Diego Silva

ObjectiveTo identify the ethical challenges associated with the development and implementation of new tuberculosis drugs and diagnostics.MethodsTwenty-three semi-structured qualitative interviews conducted between December 2015 and September 2016 with programme administrators, healthcare workers, advocates, policymakers, and funders based in the Americas, Europe, and Africa. Interviews were analysed using thematic analysis.ResultsDivergent interests and responsibilities, coupled with power imbalances, are a primary source of ethical challenges; the uncertain risk profiles of new drugs present an additional one. Although this challenge can be partially mitigated through stringent pharmacovigilance, respondents highlighted that high-burden countries tend to lack the resources to facilitate safe implementation. Increased advocacy and community engagement are considered an ethical imperative for future TB development and implementation.ConclusionsThis project helps identify some of the ethical challenges of new TB technologies. It demonstrates that investigating ethical challenges through qualitative research is one way to apprehend the difficulty of implementing new TB technologies. Addressing this difficulty will require that those in positions of power reconsider their interests in relation to disempowered communities.Policy implicationsEfforts to build consensus regarding what values should underpin the global governance of TB research, prevention, and care are essential to facilitate the ethical implementation of new TB technologies.

Background The concept of “health security” is often used to motivate public health responses, yet the ethical values that underpin this concept remain largely unexamined. The recent Australian responses to COVID-19 serve as an important case study by which we can analyse the pre-existing literature to see what ethical values shaped, and continue to shape, Australia’s response. Methods We conducted a critical interpretive literature review of academic and grey literatures within key databases, resulting in 2,220 sources. After screening for duplicates and relevance, we analysed ninety-six sources. Results First, risk and uncertainty are a leading focus, with a heavy concentration on risks to life and health. Second, free movement, safety, and security were recurringly emphasized, albeit narrowly focused upon the safety of the population. Third, legitimacy was a recurring theme, and it is here that discussions of “health security” figured highly. Conclusion Discussions of harm from government and associated official bodies fail to adequately distinguish between various senses of harm. Moreover, while the literature often discusses the balancing of rights, the steps involved in the weighing of these rights is rarely adequately explained and defended. We suggest that decision-makers should endeavour to clearly identify and defend the values undergirding their decisions in the public sphere.

South Africa shared with the world the warning of a new strain of SARS-CoV2, Omicron, in November 2021. As a result, many high-income countries (HICs) instituted complete travel bans on persons leaving South Africa and other neighbouring countries. These bans were unnecessary from a scientific standpoint, and they ran counter to the International Health Regulations. In short, South Africa was penalized for sharing data. Data sharing during pandemics is commonly justified by appeals to solidarity. In this paper, we argue that solidarity is, at best, an aspirational ideal to work toward but that it cannot ground an obligation to share data. Instead, low-and-middle income countries (LIMCs) should be guided by the principle of reciprocity, which states that we ought to return good for good received. Reciprocity is necessarily a conditional principle. LMICs, we argue, should only share data during future pandemics on the condition that HICs provide enforceable assurances that the benefits of data sharing will be equitably distributed and that LMICs won’t be penalized for sharing information.

This paper explores the notion of reciprocity in the context of active pulmonary and laryngeal tuberculosis treatment and related control policies and practices. We seek to do three things: First, we sketch the background to contemporary global TB care and suggest that poverty is a key feature when considering the treatment of TB patients. We use two examples from TB care to explore the role of reciprocity: isolation and the use of novel TB drugs. Second, we explore alternative means of justifying the use of reciprocity through appeal to different moral and political theoretical traditions. We suggest that each theory can be used to provide reasons to take reciprocity seriously as an independent moral concept, despite any other differences. Third, we explore general meanings and uses of the concept of reciprocity, with the primary intention of demonstrating that it cannot be simply reduced to other more frequently invoked moral concepts such as beneficence or justice. We argue that reciprocity can function as a mid-level principle in public health, and generally, captures a core social obligation arising once an individual or group is burdened as a result of acting for the benefit of others. We conclude that while more needs to be explored in relation to the theoretical justification and application of reciprocity, sufficient arguments can be made for it to be taken more seriously as a key principle within public health ethics and bioethics more generally

