Marcel Verweij

Thanks to developments in genomics,dietary recommendations adapted to genetic riskprofiles of individual persons are no longerscience fiction. But what are the consequencesof these diets? An examination of possibleimpacts of genetically tailor-made diets raisesmorally relevant concerns that are analogous to(medical-ethical) considerations aboutscreening and testing. These concerns oftengive rise to applying norms for informedconsent and for the weighing of burdens andbenefits. These diets also have a broaderimpact, especially because food patterns arefull of personal, social and cultural meanings.Diets will change one's food patterns and one'sattitude towards food, and this may implychanges in one's identity. We argue that suchan impact does not necessarily raise moralproblems. Moral concerns are, however, relevantif collective values and shared meanings infood practices are at issue. Therefore, thedevelopment of genetically tailor-made dietsdoes not merely require emphasis on weighingpersonal benefits and burdens and on informedconsent. It also asks for attention to andmoral reflection on the collective valuesinvolved in food practices.

One of the societal problems in a new influenza pandemic will be how to use the scarce medical resources that are available for prevention and treatment, and what medical, epidemiological and ethical justifications can be given for the choices that have to be made. Many things may become scarce: personal protective equipment, antiviral drugs, hospital beds, mechanical ventilation, vaccination, etc. In this paper I discuss two general ethical principles for priority setting (utility and equity) and explain how these principles will often point in diverging directions. Moreover, each of these principles can be understood in different, again often competing, ways. Notwithstanding these controversies and conflicts, in the context of pandemic response there are at least some points of convergence: several policies can be justified by appeal to different ethical principles and theories. Convergence may be found with respect to a focus on saving the most lives (instead of other aggregative accounts); giving priority antiviral prophylaxis and therapy for life-saving pandemic responders; and, partly depending on epidemiology of the pandemic, to prioritise vaccination of children. Although decision-making about access to intensive care will involve choices with immediate tragic implications, the ethical complexity of these choices is relatively modest (although decisions will not be easy): there are persuasive moral reasons for giving priority to patients who are expected to benefit most within the shortest time. Finally, in the last section I tentatively argue that constraints on people’s freedom, as necessary for an effective public health approach, may support giving somewhat more weight to saving the most lives, than to concerns of equity.

Many nursing homes have an influenza vaccination policy in which it is assumed that express (proxy) consent is not necessary. Tacit consent procedures are more efficient if one aims at high vaccination rates. In this paper I focus on incompetent residents and proxy consent. Tacit proxy consent for vaccination implies a deviance of standard proxy consent requirements. I analyse several arguments that may possibly support such a deviance. The primary reason to offer influenza vaccination is that vaccinated persons have a significantly reduced risk of getting the flu. This reason however cannot support the assumption that each nursing home resident is ‘better off ’ if she is vaccinated. Neither can it support tacit proxy consent policies. More promising are arguments that take the collective nature of infectious diseases into account. A potentially strong, but ultimately insufficient, argument for non‐express consent is that vaccination contributes to prevention of harm to others. Other arguments emphasise the importance of group protection: herd immunity. I discuss three collective reasons for aiming at herd immunity: solidarity, a common interest in reducing the risk of illness, and a common interest in the prevention of an influenza outbreak. The latter argument appears to be most important. An outbreak is not just detrimental to the health of residents; it is detrimental to their everyday social life as well. Outbreaks can be seen as a collective evil. My analysis shows that there are valid (though not necessarily sufficient) moral arguments for a tacit proxy consent policy.

Machine generated contents note: Preface; Introduction Angus Dawson; Part I. Concepts: 1. Resetting the parameters: public health as the foundation for public health ethics Angus Dawson; 2. Health, disease and the goal of public health Bengt Brülde; 3. Selective reproduction, eugenics and public health Stephen Wilkinson; 4. Risk and precaution Stephen John; Part II. Issues: 5. Smoking, health and ethics Richard Ashcroft; 6. Infectious disease control Marcel Verweij; 7. Population screening Ainsley Newson; 8. Vaccination ethics Angus Dawson; 9. Environment, ethics and public health: the climate change dilemma Anthony Kessel and Carolyn Stephens; 10. Public health research ethics: is non-exploitation the new principle for population-based research ethics? John McMillan; 11. Equity and population health: toward a broader bioethics agenda Norman Daniels; 12. Health inequities James Wilson; Index.

Newborn screening consists of taking a few drops of blood from a baby's heel in the first week of life and testing it for a list of disorders. In the United States and most countries in Europe, newborn screening programs began in the 1960s and 1970s with screening for phenylketonuria (PKU), a rare metabolic disease that causes severe and irreversible mental retardation unless treated before problems arise. As knowledge about rare diseases expanded and new screening technologies were introduced—such as the tandem mass spectrometer and high‐performance liquid chromatography—the same blood sample could be used to test for a whole list of disorders. In general, screening programs in most countries have tended to expand, but in different countries they have expanded in different ways. Regulation also varies. In some states, screening is mandatory, whereas in others—Wyoming and Maryland—parents are asked for their informed consent. Germany and France have adopted an explicit informed consent procedure, whereas other European countries have a more informal “opt‐out” procedure that does not require signing an informed consent form. Whether newborn screening requires informed consent is an ongoing issue in bioethics. In this article, we will focus on the tension between informed consent and the problem of compliance in newborn screening. Asking for informed consent—allowing parents to opt out—is often thought to pose a threat to compliance. Building on the work of Onora O'Neill on informed consent and trust, however, as well as on work she coauthored with Neil Manson, we will argue that informed consent procedures may actually help maintain trust in newborn screening and may therefore support compliance.

