Verina Wild

Despite the attempts to promote the inclusion of pregnant women into clinical research, this group is still widely excluded. An analysis of the “vulnerability of pregnant women” that questions deeply internalized stereotypes is necessary for finding the right balance in the protection of pregnant women as research participants. Criticism of the traditional account of vulnerability will lead to an alternative that focuses on situations rather than groups and on the obligations of responsible parties. The paper adds to the current general discussion of vulnerability and at the same time addresses the specific problem of drug treatment during pregnancy.

Dieser Beitrag diskutiert „kulturelle Fragen“ in klinischer Ethik am Beispiel der Hymenrekonstruktion. Zunächst werden drei grundsätzliche Argumente genannt: 1) Wenn „kultur-sensitive“ Themen in klinischer Ethik explizit als solche diskutiert werden, kann das zu einem essentialistischen Verständnis von Kultur beitragen. Stattdessen wird in diesem Beitrag für ein dynamisches Verständnis von Kultur argumentiert und für eine grundsätzlich kontextsensitive, pluralistische klinische Ethik. 2) Klinische Ethik fokussiert häufig auf die individuelle Arzt-Patienten-Beziehung. Public Health Ethik und Globale Bioethik sind dagegen eher mit den strukturellen Bedingungen von Gesundheit und Gesundheitsversorgung befasst. Der Beitrag argumentiert für eine systematischere Verknüpfung dieser verschiedenen Ebenen. 3) „Migration“ als bioethisches Thema wird häufig unter „Kultur“ subsumiert. Doch diese beiden Themen sind nicht koextensiv, stattdessen umfassen beide Bereiche jeweils unterschiedliche Fragestellungen. Insbesondere im Bereich von „Migration“ bestehen in der Bioethik noch Forschungslücken. Auf diesen Ausgangsüberlegungen aufbauend wird die Hymenrekonstruktion aus ethischer Sicht diskutiert und dafür argumentiert, sie nur als ultima ratio durchzuführen. Zugleich sollte über die Unmöglichkeit eines Jungfräulichkeitsnachweises aufgeklärt werden. Es bleibt eine Herausforderung, „kultursensitive“ Gesundheitsversorgung zu leisten, dabei jedoch ein essentialistisches Kulturverständnis und Stereotypisierung zu vermeiden. Dieser Beitrag argumentiert für eine grundsätzliche Kontextsensitivität in einer globalisierten, heterogenen Welt, in der die Verbindung zwischen individuellem Handeln und strukturellen Gegebenheiten bewusst wird

In this editorial we introduce the special Public Health Ethics symposium on social justice in public health. We present here a select set of papers arising from an international workshop, organized on 4–5 June 2012 by the Institute of Biomedical Ethics, in collaboration with the University Research Priority Program for Ethics at the University of Zurich. Meeting the Author is a series of international workshops organized by the Ethics Center of the University of Zurich. In this workshop format, a selected group of junior and senior researchers discusses a seminal work in ethics together with the authors.

This article discusses cosmopolitanism as the moral foundation for access to health care for migrants. The focus is on countries with sufficiently adequate universal health care for their citizens. The article argues for equal access to this kind of health care for citizens and migrants alike—including migrants at special risk such as asylum seekers or undocumented migrants. Several objections against equal access are raised, such as the cosmopolitan approach being too restrictive or too permissive, or the consequences being undesirable; but the objections are largely refuted. Some special cases in which a restriction of equal access to health care might be justified are described: humanitarian crisis, short term tourism, and the case of a migrant or refugee who will stay only very briefly on a state's territory

Debates about effective responses to the COVID-19 pandemic have emphasized the paramount importance of digital tracing technology in suppressing the disease. So far, discussions about the ethics of this technology have focused on privacy concerns, efficacy, and uptake. However, important issues regarding power imbalances and vulnerability also warrant attention. As demonstrated in other forms of digital surveillance, vulnerable subpopulations pay a higher price for surveillance measures. There is reason to worry that some types of COVID-19 technology might lead to the employment of disproportionate profiling, policing, and criminalization of marginalized groups. It is, thus, of crucial importance to interrogate vulnerability in COVID-19 apps and ensure that the development, implementation, and data use of this surveillance technology avoids exacerbating vulnerability and the risk of harm to surveilled subpopulations, while maintaining the benefits of data collection across the whole population. This paper outlines the major challenges and a set of values that should be taken into account when implementing disease surveillance technology in the pandemic response.

