Implementing Health in All Policies - Time and Ideas Matter Too! Comment on "Understanding the Role of Public Administration in Implementing Action on the Social Determinants of Health and Health Inequities"

Carey and Friel suggest that we turn to knowledge developed in the field of public administration, especially new public governance, to better understand the process of implementing health in all policies (HiAP). In this commentary, I claim that theories from the policy studies bring a broader view of the policy process, complementary to that of new public governance. Drawing on the policy studies, I argue that time and ideas matter to HiAP implementation, alongside with interests and institutions. Implementing HiAP is a complex process considering that it requires the involvement and coordination of several policy sectors, each with their own interests, institutions and ideas about the policy. Understanding who are the actors involved from the various policy sectors concerned, what context they evolve in, but also how they own and frame the policy problem (ideas), and how this has changed over time, is crucial for those involved in HiAP implementation so that they can relate to and work together with actors from other policy sectors.

Clarifying the best interests standard: the elaborative and enumerative strategies in public policy-making

One recurring criticism of the best interests standard concerns its vagueness, and thus the inadequate guidance it offers to care providers. The lack of an agreed definition of 'best interests', together with the fact that several suggested considerations adopted in legislation or professional guidelines for doctors do not obviously apply across different groups of persons, result in decisions being made in murky waters. In response, bioethicists have attempted to specify the best interests standard, to reduce the indeterminacy surrounding medical decisions. In this paper, we discuss the bioethicists' response in relation to the state's possible role in clarifying the best interests standard. We identify and characterise two clarificatory strategies employed by bioethicists -elaborative and enumerative-and argue that the state should adopt the latter. Beyond the practical difficulties of the former strategy, a state adoption of it would inevitably be prejudicial in a pluralistic society. Given the gravity of best interests decisions, and the delicate task of respecting citizens with different understandings of best interests, only the enumerative strategy is viable. We argue that this does not commit the state to silence in providing guidance to and supporting healthcare providers, nor does it facilitate the abuse of the vulnerable. Finally, we address two methodological worries about adopting this approach at the state level. The adoption of the enumerative strategy is not defeatist in attitude, nor does it eventually collapse into (a form of) the elaborative strategy.

Snakes and ladders: state interventions and the place of liberty in public health policy

In this paper I outline and explore some problems in the way that the Nuffield Council of Bioethics' report Public Health: Ethical Issues (2007) presents its 'Intervention Ladder'. They see the metaphor of a ladder both as capturing key normative priorities and as making a real and important contribution to ethical policymaking in public health. In this paper I argue that the intervention ladder is not a useful model for thinking about policy decisions, that it is likely to produce poor decisions and that it is incompatible with the report's stated approach to relevant public health policy values.

Towards a bioethics of innovation

In recent years, it has become almost axiomatic that biomedical research and clinical practice should be 'innovative'-that is, that they should be always evolving and directed towards the production, translation and implementation of new technologies and practices. While this drive towards innovation in biomedicine might be beneficial, it also raises serious moral, legal, economic and sociopolitical questions that require further scrutiny. In this article, we argue that biomedical innovation needs to be accompanied by a dedicated 'bioethics of innovation' that attends systematically to the goals, process and outcomes of biomedical innovation as objects of critical inquiry. Using the example of personalised or precision medicine, we then suggest a preliminary framework for a bioethics of innovation, based on the research policy initiative of 'Responsible Innovation'. We invite and encourage critiques of this framework and hope that this will provoke a challenging and enriching new bioethical discourse.

The case for banning cigarettes

Lifelong smokers lose on average a decade of life vis-à-vis non-smokers. Globally, tobacco causes about 5-6 million deaths annually. One billion tobacco-related deaths are predicted for the 21st century, with about half occurring before the age of 70. In this paper, we consider a complete ban on the sale of cigarettes and find that such a ban, if effective, would be justified. As with many policy decisions, the argument for such a ban requires a weighing of the pros and cons and how they impact on different individuals, both current and future. The weightiest factor supporting a ban, we argue, is the often substantial well-being losses many individuals suffer because of smoking. These harms, moreover, disproportionally affect the disadvantaged. The potential gains in well-being and equality, we argue, outweigh the limits a ban places on individuals' freedom, its failure to respect some individuals' autonomous choice and the likelihood that it may, in individual cases, reduce well-being.

