Tess Johnson

Antibiotic treatment course duration has for decades been dictated by two questionable ideas: first, that longer courses are more effective at curing bacterial infections; second, that longer courses are less likely to lead to drug resistance. Recently, the “shorter is better” movement has challenged the received wisdom, showing shorter-duration antibiotic courses provide similar cure rates, fewer antibiotic-related harms, and possibly less contribution to of antibiotic resistance for common infections. Yet, physicians typically still prescribe longer courses of antibiotics than clinical guidelines recommend. This is ethically unacceptable. In this paper, we argue that prescribing physicians are ethically obligated to prescribe shorter antibiotic courses, given that prescribing physicians bear duties both toward their patients and to protect public health. We rebut objections to our argument and furthermore argue for an ethical obligation of physician-researchers to conduct further trials comparing the shortest current evidence-based course of antibiotics with courses that are even shorter.

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.

Molecular HIV surveillance, involving the collection and analysis of HIV genome sequences, has become an integral part of public health programmes in high‐income countries. By employing phylogenetic analysis, molecular HIV surveillance can identify individuals and their positions within networks of HIV transmission. While the primary aim of molecular surveillance is to yield public health benefits, such as linking people to care and reducing transmission, it also poses risks and potential infringements on individual privacy and liberty. This paper examines the ethical implications of using phylogenetics to identify individuals involved in multiple transmission events in high‐income countries. Although public health responses tailored to such individuals can significantly reduce further transmission, these individuals often face multiple intersecting vulnerabilities and bear the greatest risks associated with molecular surveillance. We analyze the risks related to privacy, stigma, mistrust, criminalization, and liberty infringements, alongside the benefits of preventing further transmission and increasing healthcare engagement for people living with HIV. We conclude by outlining plausible and ethically acceptable policy options for molecular surveillance practice.

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.

Public health policies designed to improve individual and population health may involve coercion. These coercive policies require ethical justification, and yet it is unclear in the public health ethics literature which ethical concepts might justify coercion, and what their limitations are in applying across contexts. In this paper, we analyse a number of concepts from Western bioethics, including the harm principle, paternalism, the public interest, and a duty of easy rescue. We find them plausible justifications for coercion in theory, but when applied to case studies, including HIV testing in Malawi, vaccine mandates in South Africa, and prohibitions of antibiotic use in livestock in the EU, their limitations become clear. We argue that the context-specificity of ethical justifications for coercion has been overlooked, and there is more work needed to identify context-relevant ethical justifications for coercive policies in various settings and for various populations, rather than relying on universalising Western bioethical justifications across all contexts.

Antimicrobial resistance has been termed a ‘silent pandemic’, a ‘hidden killer.’ This language might indicate a threat of significant future harm to humans, animals, and the environment from resistant microbes. If that harm is uncertain but serious, the precautionary principle might apply to the issue, and might require taking ‘precautionary measures’ to avert the threat of antimicrobial resistance, including stewardship interventions like antibiotic prescription caps, bans on certain uses in farming sectors, and eliminating over-the-counter uses of antibiotics. The precautionary principle is a useful tool in ethical analyses of antimicrobial stewardship measures, but as I argue in this article, it ought not be used as a standalone tool. The principle considers the magnitude of harms to be averted and those arising from precautionary measures, but—importantly—it does not consider the distribution of those harms. That may raise issues of social justice if the harms of stewardship measures befall already disadvantaged populations. To avoid this blind spot in ethical analysis using the precautionary principle, it ought never be used alone, but rather always alongside justice-considering ethical concepts such as reciprocity, benefit-sharing, or a just transition.