Asgary and Smith (2013) identify an important challenge: the difficult position of physicians caught between the obligation to treat every human being with the same professional rigor, and their feelings of responsibility toward the state and its judicial decisions on asylum requests. The authors show that in some cases this conflict leads to a tendency to "sacrifice their medical responsibilities". The authors' core demand is that health care workers should be independent of the state and judiciary systems, and thus prioritize the interests of the patient. We agree entirely with the authors, that well-performed documenting is the only ethically justifiable option and should not be influenced by a feeling of responsibility for contributing to judicial decisions. However, the authors also address the more general, and ethically more challenging, issue of the responsibility of health care workers and the state toward asylum seekers and ask, how much health care provision is appropriate?

How health care providers are paid affects how medicine is practiced. It is thus important to assess provider payment models not only from the economic perspective but also from the ethical perspective. China recently started to reform the provider payment model in the health care system from fee-for-service to case-based payment. This paper aims to examine this transition from an ethical perspective. We collected empirical studies on the impact of case-based payment in the Chinese health care system and applied a systematic ethical matrix that integrates clinical ethics and public health ethics to analyze the empirical findings. We identified eleven prominent ethical issues related to case-based payment. Some ethical problems of case-based payment in China are comparable to ethical problems of managed care and diagnosis related groups in high-income countries. However, in this paper we discuss in greater detail four specific ethical issues in the Chinese context: professionalism, the patient-physician relationship, access to care and patient autonomy. Based on the analysis, we cautiously infer that case-based payment is currently more ethically acceptable than fee-for-service in the context of China, mainly because it seems to lower financial barriers to access care. Nonetheless, it will be difficult to justify the implementation of case-based payment if no additional measures are taken to monitor and minimize its existing negative ethical implications

There is growing interest in contact tracing apps for pandemic management. It is crucial to consider ethical requirements before, while, and after implementing such apps. In this paper, we illustrate the complexity and multiplicity of the ethical considerations by presenting an ethical framework for a responsible design and implementation of CT apps. Using this framework as a starting point, we briefly highlight the interconnection of social and political contexts, available measures of pandemic management, and a multi-layer assessment of CT apps. We will discuss some trade-offs that arise from this perspective. We then suggest that public trust is of major importance for population uptake of contact tracing apps. Hasty, ill-prepared or badly communicated implementations of CT apps will likely undermine public trust, and as such, risk impeding general effectiveness.

The ethics of health incentive research—a form of public health research—are not well developed, and concerns of justice have been least examined. In this paper, we explore what potential long term harms in relation to justice may occur as a result of such research and whether they should be considered as part of its ethical evaluation. ‘Long term harms’ are defined as harms that contribute to existing systematic patterns of disadvantage for groups. Their effects are experienced on a long term basis, persisting even once an incentive research project ends. We will first establish that three categories of such harms potentially arise as a result of health incentive interventions. We then argue that the risk of these harms also constitutes a morally relevant consideration for health incentive research and suggest who may be responsible for assessing and mitigating these risks. We propose that responsibility should be assigned on the basis of who initiates health incentive research projects. Finally, we briefly describe possible strategies to prevent or mitigate the risk of long term harms to members of disadvantaged groups, which can be employed during the design, conduct and dissemination of research projects.

ZusammenfassungSeit einigen Jahren erscheinen in deutschsprachigen Medien Beiträge, die einen neuen Trend in der Versorgung von langzeitpflegebedürftigen Menschen beschreiben: die Migration in ausländische Pflegeheime, insbesondere nach Thailand oder Ost-Europa. Diese Art der Migration wird kontrovers aufgenommen. Einige Medienbeiträge beschreiben diese Praxis u. a. als „Greisen-Export“, „gerontologischen Kolonialismus“ oder „inhumane Deportation“. Die Begriffe weisen darauf hin, dass diese Migration aus sogenannten High Income Countries in Low and Middle Income Countries aus ethischer Sicht problematisch sein könnte. Allerdings gibt es bislang keine wahrnehmbare wissenschaftliche ethische Auseinandersetzung mit dem Phänomen. In diesem Beitrag diagnostizieren wir, dass es sich bei der Migration Langzeit-Pflegebedürftiger tatsächlich um ein ethisch relevantes Problem handelt, und wir ordnen die von uns identifizierten ethisch relevanten Bereiche unterschiedlichen Ebenen zu: einer individual-, einer gesellschafts-, und einer global-ethischen Ebene. Auf der individualethischen Ebene diskutieren wir Fragen der Autonomie, der Verwandtschaftsbeziehungen, der Rolle von Kultur und Traditionen und der „guten Pflege“. Auf der gesellschaftsethischen Ebene diskutieren wir strukturelle Herausforderungen der Langzeitpflege und Fragen der sozialen Gerechtigkeit. Auf der globalethischen Ebene verbinden wir unser Thema mit der ethischen Diskussion des Medizintourismus und des Brain Drains und mit Fragen globaler Gerechtigkeit. Um eine weiterführende normative Analyse vornehmen zu können, sind weitere empirische Daten zu dem Phänomen notwendig.