During the early years of the COVID-19 pandemic, preclinical and clinical research were sped up and scaled up in both the public and private sectors and in partnerships between them. This resulted in some extraordinary advances, but it also raised a range of issues regarding the ethics, rigour, and integrity of scientific research, academic publication, and public communication. Many of the failures of scientific rigour and integrity that occurred during the pandemic were exacerbated by the rush to generate, disseminate, and implement research findings, which not only created opportunities for unscrupulous actors but also compromised the methodological, peer review, and advisory processes that would usually identify sub-standard research and prevent compromised clinical or policy-level decisions. While it would be tempting to attribute these failures of science and its translation solely to the “unprecedented” circumstances of the COVID-19 pandemic, the reality is that they preceded the pandemic and will continue to arise once it is over. Existing strategies for promoting scientific rigour and integrity need to be made more rigorous, better integrated into research training and institutional cultures, and made more sophisticated. They might also need to be modified or supplemented with other strategies that are fit for purpose not only in public health emergencies but in any research that is sped-up and scaled up to address urgent unmet medical needs.

In May 2021, when the Delta variant of SARS-CoV2 was wreaking havoc in India, the Australian Federal Government banned its citizens and residents who were there from coming back to Australia for 14 days on penalty of fines or imprisonment. These measures were justified on the grounds of protecting the broader Australian public from potentially importing the Delta strain, which officials feared would then seed a local outbreak. Those Australians stranded in India, and their families and communities back home, claimed that they were abandoned by Prime Minister Scott Morrison’s government. This case—along with other barriers used as part of border control measures in the name of public health—raises the following question: is it ever morally permissible for a state to ban its citizens and residents from entering their own country during a pandemic? I conclude that it’s impermissible. I argue that persons have a right of entry that should be understood as a security right. This security right should be non-derogable because it’s a foundational good that is necessary for life-planning purposes. Moreover, it is a right that people should be able to rely upon absolutely, even during pandemics. At the very least, should someone believe that there are rare exceptions to the right of entry on public health grounds, governments have a duty—grounded in the principle of reciprocity—to support those who are temporarily denied entry. In the case of Australians stranded in India, I will argue that the Australian Federal Government failed on all accounts.

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

Accelerated changes to the planet have created novel spaces to re-imagine the boundaries and foci of environmental health research. Climate change, mass species extinction, ocean acidification, biogeochemical disturbance, and other emergent environmental issues have precipitated new population health perspectives, including, but not limited to, one health, ecohealth, and planetary health. These perspectives, while nuanced, all attempt to reconcile broad global challenges with localized health impacts by attending to the reciprocal relationships between the health of ecosystems, animals, and humans. While such innovation is to be encouraged, we argue that a more comprehensive engagement with the ethics of these emerging fields of inquiry will add value in terms of the significance and impact of associated interventions. In this contribution, we highlight how the concept of spatial and temporal scale can be usefully deployed to shed light on a variety of ethical issues common to emerging environmental health perspectives, and that the potential of scalar analysis implicit to van Potter’s conceptualization of bioethics has yet to be fully appreciated. Specifically, we identify how scale interacts with key ethical issues that require consideration and clarification by one health, ecohealth, and planetary health researchers and practitioners to enhance the effectiveness of research and practice, including justice and governance.

