Marcel Verweij

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.

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.

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.

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.

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.

ABSTRACT If we have a duty not to infect others, how far does it go? This question is often discussed with respect to HIV transmission, but reflection on other diseases like influenza raises a number of interesting theoretical issues. I argue that a duty to avoid infection not only yields requirements for persons who know they carry a disease, but also for persons who know they are at increased risk, and even for those who definitely know they are completely healthy. Given the numerous ways in which human interaction facilitates the spread of communicable diseases, a maximum level of precaution would be very demanding – possibly unreasonably demanding. The ‘over‐demandingness problem’ is mostly invoked as a criticism of utilitarianism, as this theory requires moral agents to always maximise general welfare, even at significant cost for themselves. However, I argue that, with respect to precautions against infectious diseases like influenza, utilitarianism is able to avoid the over‐demandingness problem. A contractualist account, on the other hand, whilst able to explain how one's obligations to avoid infection can be limited, given that other persons have opportunities and responsibilities to protect themselves, in the end requires precautions that raise the over‐demandingness problem.

The futility debate may be considered as an effort to provide a clear and justified borderline between physician and patient decision–making authority. In this paper we argue that the search for a definition of futility that provides physicians with a final argument in discussions about life–prolonging treatment, is misplaced. An acceptable and meaningful criterion of futility that satisfies this effort seems impossible. As a consequence, we reject a dichotomous domain of decision–making power as the starting point for definitions of futility. A good decision about withholding life–sustaining treatment should be justified from the perspectives of both physician and patient. In this light, a range of definitions of futility is still useful as it can clarify intuitions that a treatment is inappropriate.

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.

The prescription of growth hormone therapy for children who are not growth hormone deficient is one of the controversies in contemporary paediatric endocrinology. Is it morally appropriate to enhance the growth, by means of medical treatment, of a child wish idiopathic short stature? The medical, moral, and philosophical questions in this area are many. Data on the effects of human growth hormone (hGH) treatment will not on their own provide us with answers, as these effects have to be evaluated from a normative perspective. In this article we consider hGH treatment for children of idiopathic short stature from three normative perspectives: the goals of medicine, the good of the patient, and the public good. We argue that the prevention of psychological and social problems due to short stature (and not merely the enhancement of growth) should be the ultimate goal of medical treatment and research