Mobile applications (apps) have gained significant popularity as a new intervention strategy responding to violence against women and girls. Despite their growing relevance, an assessment from the perspective of public health ethics is still lacking. Here, we base our discussion on the understanding of violence against women and girls as a multidimensional, global public health issue on structural, societal and individual levels and situate it within the theoretical framework of structural injustice, including epistemic injustice. Based on a systematic app review we previously conducted, we evaluate the content and functions of apps through the lens of structural injustice. We argue that technological solutions such as apps may be a useful tool in the fight against violence against women and girls but have to be situated within the broader frame of public health that considers the structural dimensions of such violence. Ultimately, the concerns raised by structural injustice are—alongside key concerns of safety, data privacy, importance of human supportive contact, and so forth—crucial dimensions in the ethical assessment of such apps. However, research on the role and relevance of apps as strategies to address the structural and epistemic dimensions of violence remains scarce. This article aims to provide a foundation for further discussion in this area and could be applicable to other areas in public health policy and practice.

The COVID-19 pandemic presents unprecedented challenges to public health decision-making. Specifically, the lack of evidence and the urgency with which a response is called for, raise the ethical challenge of assessing how much (and what kind of) evidence is required for the justification of interventions in response to the various threats we face. Here we discuss the intervention of introducing technology that aims to trace and alert contacts of infected persons—contact tracing (CT) technology. Determining whether such an intervention is proportional is complicated by complex trade-offs and feedback loops. We suggest that the resulting uncertainties necessitate a precautionary approach. On the one hand, precautionary reasons support CT technology as a means to contribute to the prevention of harms caused by alternative interventions, or COVID-19 itself. On the other hand, however, both the extent to which such technology itself present risks of serious harm, as well as its effectiveness, remain unclear. We therefore argue that a precautionary approach should put reversibility of CT technology at the forefront. We outline several practical implications.

The COVID-19 pandemic is affecting countries across the globe. Only a globally coordinated response, however, will enable the containment of the virus. Responding to a request from policy makers for ethics input for a global resource pledging event as a starting point, this paper outlines normative and procedural principles to inform a coordinated global coronavirus response. Highlighting global connections and specific vulnerabilities from the pandemic, and proposing standards for reasonable and accountable decision-making, the ambition of the paper is two-fold: to raise awareness for the justice dimensions in the global response, and to argue for moving health from the periphery to the centre of philosophical debates about social and global justice.

Definition of the problemThe upcoming reforms according to the specifications of the Master Plan 2020 provide for a competency-oriented restructuring of medical studies. This article aims to develop perspectives on how teaching ethics in medical studies can be more strongly oriented at building competencies. In this way, it pursues the goal of making the concept of competency more tangible for medical ethics and usable for the design of medical ethics education.ArgumentsWe understand competencies as dispositions for actions that enable problem solving. By transferring the concept of moral intelligence to the moral actions of physicians in patient care, we specify five ethical–moral competencies that must be present for morally appropriate, ethically reflected actions by future physicians: (1) the ability to form a professional moral compass, (2) the willingness to align oneself with professional ethical norms and values, (3) the ability to perceive moral dimensions of medical action, (4) the ability to make moral judgments based on ethical considerations about the right action, and (5) the willingness to realize ethically justified action. We illustrate their importance for teaching medical ethics using the example of teaching clinical ethics in medical studies.ConclusionOur conceptualization of moral–ethical competencies can be used to design concrete courses in a competency-oriented way. Our approach could be applied analogously to other areas of teaching ethics in health care.

Our paper was written to highlight the need for mitigating vulnerability in COVID-19 tracing technology. As the pandemic was unravelling in mid 2020 and infection rates were rising steeply across the globe, we were following the news on emerging response measures and their social impact. We were alarmed by media reports regarding racial profiling and criminalization related to the implementation of physical distancing measures. Media reports documenting the fining of predominantly Black and Hispanic people in New York City, the closures of Roma settlements in Spain, Slovakia, or Romania, or the disproportionate patrolling of migrant neighborhoods in Sydney, Australia, made it obvious that...