In his feature article, Tyler Paetkau1 argues that the Nuffield Council on Bioethics’ (NCOB) infamous intervention ladder2 fails to acknowledge systemic influences towards poor health outcomes and instead places the blame on individuals. The ladder of interventions to change individual health behaviours runs from less intrusive to more intrusive and pays less attention to possible regulatory mechanisms for big businesses that would often avoid such intrusion on individuals and the punitive implications of that intrusion. Paetkau cites smoking bans and food labelling as examples of various levels of public health measures intruding on individual freedoms. According to him, instead of preventing people from smoking in public spaces or trying to influence their food purchase decisions, we should instead address the social determinants of health through systemic interventions, by which he means ‘interventions that operate on the level of systems rather than individuals and do not target or require individual behaviour change’1 (p. 2). The argument, however, might be questioned. At points in the article, Paetkau proposes that his new, broadened ‘stairway’ set of public health interventions ‘highlights the intimate connection between systemic interventions and individual outcomes’1 (p. 5). However, in some places, …

Antimicrobial resistance (AMR) is an urgent, global threat to public health. The development and implementation of effective measures to address AMR is vitally important but presents important ethical questions. This is a policy area requiring further sustained attention to ensure that policies proposed in National Action Plans on AMR are ethically acceptable and preferable to alternatives that might be fairer or more effective, for instance. By ethically analysing case studies of coercive actions to address AMR across countries, we can better inform policy in a context-specific manner. In this article, I consider an example of coercive antimicrobial stewardship policy in Canada, namely restrictions on livestock farmers' access to certain antibiotics for animal use without a vet's prescription. I introduce and analyse two ethical arguments that might plausibly justify coercive action in this case: the harm principle and a duty of collective easy rescue. In addition, I consider the factors that might generally limit the application of those ethical concepts, such as challenges in establishing causation or evidencing the scale of the harm to be averted. I also consider specifics of the Canadian context in contrast to the UK and Botswana as example settings, to demonstrate how context-specific factors might mean a coercive policy that is ethically justified in one country is not so in another.

Antimicrobial resistance (AMR) has been declared one of the top ten global public health threats facing humanity. To address AMR, coercive antimicrobial stewardship policies are being enacted in some settings. These policies, like all in public health, require ethical justification. Here, I introduce a framework for ethically evaluating coercive antimicrobial stewardship policies on the basis of ethical justifications (and their limitations). I consider arguments from effectiveness; duty of easy rescue; tragedy of the commons; responsibility-tracking; the harm principle; paternalism; justice and development; a precautionary approach; and professional duties. I consider how these justifications might form the basis for developing a comprehensive ethical framework, and the need for this to be context-specific and aligned with the priorities, evidence and needs of the particular jurisdictions in which a policy is to be enacted. I demonstrate how the ethical justifications might be used by reference to an example policy of the EU ban on the use of certain human-critical antibiotics for livestock, before concluding with challenges for further development of the framework.

Actions to prepare for and prevent pandemics are a common topic for bioethical analysis. However, little attention has been paid to global catastrophic biological risks more broadly, including pandemics with artificial origins, the creation of agents for biological warfare, and harmful outcomes of human genome editing. What’s more, international policy discussions often focus on economic arguments for state action, ignoring a key potential set of reasons for states to mitigate global catastrophic biological risks: moral reasons. In this paper, I frame the mitigation of such risks as a global public good, and I explore three possible categories of moral reasons that might motivate states to provide this global public good: nationalism, cosmopolitanism, and interstate obligations. Whilst there are strong objections to moral nationalism as a reason for states to act, moral cosmopolitanism may provide a broad reason which is further supplemented for individual states through the elaboration of interstate moral obligations. The obligations I consider are moral leadership, fairness, and reciprocity. Moral reasons for individual states action may more effectively or more appropriately motivate states to mitigate global catastrophic biological risks.

Nipah virus is a priority pathogen that is receiving increasing attention among scientists and in work on epidemic preparedness. Despite this trend, there has been almost no bioethical work examining ethical considerations surrounding the epidemiology, prevention, and treatment of Nipah virus or research that has already begun into animal and human vaccines. In this paper, we advance the case for further work on Nipah virus disease in public health ethics due to the distinct issues it raises concerning communication about the modes of transmission, the burdens of public health surveillance, the recent use of stringent public health measures during epidemics, and social or religious norms intersecting with preventive measures. We also advance the case for further work on Nipah virus disease in research ethics, given ethical issues surrounding potential vaccine trials for a high-fatality disease with sporadic spillover events, the different local contexts where trials may occur, and the potential use of unproven therapeutics during outbreaks. Further bioethics work may help to ensure that research and public health interventions for Nipah virus disease are ethically acceptable and more likely to be effective.