In Patients With Cirrhosis, Driving Simulator Performance Is Associated With Real-life Driving

BACKGROUND & AIMS

Minimal hepatic encephalopathy (MHE) has been linked to higher real-life rates of automobile crashes and poor performance in driving simulation studies, but the link between driving simulator performance and real-life automobile crashes has not been clearly established. Furthermore, not all patients with MHE are unsafe drivers, but it is unclear how to distinguish them from unsafe drivers. We investigated the link between performance on driving simulators and real-life automobile accidents and traffic violations. We also aimed to identify features of unsafe drivers with cirrhosis and evaluated changes in simulated driving skills and MHE status after 1 year.

METHODS

We performed a study of outpatients with cirrhosis (n = 205; median 55 years old; median model for end-stage liver disease score, 9.5; none with overt hepatic encephalopathy or alcohol or illicit drug use within previous 6 months) seen at the Virginia Commonwealth University and McGuire Veterans Administration Medical Center, from November 2008 through April 2014. All participants were given paper-pencil tests to diagnose MHE (98 had MHE; 48%), and 163 patients completed a standardized driving simulation. Data were collected on traffic violations and automobile accidents from the Virginia Department of Motor Vehicles and from participants' self-assessments when they entered the study, and from 73 participants 1 year later. Participants also completed a questionnaire about alcohol use and cessation patterns. The driving simulator measured crashes, run-time, road center and edge excursions, and illegal turns during navigation; before and after each driving simulation session, patients were asked to rate their overall driving skills. Drivers were classified as safe or unsafe based on crashes and violations reported on official driving records; simulation results were compared with real-life driving records. Multivariable regression analyses of real-life crashes and violations was performed using data on demographics, cirrhosis details, MHE status, and alcohol cessation patterns, at baseline and at 1 year.

RESULTS

Drivers categorized as unsafe had more crashes and made more illegal turns on the driving simulator than drivers categorized as safe; a higher proportion of subjects with MHE were categorized as unsafe drivers at baseline (16%) than subjects without MHE (7%; P = .02), and at 1-year follow-up (18% vs 0%; P = .02). Alcohol cessation within <1 year and illegal turns during simulator navigation tasks were associated with real-life automobile crashes and MHE in regression analysis; road edge excursions in the simulator were associated with real-life traffic violations. Personal assessment of driving skills improved after each simulation episode.

CONCLUSIONS

In a study of 205 patients with cirrhosis, we associated results from driving simulation tests with real-life driving records and MHE. Traffic safety counseling should focus on patients with cirrhosis who recently quit consuming alcohol and perform poorly on driving simulation.

A Sophisticated Architecture Is Indeed Necessary for the Implementation of Health in All Policies but not Enough Comment on "Understanding the Role of Public Administration in Implementing Action on the Social Determinants of Health and Health Inequities"

In this commentary, I argue that beyond a sophisticated supportive architecture to facilitate implementation of actions on the social determinants of health (SDOH) and health inequities, the Health in All Policies (HiAP) project faces two main barriers: lack of awareness within policy networks on the social determinants of population health, and a tendency of health actors to neglect investing in other sectors' complex problems.

Whistleblowing: Don't Encourage It, Prevent It Comment on "Cultures of Silence and Cultures of Voice: The Role of Whistleblowing in Healthcare Organisations"

In a recent article, Mannion and Davies argue that there are a multitude of ways in which organizations (such as the National Health Service [NHS]) can deal with wrongdoing or ethical problems, including the formation of policies that encourage and protect would-be whistleblowers. However, it is important to distinguish internal reporting about wrongdoing from whistleblowing proper, because the two are morally quite different and should not be dealt with in the same way. This article argues that we should not understand the authors' conclusions to apply to "whistleblowing" proper, because their recommended approach would be both unfeasible and undesirable for addressing whistleblowing defined in this way.

