luck egalitarianism to health. (shrink)

Ableist attitudes and structures regarding disability are increasingly recognized across all sectors of healthcare delivery. After Dobbs, novel questions arose in the USA concerning how to protect reproductive autonomy while avoiding discrimination against and devaluation of disabled persons. As a case study, we examine the Louisiana’s Department of Public Health August 1st Emergency Declaration, “List of Conditions that shall deem an Unborn Child ‘Medically Futile.’” We raise a number of medical, ethical, and public health concerns that lead us (...) to argue the declaration should be rescinded. The ethically objectionable declaration provides valuable lessons concerning how to uphold both reproductive and disability justice in a post-Dobbs landscape. (shrink)

The growing epidemic of allergy and allergy-induced asthma poses a significant challenge to population health. This article, written for a target audience of policy-makers in public health, aims to contribute to the development of policies to counter allergy morbidities by demonstrating how principles of social justice can guide public health initiatives in reducing allergy and asthma triggers. Following a discussion of why theories of social justice have utility in analyzing allergy, a step-wise policy assessment protocol (...) formulated on Rawlsian principles of social justice is presented. This protocol can serve as a tool to aid in prioritizing public health initiatives and identifying ethically problematic policies that necessitate reform. Criteria for policy assessment include: 1) whether a tentative public health intervention would provide equal health benefit to a range of allergy and asthma sufferers, 2) whether targeting initiatives towards particular societal groups is merited based on the notion of ‘worst-off status’ of certain population segments, and 3) whether targeted policies have the potential for stigmatization. The article concludes by analyzing three examples of policies used in reducing allergy and asthma triggers in order to convey the general thought process underlying the use of the assessment protocol, which public health officials could replicate as a guide in actual, region-specific policy development. (shrink)

In response to commentators, we argue that whether waiving patent rights will meaningfully improve access to COVID-19 vaccines for low income and middle-income countries (LMICs), particularly in the short term, is an empirical matter. We also reject preferentially allocating vaccines to countries that hosted trials because doing so unethically favours those with research infrastructure, rather than those facing the worst burdens from COVID-19.

I outline and defend two egalitarian theories, which yield distinctive and, I argue, complementary answers to why health-related inequalities matter: a brute luck egalitarian view, according to which inequalities due to unchosen, differential luck are bad because unfair, and a social egalitarian view, according to which inequalities are bad when and because they undermine people’s status as equal citizens. These views identify different objects of egalitarian concern: the brute luck egalitarian view directs attention to health-related well-being, while social (...) egalitarianism focuses on health-related capabilities that are central to a person’s status as a citizen. I argue that both views are correct and should jointly guide priority-setting in health. (shrink)

One of the most frequently voiced criticisms of free will skepticism is that it is unable to adequately deal with criminal behavior and that the responses it would permit as justified are insufficient for acceptable social policy. This concern is fueled by two factors. The first is that one of the most prominent justifications for punishing criminals, retributivism, is incompatible with free will skepticism. The second concern is that alternative justifications that are not ruled out by the skeptical view per (...) se face significant independent moral objections (Pereboom 2014: 153). Despite these concerns, I maintain that free will skepticism leaves intact other ways to respond to criminal behavior—in particular incapacitation, rehabilitation, and alteration of relevant social conditions—and that these methods are both morally justifiable and sufficient for good social policy. The position I defend is similar to Derk Pereboom’s (2001, 2013, 2014), taking as its starting point his quarantine analogy, but it sets out to develop the quarantine model within a broader justificatory framework drawn from public health ethics. The resulting model—which I call the public health-quarantine model (Caruso 2016, 2017a)—provides a framework for justifying quarantine and criminal sanctions that is more humane than retributivism and preferable to other non-retributive alternatives. It also provides a broader approach to criminal behavior than Pereboom’s quarantine analogy does on its own since it prioritizes prevention and social justice. -/- In Section 1, I begin by (very) briefly summarizing my arguments against free will and basic desert moral responsibility. In Section 2, I then introduce and defend my public health-quarantine model, which is a non-retributive alternative to criminal punishment that prioritizes prevention and social justice. In Sections 3 and 4, I take up and respond to two general objections to the public health-quarantine model. Since objections by Michael Corrado (2016), John Lemos (2016), Saul Smilanksy (2011, 2017), and Victor Tadros (2017) have been addressed in detail elsewhere (see Pereboom 2017a; Pereboom and Caruso 2018), I will here focus on objections that have not yet been addressed. In particular, I will respond to concerns about proportionality, human dignity, and victims’ rights. I will argue that each of these concerns can be met and that in the end the public health-quarantine model offers a superior alternative to retributive punishment and other non-retributive accounts. (shrink)