There are increasing pressures for bioethics to emphasise ‘translation’. Against this backdrop, we defend ‘speculative bioethics’. We explore speculation as an important tool and line of bioethical inquiry. Further, we examine the relationship between speculation and translational bioethics and posit that speculation can support translational work. First, speculative research might be conducted as ethical analysis of contemporary issues through a new lens, in which case it supports translational work. Second, speculation might be a first step prior to translational work on a topic. Finally, speculative bioethics might constitute different content altogether, without translational objectives. For each conception of speculative bioethics, important methodological aspects determine whether it constitutes good bioethics research. We conclude that whether speculative bioethics is compatible with translational bioethics—and to what extent—depends on whether it is being employed as tool or content. Applying standards of impact uniformly across bioethics may inappropriately limit speculative bioethics.

There are increasing pressures for bioethics research to have translational purposes. Against this backdrop, we argue in defense of speculative bioethics. We explore methods of speculation and their importance. Further, we examine the relationship between speculative bioethics and translational bioethics and posit that they are not dimorphous enterprises, but often support each other. First, speculative research might be conducted as ethical analysis of contemporary issues through a new lens, in which case it is a means of conducting translational work. Second, speculative bioethics research might be a first step prior to translational work on a topic, in which case speculative bioethics is a necessary requirement for later translational work. Finally, speculative bioethics research might be a separate kind of bioethics altogether, in which case it does not have the same objectives of impact and translation as other bioethics work. For each type of work, important methodological aspects determine whether it constitutes good speculative bioethics research. We conclude that speculative bioethics is multipurpose, and whether it should have a translational dimension—and to what extent—depends on the issue. Applying standards of impact and translation as the gold standard across bioethics may inappropriately limit bioethics, particularly on emerging technologies.

Global consumption of antibiotics has accelerated the evolution of bacterial antimicrobial resistance. Yet, the risks from increasing bacterial antimicrobial resistance are not restricted to human populations: transmission of antimicrobial resistant bacteria occurs between humans, farms, the environment and other reservoirs. Policies that take a ‘One Health’ approach deal with this cross-reservoir spread, but are often more restrictive concerning human actions than policies that focus on a single reservoir. As such, the burden of justification lies with these more restrictive policies. We argue that an ethical justification for preferring One Health policies over less restrictive alternatives relies on empirical evidence as well as theory. The ethical justification for these policies is based on two arguments: (i) comparatively greater effectiveness, and (ii) comparatively better tracking of moral responsibility. Yet the empirical assumptions on which these claims rest are limited by existing empirical knowledge. Using livestock farming as an example, we suggest that scientific research into characterising antimicrobial resistance and linking practices to outcomes ought to be guided (at least in part) by the imperative to supply the context-specific data needed to ethically justify preferring a One Health policy over less restrictive alternatives.

The development of some COVID-19 vaccines by private companies like Moderna and Sanofi-GSK has been substantially funded by various governments. While the Sanofi CEO has previously suggested that countries that fund this development ought to be given some priority, this suggestion has not been taken seriously in the literature. Considerations of nationalism, sustainability, need, and equitability have been more extensively discussed with respect to whether and how much a country is entitled to advance purchase orders of the vaccine under conditions of absolute scarcity. Yet, little attention has been paid to whether prior investment into developing a vaccine entitles a country to some priority with respect to these orders. Moreover, while not a majority view, some survey results show that a significant minority of the populace does endorse some view like this. This article argues that the minority have a point: recognizing funder countries some priority is justified by the weak Lockean claim (WLC). According to the WLC, the fact that someone has contributed to the development of something gives them some entitlement to the resultant product. This article will defend the WLC, and address objections to the argument, including those pertaining to questions of historical injustice and medical need. This argument does not imply an unconstrained entitlement. Rather, contribution to development is one morally relevant factor that must be tempered by and weighed against potentially more substantial claims to priority based on need, equity, and other considerations.