The concept of dignity has occasioned a robust conversation in recent healthcare scholarship. When viewed as a whole, research on dignity in healthcare has engaged each of the four bioethical principles popularized by Beauchamp and Childress, but has paid the least attention to beneficence. In this paper, we look at dignity and beneficence. We focus on the dignity promotion component of a model of dignity derived from a grounded theory study. After describing the study and presenting a précis of the resulting model, we review the principle of beneficence and look at the ways in which the notion of dignity promotion can be used to complement our understanding of this principle. Specifically, we explore what we can learn from dignity promotion about the relational nature of beneficence in healthcare and how dignity promotion can be marshaled to help address the epistemological quandary of soft paternalism

Background: Demand for organisational ethics capacity is growing in health organisations, particularly among managers. The role of clinical ethicists in, and perspective on, organisational ethics has not been well described or documented in the literature. Objective: To describe clinical ethicists’ perspectives on organisational ethics issues in their hospitals, their institutional role in relation to organisational ethics, and their perceived effectiveness in helping to address organisational ethics issues. Design and Setting: Qualitative case study involving semi-structured interviews with 18 clinical ethicists across 13 health organisations in Toronto, Canada. Results: From the clinical ethicists’ perspective, the most pressing organisational ethics issues in their organisations are: resource allocation, staff moral distress linked to the organisation’s moral climate, conflicts of interest, and clinical issues with a significant organisational dimension. Clinical ethicists were consulted in particular on issues related to staff moral distress and clinical issues with an organisational dimension. Some ethicists described being increasingly consulted on resource allocation, conflicts of interest, and other corporate decisions. Many clinical ethicists felt they lacked sufficient knowledge and understanding of organisational decision-making processes, training in organisational ethics, and access to organisational ethics tools to deal effectively with the increasing demand for organisational ethics support. Conclusion: Growing demand for organisational ethics expertise in healthcare institutions is reshaping the role of clinical ethicists. Effectiveness in organisational ethics entails a re-evaluation of clinical ethics training to include capacity building in organisational ethics and organisational decision-making processes as a complement to traditional clinical ethics education

Managing the perceived or actual risks of vaccine policy remains a challenge for public health. Vaccines are among the most significant public health achievements; however, current public and political discourse focuses on the risk of harm they purportedly produce. While the vaccine-related bioethics literature often centres on risk, it has largely overlooked the growing normative scholarship on ethical risk imposition and just distribution. We undertook an analytic scoping review to understand how risk is applied in the bioethics literature, primarily to take stock of where we stand as a bioethics community to advance discussions on ethical vaccination policy. Sixty-two papers were included. Most of the literature adopts an agent-relative rather than agent-neutral account of risk, prioritising duties and rights related to avoiding harm, respecting autonomy and ensuring fairness over simplistic consequentialist reasoning. While individual papers often convey risk as flowing in a single direction – falling into either agent-centred or patient-centred perspectives – the literature as a whole reveals risk to be multidirectional. We are simultaneously both vector and victim, and with regard to risk imposition and distribution, also, morally, both agent and patient. Recognising this is critical for clearer ethical reasoning and more effective discourse and policymaking.

Este ensaio propõe uma releitura filosófico-política das ações de Oskar Schindler à luz da obra O Príncipe, de Nicolau Maquiavel. Longe de uma análise moralista ou romantizada, argumenta-se que Schindler pode ser interpretado como um “príncipe” maquiavélico que, ciente da instabilidade da fortuna, utilizou a virtù – entendida como capacidade de ação eficaz frente às circunstâncias – para subverter um sistema opressor e salvar centenas de vidas. Schindler, como um “príncipe” em seu microcosmo, empregou a virtù (habilidade de adaptação) e ante a fortuna (oportunidade) para proteger seu “Estado” simbólico, agindo com pragmatismo ético. O texto contrapõe essa leitura a princípios jurídico-morais abstratos e universalizantes, sugerindo que, em contextos-limite como o nazismo, uma ética da ação concreta e estratégica – nos moldes maquiavélicos – mostra seu valor teleológico ao ser capaz de produzir efeitos humanitários reais. O trabalho também dialoga com autores como Viktor Frankl e Jean-Paul Sartre, reforçando a dimensão existencial da liberdade diante da catástrofe. Conclui-se que Maquiavel não defende a crueldade gratuita, mas sim a eficácia adaptativa, que pode servir tanto a fins opressivos quanto humanitários.