Understanding the Role of Public Administration in Implementing Action on the Social Determinants of Health and Health Inequities

Many of the societal level factors that affect health - the 'social determinants of health (SDH)' - exist outside the health sector, across diverse portfolios of government, and other major institutions including non-governmental organisations (NGOs) and the private sector. This has created growing interest in how to create and implement public policies which will drive better and fairer health outcomes. While designing policies that can improve the SDH is critical, so too is ensuring they are appropriately administered and implemented. In this paper, we draw attention to an important area for future public health consideration - how policies are managed and implemented through complex administrative layers of 'the state.' Implementation gaps have long been a concern of public administration scholarship. To precipitate further work in this area, in this paper, we provide an overview of the scholarly field of public administration and highlight its role in helping to understand better the challenges and opportunities for implementing policies and programs to improve health equity.

Phase-dependent justification: the role of personal responsibility in fair healthcare

The main aim of this paper is to examine the fairness of different ways of holding people responsible for healthcare-related choices. Our focus is on conceptualisations of responsibility that involve blame and sanctions, and our analytical approach is to provide a systematic discussion based on interrelated and successive health-related, lifestyle choices of an individual. We assess the already established risk-sharing, backward-looking and forward-looking views on responsibility according to a variety of standard objections. In conclusion, all of the proposed views on holding people responsible for their lifestyle choices are subjected to reasonable critiques, although the risk-sharing view fare considerably better than the others overall considered. With our analytical approach, we are able to identify how basic conditions for responsibility ascription alter along a time axis. Repeated relapses with respect to healthcare associated with persistent, unhealthy lifestyle choices, call for distinct attention. In such situations, contextualised reasoning and transparent policy-making, rather than opaque clinical judgements, are required as steps towards fair allocation of healthcare resources.

Public participation in genetic databases: crossing the boundaries between biobanks and forensic DNA databases through the principle of solidarity

The ethical aspects of biobanks and forensic DNA databases are often treated as separate issues. As a reflection of this, public participation, or the involvement of citizens in genetic databases, has been approached differently in the fields of forensics and medicine. This paper aims to cross the boundaries between medicine and forensics by exploring the flows between the ethical issues presented in the two domains and the subsequent conceptualisation of public trust and legitimisation. We propose to introduce the concept of 'solidarity', traditionally applied only to medical and research biobanks, into a consideration of public engagement in medicine and forensics. Inclusion of a solidarity-based framework, in both medical biobanks and forensic DNA databases, raises new questions that should be included in the ethical debate, in relation to both health services/medical research and activities associated with the criminal justice system.

Opt-out and consent

A chief objection to opt-out organ donor registration policies is that they do not secure people's actual consent to donation, and so fail to respect their autonomy rights to decide what happens to their organs after they die. However, scholars have recently offered two powerful responses to this objection. First, Michael B Gill argues that opt-out policies do not fail to respect people's autonomy simply because they do not secure people's actual consent to donation. Second, Ben Saunders argues that opt-out policies do secure people's actual-if not explicit-consent, provided that certain conditions are satisfied. I argue that Gill and Saunders' arguments are not successful. My conclusion does not imply that jurisdictions should not implement opt-out policies-their failure to secure people's actual consent may be outweighed by other considerations. But, my conclusion does imply that Gill and Saunders are mistaken to claim that opt-out policies are respectful of people's autonomy.

Putting a price on empathy: against incentivising moral enhancement

Concerns that people would be disinclined to voluntarily undergo moral enhancement have led to suggestions that an incentivised programme should be introduced to encourage participation. This paper argues that, while such measures do not necessarily result in coercion or undue inducement (issues with which one may typically associate the use of incentives in general), the use of incentives for this purpose may present a taboo trade-off. This is due to empirical research suggesting that those characteristics likely to be affected by moral enhancement are often perceived as fundamental to the self; therefore, any attempt to put a price on such traits would likely be deemed morally unacceptable by those who hold this view. A better approach to address the possible lack of participation may be to instead invest in alternative marketing strategies and remove incentives altogether.

