Identifying and evaluating layers of vulnerability - a way forward

“Vulnerability” is a key concept for research ethics and public health ethics. This term can be discussed from either a conceptual or a practical perspective. I previously proposed the metaphor of layers to understand how this concept functions from the conceptual perspective in human research. In this paper I will clarify how my analysis includes other definitions of vulnerability. Then, I will take the practical‐ethical perspective, rejecting the usefulness of taxonomies to analyze vulnerabilities. My proposal specifies two steps and provides a procedural guide to help rank layers. I introduce the notion of cascade vulnerability and outline the dispositional nature of layers of vulnerability to underscore the importance of identifying their stimulus condition. In addition, I identify three kinds of obligations and some strategies to implement them.

This strategy outlines the normative force of harmful layers of vulnerability. It offers concrete guidance. It contributes substantial content to the practical sphere but it does not simplify or idealize research subjects, research context or public health challenges.

Public health agencies' obligations and the case of Zika

This article focuses on the initial reactions to the Zika epidemic by national and international public health agencies. It presents and analyzes some responses public officials made about sexual and reproductive health at the inception of the epidemic. It also describes the different challenges and obligations faced by local and international public health agencies, as these have not been clearly outlined. The article argues that these agencies have different obligations and should fulfill them despite existing obstacles. While international agencies should honor their leadership role and make recommendations at a meta-level, local agencies should provide, in the case of Zika, a framework for empowerment and grant women the freedom to achieve sexual and reproductive health so that they can avoid the consequences of this epidemic.

Straightforward method to measure optomechanically induced transparency

We demonstrate a simple method to measure optomechanically induced transparency (OMIT) in a Fabry-Perot based system using a trampoline resonator. In OMIT, the transmitted intensity of a weak probe beam in the presence of a strong control beam is modified via the optomechanical interaction, leading to an ultra-narrow optical resonance. To retrieve both the magnitude and the phase of the probe beam, a homodyne detection technique is typically used. We have greatly simplified this method by using a single acousto-optical modulator to create a control and two probe beams. The beat signal between the transmitted control and probe beams shows directly the typical OMIT characteristics. This method therefore demonstrates an elegant solution when a homodyne field is needed but experimentally not accessible.

Globalization and Global Health

Globalization shrinks the world. The world watches on television people dying of hunger or in extreme poverty conditions. Every year, 8 million children die before they reach the age of 5 from preventable diseases. "Exotic illnesses" cease to be so exotic, they can cross borders easily. Ebola, originally an African worry, in 2014 was an international threat. The revolution in information technologies enables us witness the emergence of transnational epistemic communities exhibiting, measuring and explaining health and disease. Presently, the authors are more aware than ever of the health problems of people from far away countries, which decades ago were unknown and distant. The transparency and availability of this information exhibits, in a quasi-obscene way, an unacceptable world. A world that is willing to rescue banks and ignores the worst off - those people whose unlucky birth seals a never ending cycle of misery with almost no possibility of breaking it. This paper address the situation just described by asking: Are these new empiric circumstances reflected in the authors' moral understanding of the issues? How should the world think of global health and their obligations towards people living in deprivation? How can the new empiric possibilities the global world offers be related to the implementation of such obligations? What are some of the challenges to the translation of new obligations to the present world? In addressing these questions, the paper argues that if the world seriously wants to address the obligations towards those in need, even if they are far away from the places they may need to work not only with ideal proposals such as the "new obligations" pointed by Singer and Pogge, but also with different transitional theories and non-ideal strategies in order to solve some of the big challenges the real world impose to theories.

Medical ethics and more: ideal theories, non-ideal theories and conscientious objection

Doing 'good medical ethics' requires acknowledgment that it is often practised in non-ideal circumstances! In this article I present the distinction between ideal theory (IT) and non-ideal theory (NIT). I show how IT may not be the best solution to tackle problems in non-ideal contexts. I sketch a NIT framework as a useful tool for bioethics and medical ethics and explain how NITs can contribute to policy design in non-ideal circumstances. Different NITs can coexist and be evaluated vis-à-vis the IT. Additionally, I address what an individual doctor ought to do in this non-ideal context with the view that knowledge of NITs can facilitate the decision-making process. NITs help conceptualise problems faced in the context of non-compliance and scarcity in a better and more realistic way. Deciding which policy is optimal in such contexts may influence physicians' decisions regarding their patients. Thus, this analysis-usually identified only with policy making-may also be relevant to medical ethics. Finally, I recognise that this is merely a first step in an unexplored but fundamental theoretical area and that more work needs to be done.