We agree with Smith and Mackie1 that voluntariness is a necessary condition of informed consent in medicine, including instances when people undergo vaccination. However, we disagree with the authors’ claim that the Recipient-Focus-View (RFV) morally validates coercive measures such as vaccine mandates. While we commend their efforts, as we argue herein, if one chooses to hold voluntariness as a necessary condition of the moral permissibility of vaccine mandates, then one must track voluntariness throughout the process of vaccine delivery and uptake, not whether the consent given in the context of a vaccine mandate is valid irrespective of voluntariness. Very briefly then, we understand the conclusion of their argument as follows: a person receiving a vaccine is a consent-giver (first party), while clinicians who administer the vaccine are consent-receivers (second party). In the context of a vaccine mandate, those establishing the mandate (eg, employers) are the third party who are acting coercively. As such, in this three-party situation, assuming clinicians only remain consent-receivers but not the coercers in the context of vaccine mandates, the consent of the coerced person being vaccinated (ie, consent-giver) is valid since consent is only motivated by coercion but not obtained, as such, by the clinician. Smith and Mackie hold …

We often use certain terms as if, in using them, they contain a decided moral judgment of an action. Especially in public health ethics, this is not always the case, as shown most starkly by recent (mis)use of the terms “solidarity” and “coercion” to label, and thereby judge, public health actions responding to the COVID-19 pandemic. We analyze the terms solidarity and coercion, and argue that they cannot be used alone as moral judgements of public health actions. Rather, they are better considered as descriptive terms that are merely frequent proxies for normative terms such as justice or utility. We illustrate our argument by reference to three case studies: school reopenings in the USA, mandatory isolation measures in the UK, and vaccine distribution within the EU.

The workshop, Coercing for Health: Transdisciplinary Approaches to the Ethics of Coercive Public Health Policies was held at the University of Oxford on July 3rd and 4th, 2024. This paper provides both a summary of the workshop proceedings and reflections and directions for future research on coercive public health measures. The workshop consisted of four key parts: defining coercion; history and legal analysis of coercion; public health ethics perspectives on coercion; experiences of coercive public health measures. According to our reflections, some important questions remaining for further research include: what is the difference between coercion and enforcement? Who gets to define and address coercion? How do structural factors affect health and experiences of coercion? We encourage others to continue to work on this important area, to ensure the ethically acceptable and thoughtful implementation of any future coercive measures in the sphere of public health.

Greater attention should be given to place when considering whether to, and how to, implement restrictive measures in response to infectious disease outbreaks and pandemics. Human beings cannot experience the world except in place, while place allows us to act ethically and in relation to other persons. Some have described place as a location with meaning to humans. Our individual and collective sense of meaning and identities are partly created in and by the places we live, while our sense of agency and security are shaped by them. Although taking the concept of place seriously is central to other disciplines and cultures, it is– with some notable exceptions– absent in the bioethics literature, including that of public health ethics. This paper attempts to outline how attending to the normative aspects of place can help explain some of our lingering COVID19-related trauma, as well as be used constructively in responding to future outbreaks when we cannot avoid the use of restrictive measures.

Neste texto temos por objetivo compreender e problematizar os sentidos de diversidade que a Revista Exame faz circular sobre grupos minorizados e suas caracterizações. Partimos da premissa de que essa mídia, em perspectiva discursiva, ocupa lugar de modelar, orientando as percepções de lideranças empresariais (gestores, empresários, investidores) sobre diferentes temas, como o das diversidades. Dentre outras coisas, essa influência tende a se traduzir em cultura organizacional, portanto na forma como as diversidades podem se fazer presentes nas organizações. A perspectiva metodológica é a análise do discurso e o corpus é constituído por todos os materiais veiculados nas 24 edições da revista, em 2019, que se relacionam às “diversidades” e/ou “diferenças”. Os resultados mostram que as abordagens são isoladas e simplistas, indicando que o valor das diferenças está na sua aplicação e utilidade para a gestão.