In May 2021, the UK National Health Service (NHS) proposed a scheme—called General Practice Data for Planning Research (GPDPR)—for sharing patients’ data. Under that system, a patient who does not wish to participate must actively opt out of their data being shared with third parties for research and other purposes. In this paper, we analyse the lessons that can be learned for the responsible and ethical governance of health data from the NHS’ new scheme. More specifically, we explore the extent to which the opt-out within the planned scheme complies with the requirements stemming from the General Data Protection Regulation (GDPR), particularly in relation to the principles of lawfulness and transparency. We then evaluate, from an ethical perspective, this opt-out ‘nudge’ and whether it is sufficiently resistible, reversible, and has appropriate goals. In light of the above, we then propose improvements for the scheme’s legal and ethical acceptability.

As we combat the COVID-19 pandemic, both the prescription of antimicrobials and the use of biocidal agents have increased in many countries. Although these measures can be expected to benefit existing people by, to some extent, mitigating the pandemic's effects, they may threaten long-term well-being of existing and future people, where they contribute to the problem of antimicrobial resistance (AMR). A trade-off dilemma thus presents itself: combat COVID-19 using these measures, or stop using them in order to protect against AMR. Currently, I argue, we are choosing to continue with these measures, and thus to prioritize combatting COVID-19, without adequate ethical reflection on the AMR-associated costs of these measures. I discuss the magnitude of the possible costs and benefits involved in making the trade-off in favour of COVID-19, and their distribution. I highlight two salient aspects of distribution that can help determine whether combatting COVID-19 whilst exacerbating AMR produces justly distributed costs and benefits: distribution between current and future populations, and distribution between existing geographical populations. Adopting this account, I argue that based on the magnitude and distribution of costs and benefits of combatting COVID-19, we have good reason to rethink this trade-off, and instead consider prioritizing protecting current and future people against AMR, but jettisoning measures against COVID-19 that also exacerbate AMR.

The advent of novel assisted reproductive technologies has considerably expanded our sphere of control over our reproduction, and consequently, the scope of ethical debate surrounding reproductive choice. The widespread availability of genetic selection, in particular, raises questions regarding what reproductive choice does and should entail. Preimplantation genetic diagnosis for genetic selection builds on in vitro fertilization. It forces us to confront questions of whether a moral right to reproductive choice extends not only to the decisions whether to have children and how many to have, but also what type of children to have. Traditionally, reproductive choice has been grounded in negative...

[book blurb:] The world is changing so fast that it's hard to know how to think about what we ought to do. We barely have time to reflect on how scientific advances will affect our lives before they're upon us. New kinds of dilemma are springing up. Can robots be held responsible for their actions? Will artificial intelligence be able to predict criminal activity? Is the future gender-fluid? Should we strive to become post-human? Should we use drugs to improve our intimate relationships — or to reduce crime? Our intuitions about questions like these are often both weak and confused. David Edmonds has put together a philosophical task force to get to grips with these challenges. Twenty-nine philosophers present provocative and engaging pieces about aspects of life today, and life tomorrow — birth and death, health and medicine, brain and body, personal relationships, wrongdoing and justice, the internet, animals, and the environment. The future won't look the same when you've finished this book.

Individualist ethical analyses in the enhancement debate have often prioritised or only considered the interests and concerns of parents and the future child. The collectivist critique of the human enhancement debate argues that rather than pure individualism, a focus on collectivist, or group-level ethical considerations is needed for balanced ethical analysis of specific enhancement interventions. Here, I defend this argument for the insufficiency of pure individualism. However, existing collectivist analyses tend to take a negative approach that hinders them from adequately contributing to balanced ethical analysis, and often leads to a prohibitive stance. I argue this is due to two common problems with collectivist analyses: inappropriate acceptance of individualist assumptions, and failure to appropriately weigh individual vs collective ethical considerations. To further develop the collectivist critique in the enhancement debate, I suggest we may look to collectivism in public health ethics, which avoids these problems.

A paper by Andorno and colleagues, recently published in Trends in Biotechnology, condemns support for heritable human genome editing (HHGE) that is claimed to be premature and to have occurred without sufficient public consultation. The general message of the paper is welcome in its emphasis on the importance of gaining broader perspectives on the uses and regulation of HHGE before calls for clinical use are made. However, some problematic arguments for their position lead them to seemingly condemn not only current premature calls for clinical use of HHGE but also any analysis of the ways in which it might be appropriately regulated in the future.