Norman Daniels’s theory of health justice is the most comprehensive and systematic such theory we have. In one of the few articles published so far on Daniels’s new book, Just Health, Benjamin Sachs argues that Daniels’s core “principle of equality of opportunity does not do the work Daniels needs it to do.” Yet Sachs’s objections to Daniels’s framework are deeply flawed. Where these arguments do not rely on significant misreadings of Daniels, they ignore sensible strands in Just (...) Health that considerably dull their force. After disarming Sachs’s arguments against Daniels’s theory, I explain why I agree with Sachs’s conclusion: Daniels’s equality of opportunity-based account of health justice rests on shaky foundations. (shrink)

Background. The COVID-19 pandemic necessitated drastic changes to undergraduate medical training at the University of Botswana (UB). To save the academic year when campus was locked down, the Department of Medical Education conducted a needs assessment to determine the readiness for emergency remote teaching (ERT) of the Faculty of Medicine, UB. Objectives. To report on the findings of needs assessment surveys to assess learner and teaching staff preparedness for fair and just ERT, as defined by philosopher John Rawls. Methods. Needs (...) assessment surveys were conducted using Office 365 Forms distributed via WhatsApp, targeting medical students and teaching staff during the 5 undergraduate years. Data were analysed quantitatively and qualitatively. Results. Ninety-two percent (266/289) of students and 73.5% (62/84) of teaching staff responded. Surveys revealed a high penetration of smartphones among students, but poor internet accessibility and affordability in homes. Some teaching staff also reported internet and device insufficiencies. Only WhatsApp was accessible to students and teaching staff. Conclusions. For equitable access to ERT in the future, the surveys revealed infrastructural improvement needs, including wider, stronger, affordable WiFi coverage within Botswana and enhanced digital infrastructures in educational institutions, with increased support for students. (shrink)

This thesis under the title “Public Health Policy in Resource Allocation: the Role of Ubuntu Ethics in Redressing Resource Disparity between Public and Private Healthcare in South Africa” explores health care disparities pertaining to resource allocation between public and private sector. It is of relevance and importance in South Africa where 54% of the population live on less than US$3 per day. Although the government has instituted certain changes aimed at transforming the public health care system, the (...) resource allocation gap between the two persists and remains wide. The research gives special attention to the role that Ubuntu ethics can play in redressing the resource allocation disparities between public and private health care sectors in South Africa, pointing out the existing gap in financing, as well as human resource between public and private health care sectors, which leads to poor health outcomes in public sector. Therefore, the problem is the prevalent inequality of resource allocation between private and public health care sectors. The analysis of policy gaps, as well as evaluating the cause of disparities in the health system is the goal of this research. The study endeavours to redress the disparities within the context of Ubuntu ethical principles and proposes a change in public policy so as to enhance healthcare for the benefit of the people. The study is philosophical and ethical, so the methodology used is discursive in nature, majorly focusing on critically reviewing existing literature, that is, the philosophical resources on Ubuntu ethics and justice theories as well as a range of government resources inclusive of public health policy documents. Social determinants of health and their impact in a South African context are discussed with the implication that health is not merely freedom from disease and or incapacity, but rather being well mentally, physically and socially. The attainment of a healthy status goes beyond ability to access healthcare services, and incorporates social determinants including but not limited to conditions in which people have been born into, stay, establish career and grow old in. It also includes the arrangements put in place to deal with illness and determine health. Issues of revenue, literacy, communal safety networks, vocation and conditions under-which vocation is undertaken, lack of work and vocation insecurity, early stages of human development, gender, cultural group, dietary insecurity, housing communal exclusion and disability all come into the picture as factors that determine health. But there is also discussion of the socio-economic status as contributors to health inequity wherein alcohol abuse, sugar intake, and smoking are identified as behavioural factors that complicate public health. One outstanding feature of this research is that it establishes a link between Ubuntu and public health policy. The researcher establishes that Ubuntu ethics is appropriate for not only discussing public morality, but also for formulating public policy that is morally tenable for South Africa, especially for the public health sector. This thesis calls for an application of Ubuntu in a proper context in order to enhance societal well-being for the benefit of many, if not all. The research proposes the fundamental principle of Ubuntu ethics in which the good of the community is as important as the good of every member of the community. Since Ubuntu ethics does not merely seek to fulfil what benefits the majority, as would be the case in a utilitarian society, the researcher advocates for the building of consensus on the common good, which should be understood to imply not just what is good for everyone in the community, but also what is good for the continued well-being of the community as a single unit. In this regard, the research finds it important that deliberate effort be made to integrate Ubuntu ethics into policies, citing the example of the National Health Insurance (NHI). The good health of all the members of a community is an assurance of the well-being and continuity of the whole national community. The research concludes that public health policy should integrate Ubuntu ethical values such as community, sharing, care, solidarity, identity, harmony, respect, and dignity into policy documents and legislation. (shrink)