In late March 2020 in response to the COVID-19 pandemic, Australia introduced mandatory 14-day supervised quarantine at hotels and other designated facilities for all international arrivals. From July 2020, most states and territories introduced a fixed charge for quarantine of up to $3220 per adult. The introduction of the fee was rationalised on the basis that Australians had been allowed sufficient time to return and there was a need to recover some of the cost associated with administering the program. Drawing on an empirical study of 58 returned Australian citizens and residents quarantined between March 2020 and January 2021, this paper aims to explore how people experienced paying for hotel quarantine, particularly with respect to fairness and relatedly, the principle of reciprocity. Reciprocity requires that the state has an obligation to assist individuals in discharging their duty to comply with public health measures and avoid disproportionate burdens accruing to populations or individuals. Though participants had varying opinions on whether they thought it fair to be charged for their quarantine, for many, the fee constituted a significant burden and source of stress. Given the undertaking of quarantine is primarily for the benefit of the public good, we argue the financial cost imposed on individuals does not meet the demands of reciprocity. It is imperative that future quarantine and isolation arrangements consider seriously the need to minimise burdens of individuals subject to such measures, and that fees do not become a new norm in public health and infectious disease control.

Efforts to improve public health, both in the context of infectious diseases and non-communicable diseases, will often consist of measures that confer risk on some persons to bring about benefits to those same people or others. Still, it is unclear what exactly justifies implementing such measures that impose risk on some people and not others in the context of public health. Herein, we build on existing autonomy-based accounts of ethical risk imposition by arguing that considerations of imposing risk in public health should be centered on a relational autonomy and relational justice approach. Doing so better captures what makes some risk permissible and others not by exploring the importance of power and context in such deliberations. We conclude the paper by applying a relational account of risk imposition in the cases of (a) COVID-19 measures and (b) the regulation of sugar-sweetened beverages to illustrate its explanatory power.

Complexity abounds in public health, yet public health ethics—as currently practiced—often struggles to accept this state-of-affairs; this results in moral debates that overemphasize the potential overreach of states in the pursuit of public health, while underemphasizing its morally troubling underreach. James Wilson’s Philosophy for Public Health and Public Policy: Beyond the Neglectful State (2021) represents a culmination of over a decade of his work where he tries addressing directly the challenge of complexity of reasoning about values in applied political philosophy. The result is an important, well-argued, and well-written book that should be read by those who are both interested in the methods of public health ethics and how complexity-informed public health ethics can help shape policy debates.The thesis of the book is as follows: much time has been spent debating whether the state is acting as a ‘nanny’ state in regard to public health policy and practice x, and when and how this amounts to a justified burden on one’s autonomy and subsequent choices. But this misses the point: we all have a right to health, which includes a right to the fruits of public health because we are autonomous persons and autonomy is valuable. We should be wary not only of a nanny state, but of a neglectful state which absolves itself of responsibility for the various determinants of health within its control and legitimate remit. In turn, philosophers keen to help governments resolve real-world public health problems—and help states discharge their positive duty to promote health—must do so with humility while helping policy makers think through the values that underpin complex social problems.

This article presents and discusses alchemy and cybernetics as fields in interaction through a conversation model. The starting point for establishing this relationship is the distinction between communication and conversation as pointed out by authors such as Gordon Pask, Ranulph Glanville and Vilém Flusser. Alchemy was the field of knowledge that best managed to unify Europe’s technological, philosophical and mystical world-view in the late Middle Ages. From an experimental basis, alchemy dealt with the transformation processes mirrored both in a particular understanding of the dynamics of nature as in the connection between man and universe. Cybernetics, like alchemy, was a field developed from an interdisciplinary view of knowledge associated with a particular historical context, being, since its origin, the field that relates and operationalizes complexity and unpredictability in mechanical, biological and social systems. Cybernetics and alchemy are, from a constructivist perspective, models for structuring the world and collective systems of communication within cultural processes. Both are taken here as co-participants in an elliptical dialogue based on three main concepts: distinction, dialogue and emergence. The elliptical conversation model can be understood as a map of the complexity of the interactive field that is established between alchemy and cybernetics, generating a new entity while encapsulating two others, it is the distinction that accommodates two others, a dialogue between black boxes.