Twelve years of Fogarty-funded bioethics training in Latin America and the Caribbean: achievements and challenges

The landscape in research ethics has changed significantly in Latin America and the Caribbean over the past two decades. Research ethics has gone from being a largely foreign concept and unfamiliar practice to an integral and growing feature of regional health research systems. Four bioethics training programs have been funded by the Fogarty International Center (FIC) in this region in the past 12 years. Overall, they have contributed significantly to changing the face of research ethics through the creation of locally relevant training materials and courses (including distance learning), academic publications, workshops, and conferences in Spanish, and strengthening ethics review committees and national systems of governance. This paper outlines their achievements and challenges, and reflects on current regional needs and what the future may hold for research ethics and bioethics training in Latin America and the Caribbean.

An analysis of online courses in research ethics in the Fogarty-sponsored bioethics training programs

Several training programs sponsored by the NIH/Fogarty International Center's International Research Ethics Education and Curriculum Development Program offer online graduate-level courses in research ethics to participants in lowand middle-income countries. This paper describes the evaluation of four of these online courses and recommendations for improvements to achieve the highest-quality design and delivery. We used an evaluation matrix consisting of 95 criteria based on recommended best practices in eLearning. Our results showed that these courses are developing or meeting nearly 73% of the criteria, while they are not meeting approximately 21% of the criteria. Together, one or more of the courses are developing or meeting 89 of the 95 criteria. These results suggest that the necessary skills and expertise exist in these programs to bring all of the eLearning courses close to 100% proficiency by sharing a common set of best practices. This paper is part of a collection of articles analyzing the Fogarty International Center's International Research Ethics Education and Curriculum Development Program.

Challenges for assisted reproduction and secondary infertility in Latin America

This essay explores a new way to think about Assisted Reproductive Technologies (ARTs) in the Latin American context. The infertility caused by inadequately treated sexually transmitted diseases and by unsafe or illegal abortions is preventable, reflects the neglect of women’s sexual health, and disproportionally affects the region’s poorest women. I suggest a new logic that revisits ARTs, to do justice to the relevance of this type of infertility. I propose utilizing these technologies so as to transform the care of women and open a new discourse. I also suggest that we be more strategic and seek new alliances.

Not the usual suspects: addressing layers of vulnerability

This paper challenges the traditional account of vulnerability in healthcare which conceptualizes vulnerability as a list of identifiable subpopulations. This list of 'usual suspects', focusing on groups from lower resource settings, is a narrow account of vulnerability. In this article we argue that in certain circumstances middle-class individuals can be also rendered vulnerable. We propose a relational and layered account of vulnerability and explore this concept using the case study of cord blood (CB) banking. In the first section, two different approaches to 'vulnerability' are contrasted: categorical versus layered. In the second section, we describe CB banking and present a case study of CB banking in Argentina. We examine the types of pressure that middle-class pregnant women feel when considering CB collection and storage. In section three, we use the CB banking case study to critique the categorical approach to vulnerability: this model is unable to account for the ways in which these women are vulnerable. A layered account of vulnerability identifies several ways in which middle-class women are vulnerable. Finally, by utilizing the layered approach, this paper suggests how public health policies could be designed to overcome vulnerabilities.

Mounting a specific immune response increases energy expenditure of the subterranean rodent Ctenomys talarum (tuco-tuco): implications for intraspecific and interspecific variation in immunological traits

It was recently hypothesised that specific induced defences, which require substantial time and resources and are mostly beneficial against repeated infections, are more likely to be favoured in ‘slow-living-pace’ species. Therefore, understanding how different types of immune defences might vary with life history requires knowledge of the costs and benefits of defence components. Studies that have explored the energetic costs of immunity in vertebrates have done so with a focus primarily on birds and less so on mammals, particularly surface-dwelling rodents. In this study, we evaluated whether an experimental induction of the immune system with a non-pathogenic antigen elevates the energetic expenditure of a subterranean rodent: Ctenomys talarum (tuco-tucos). In both seasons studied, a significant increase in oxygen consumption was verified in immune-challenged tuco-tucos injected with sheep red blood cells (SRBC) compared with control animals. The increase in oxygen consumption 10 days after the exposure to SRBC was lower for female tuco-tucos monitored in the breeding season compared with females in the non-breeding season. Interestingly, antibody titres of female tuco-tucos did not decrease during the breeding season. Our results add new insight into the role of other factors such as basal metabolic rate or degree of parasite exposure besides ‘pace of life’ in modulating the interspecific immunological variation observed in natural populations of mammals.

Prenatal diagnosis and abortion for congenital abnormalities: is it ethical to provide one without the other?