As many moral problems have a very complex nature, moral reasoning towards a justified decision in such cases may be as difficult. Many considerations have to be taken into account in order to reach a judgement based on good reasons. May the computer, as a tool in data processing, be of use for ethical decision-making? In this paper I will argue that we should be very careful in developing and using ethical expert-systems. Next, I will explain how the computer may be a useful ‘tool’ for instruction in moral reasoning. This will be done by presenting a model for Computer Assisted Instruction in ethics. Finally, I will describe the outline of a CAI program according to this model and discuss some problems which are encountered in designing this program.

Emerging infectious diseases such as Ebola, Hendra, SARS, West Nile, Hepatitis E and avian influenza have led to a renewed recognition of how diseases in human beings, wildlife and livestock are interlinked. The changing prevalence and spread of such infections are largely determined by human activities and changes in environment and climate—where the latter are often also caused by human activities. Since the beginning of the 21st century, these insights have been brought together under the heading of OneHealth—a concept that calls for interdisciplinary collaboration between various sciences as well as professional practices to promote and protect the health of human and non-human animals and the natural environment. Just as insights from public health have led to a broadened focus for health policy and medical care, from treating individual patients to protecting and promoting population health, OneHealth calls for an even broader perspective, including a concern for the environment and animals, and for social-cultural factors that affect human, animal and environmental health. OneHealth not only covers collaborative work to understand and control zoonotic diseases, but also other ways in which interactions between animals, plants and humans may positively or negatively impact on each other’s health. Thus, studies in veterinary medicine and environmental sciences may lead to new insights in human medicine, and vice versa. Acknowledgment of the links between environmental, animal and social health is of course not a novel insight. Hippocrates already pointed to the importance of a clean environment as a requirement for good health; the early public health movements emphasized hygienic living conditions including good-quality housing, sewage systems and clean air and water; and the founders of modern medicine such as William Osler and Rudolf Virchow promoted …

BACKGROUND: The availability of costly safety measures against transfusion-transmissible infections forces Western countries to confront difficult ethical questions. How to decide about implementing such measures? When are such decisions justified? As a preliminary to addressing these questions, we assessed which concerns shape actual donor blood safety policymaking in five Western countries. STUDY DESIGN AND METHODS: Our qualitative study involved determining which issues had been discussed in advisory committee meetings and capturing these issues in general categories. Appropriate documents were identified in collaboration with local decision-making experts in Canada, Germany, the Netherlands, the United States, and the United Kingdom. The introduction of hepatitis B virus nucleic acid testing and selected measures against variant Creutzfeldt-Jakob disease, West Nile virus, and Q-fever were chosen as cases representing decision-making on safety measures with high costs and low or uncertain added safety. RESULTS: A broad inventory of concerns was established, including: 1) nine categories of advantages and disadvantages of candidate safety policies; 2) six kinds of difficulties in assessing risks and forecasting the effects of safety policies; 3) 13 decision-making principles; and 4) six kinds of practical barriers hampering the translation of candidate policies into decisions. CONCLUSION: Blood safety policymaking involves a wide variety of competing concerns, and approaches to reconcile these considerations are themselves contested. Developing a systematic decision-making approach requires ethical reflection on, among others, reasonable costs of safety and the value of transparency in public policy.

Preventive medicine is sometimes criticised as it contributes to medicalization of normal life. The concept ‘medicalization’ has been introduced by Zola to refer to processes in which the labels ‘healthy’ and ‘ill’ are made relevant for more and more aspects of human life. If preventive medicine contributes to medicalization, would that be morally problematic? My thesis is that such a contribution is indeed morally problematic. The concept is sometimes used to express moral intuitions regarding the practice of prevention and health promotion. Through analysis of these intuitions as well as some other moral concerns, I give an explication of the moral problems of medicalization within the context of preventive medicine.

Vaccination involves priming the immune system with an antigenic agent that mimics a virus or bacterium, which results in immunity against the “real” microorganism. Collective vaccination policies have played an important role in the control of infectious disease worldwide. They can serve the utilitarian aim to protect public health – hence welfare – and also promote fairness: making essential vaccines accessible to all members of the public. Yet as more and more vaccines are developed, societies face the question of how far to go in expanding public programs. Decisions about adopting new vaccines in the program will require combining scientific evidence about the disease and the vaccine, with value judgments about, for example, the extent to which a disease poses a threat to public health. It makes sense to promote transparency of such deliberations because one cannot expect that citizens simply accept every government vaccination policy