Emerging genomic technologies promise more efficient infectious disease control. Whole genome sequencing is increasingly being used in tuberculosis diagnosis, surveillance, and epidemiology. However, while the use of WGS by public health agencies may raise ethical, legal, and socio-political concerns, these challenges are poorly understood. Between November 2017 and April 2018, we conducted semi-structured interviews with 22 key stakeholders across the fields of governance and policy, public health, and laboratory sciences representing the major jurisdictions currently using WGS in national TB programs. Thematic analysis of the interviews was conducted using NVivo 11. Respondents identified several ethical and practical challenges associated with WGS in TB care and surveillance, all related to issues of trust, including: 1) the power of public health; 2) data sharing and profits derived from surveillance efforts; and 3) concerns regarding who has access to, and can benefit from, the technology. Additional challenges included: the potential utility that WGS adds to a public health program, the risks associated with linking necessary epidemiological metadata to the genomic data, and challenges associated with jurisdictional capacity to implement the technology. Successful implementation of WGS is dependent on fostering relationships of trust between those working with genomics technology and those directly impacted by it, including clinicians. Building trust between the public and the public health agencies and within public health agencies themselves is critical due to the inherent complexity of WGS and its implementation for communicable disease control purposes.

Prominent tuberculosis (TB) actors are invoking solidarity to motivate and justify collective action to address TB, including through intensified development and implementation (D&I) of technologies such as drugs and diagnostics. We characterize the ethical challenges associated with D&I of new TB technologies by drawing on stakeholder perspectives from 23 key informant interviews and we articulate the ethical implications of solidarity for TB technology D&I. The fundamental ethical issue facing TB technological D&I is a failure within and beyond the TB community to stand in solidarity with persons with TB in addressing the complex sociopolitical contexts of technological D&I. The failure in solidarity relates to two further ethical challenges raised by respondents: skewed power dynamics that hinder D&I and uncertainties around weighing risks and benefits associated with new technologies. Respondents identified advocacy and participatory research practices as necessary to address such challenges and to motivate sustained collective action to accelerate toward TB elimination. We present the first empirical examination of bioethical accounts of solidarity in public and global health. Our study suggests that solidarity allows us better to understand and address the ethical challenges that arrest the D&I of new TB technologies. Solidarity lends credence to policies and practices that address the relational nature of illness and health through collective action.

The unprecedented outbreak of Ebola virus disease in West Africa has raised several novel ethical issues for global outbreak preparedness. It has also illustrated that familiar ethical issues in infectious disease management endure despite considerable efforts to understand and mitigate such issues in the wake of past outbreaks. To improve future global outbreak preparedness and response, we must examine these shortcomings and reflect upon the current state of ethical preparedness. To this end, we focus our efforts in this article on the examination of one substantial area: ethical guidance in pandemic plans. We argue that, due in part to their focus on considerations arising specifically in relation to pandemics of influenza origin, pandemic plans and their existing ethical guidance are ill-equipped to anticipate and facilitate the navigation of unique ethical challenges that may arise in other infectious disease pandemics. We proceed by outlining three reasons why this is so, and situate our analysis in the context of the EVD outbreak and the threat posed by drug-resistant tuberculosis: different infectious diseases have distinct characteristics that challenge anticipated or existing modes of pandemic prevention, preparedness, response, and recovery, clear, transparent, context-specific ethical reasoning and justification within current influenza pandemic plans are lacking, and current plans neglect the context of how other significant pandemics may manifest. We conclude the article with several options for reflecting upon and ultimately addressing ethical issues that may emerge with different infectious disease pandemics.