This target article considers the ethical implications of providing prenatal diagnosis (PND) and antenatal screening services to detect fetal abnormalities in jurisdictions that prohibit abortion for these conditions. This unusual health policy context is common in the Latin American region. Congenital conditions are often untreated or under-treated in developing countries due to limited health resources, leading many women/couples to prefer termination of affected pregnancies. Three potential harms derive from the provision of PND in the absence of legal and safe abortion for these conditions: psychological distress, unjust distribution of burdens between socio-economic classes, and financial burdens for families and society. We present Iran as a comparative case study where recognition of these ethical issues has led to the liberalization of abortion laws for fetuses with thalassemia. We argue that physicians, geneticists and policymakers have an ethical and professional duty of care to advocate for change in order to ameliorate these harms.

Elucidating the concept of vulnerability: Layers not labels

In this article I examine several criticisms of the concept of vulnerability. Rather than rejecting the concept, however, I argue that a sufficiently rich understanding of vulnerability is essential to bioethics. The challenges of international research in developing countries require an understanding of how new vulnerabilities arise from conditions of economic, social and political exclusion. A serious shortcoming of current conceptions of vulnerability in research ethics is the tendency to treat vulnerability as a label fixed on a particular subpopulation. My paper examines the role of this “label” metaphor in current statements of research ethics. In contrast to this prevailing “label” metaphor, my own positive account of vulnerability develops a dynamic way of understanding the structure of the concept of vulnerability based on the idea of “layers of vulnerability.” I examine several cases involving women, as they are sometimes labeled as a vulnerable population and sometimes not. My analysis demonstrates the essential role of this revised concept of vulnerability in bioethics and research ethics.

Single-point acupuncture and physiotherapy for the treatment of painful shoulder: a multicentre randomized controlled trial

OBJECTIVE

Evaluate the efficacy of acupuncture associated with physiotherapy for patients with painful shoulder.

METHODS

In a multicentre controlled randomized study, participants were recruited with a clinical diagnosis of unilateral subacromial syndrome from six rehabilitation medicine departments belonging to the Public Health System in two Spanish regions. All participants received 15 sessions of physiotherapy during the 3 weeks that the treatment lasted and were randomized to additionally receive, once a week, acupuncture or mock TENS (transcutaneous electrical nerve stimulation). The primary outcome measure was the change in the Constant-Murley Score (CMS) for functional assessment of the shoulder, at 4 weeks after randomization. This study is registered as an International Standard Randomized Controlled Trial, number ISRCTN28687220.

RESULTS

A total of 425 patients were recruited. The mean score (s.d.) on the CMS had increased by 16.6 (15.6) points among the acupuncture group, compared with 10.6 (13.5) points in the control group, and the mean difference between the two groups was statistically significant (6.0 points; 95% CI 3.2, 8.8 points; P < 0.001). By the end of the treatment, 53% of the patients in the acupuncture group had decreased their consumption of analgesics, compared with a corresponding 30% among the control group (P < 0.001).

CONCLUSIONS

Single-point acupuncture in association with physiotherapy improves shoulder function and alleviates pain, compared with physiotherapy as the sole treatment. This improvement is accompanied by a reduction in the consumption of analgesic medicaments.

In silico analysis identifies a C3HC4-RING finger domain of a putative E3 ubiquitin-protein ligase located at the C-terminus of a polyglutamine-containing protein

Almost identical polyglutamine-containing proteins with unknown structures have been found in human, mouse and rat genomes (GenBank AJ277365, AF525300, AY879229). We infer that an identical new gene (RING) finger domain of real interest is located in each C-terminal segment. A three-dimensional (3-D) model was generated by remote homology modeling and the functional implications are discussed. The model consists of 65 residues from terminal position 707 to 772 of the human protein with a total length of 796 residues. The 3-D model predicts a ubiquitin-protein ligase (E3) as a binding site for ubiquitin-conjugating enzyme (E2). Both enzymes are part of the ubiquitin pathway to label unwanted proteins for subsequent enzymatic degradation. The molecular contact specificities are suggested for both the substrate recognition and the residues at the possible E2-binding surface. The predicted structure, of a ubiquitin-protein ligase (E3, enzyme class number 6.3.2.19, CATH code 3.30.40.10.4) may contribute to explain the process of ubiquitination. The 3-D model supports the idea of a C3HC4-RING finger with a partially new pattern. The putative E2-binding site is formed by a shallow hydrophobic groove on the surface adjacent to the helix and one zinc finger (L722, C739, P740, P741, R744). Solvent-exposed hydrophobic amino acids lie around both zinc fingers (I717, L722, F738, or P765, L766, V767, V733, P734). The 3-D structure was deposited in the protein databank theoretical model repository (2B9G, RCSB Protein Data Bank, NJ).