Cigarette company trade secrets are not secret: an analysis of reverse engineering reports in internal tobacco industry documents released as a result of litigation

OBJECTIVES

Use previously secret tobacco industry documents to assess tobacco companies' routine claims of trade secret protection for information on cigarette ingredients, additives and construction made to regulatory agencies, as well as the companies' refusal to publicly disclose this information.

METHODS

We analysed previously secret tobacco industry documents available at (http://legacy.library.ucsf.edu) to identify 100 examples of seven major tobacco companies' reverse engineering of their competitors' brands between 1937 and 2001.

RESULTS

These reverse engineering reports contain detailed data for 142 different measurements for at least two companies, including physical parameters of the cigarettes, tobacco types, humectants, additives, flavourings, and smoke constituents of competitors' cigarettes. These 100 documents were distributed to 564 employees, including top managers in domestic and foreign offices across multiple departments, including executive leadership, research and design, product development, marketing and legal. These documents reported new competitors' products, measured ingredient changes over time, and informed companies' decisions regarding ingredients in their own products.

CONCLUSIONS

Because cigarette companies routinely analyse their competitors' cigarettes in great detail, this information is neither secret nor commercially valuable and, thus, does not meet the legal definition of a 'trade secret.' This information is only being kept 'secret' from the people consuming cigarettes and the scientific community. Public agencies should release this detailed information because it would provide valuable information about how ingredients affect addictiveness and toxicity, and would help the public health community and consumers better understand the impact of cigarette design on human health.

In defence of mandatory bicycle helmet legislation: response to Hooper and Spicer

We invoke a triple rationale to rebut Hooper and Spicer's argument against mandatory helmet laws. First, we use the laws of physics and empirical studies to show how bicycle helmets afford substantial protection to the user. We show that Hooper and Spicer erroneously downplay helmet utility and that, as a result, their attack on the utilitarian argument for mandatory helmet laws is weakened. Next, we refute their claim that helmet legislation comprises unjustified paternalism. We show the healthcare costs of bareheaded riding to pose significant third party harms. It follows, we argue, that a utilitarian case for helmet laws can be sustained by appeal to Mill's Harm Principle. Finally, we reject Hooper and Spicer's claim that helmet laws unjustly penalise cyclists for their own health-affecting behaviour. Rather, we show their argument to suffer by disanalogy with medical cases where injustice may be more evident, for example, denial of bypass surgery to smokers. We conclude that mandatory helmet laws offer substantial utility and are entirely defensible within the framework of a liberal democracy.

Physician-assisted death with limited access to palliative care

Even among advocates of legalising physician-assisted death, many argue that this should be done only once palliative care has become widely available. Meanwhile, according to them, physician-assisted death should be banned. Four arguments are often presented to support this claim, which we call the argument of lack of autonomy, the argument of existing alternatives, the argument of unfair inequalities and the argument of the antagonism between physician-assisted death and palliative care. We argue that although these arguments provide strong reasons to take appropriate measures to guarantee access to good quality palliative care to everyone who needs it, they do not justify a ban on physician-assisted death until we have achieved this goal.

Web Accessibility for Older Adults: A Comparative Analysis of Disability Laws

Access to the Internet is increasingly critical for health information retrieval, access to certain government benefits and services, connectivity to friends and family members, and an array of commercial and social services that directly affect health. Yet older adults, particularly those with disabilities, are at risk of being left behind in this growing age- and disability-based digital divide. The Americans with Disabilities Act (ADA) was designed to guarantee older adults and persons with disabilities equal access to employment, retail, and other places of public accommodation. Yet older Internet users sometimes face challenges when they try to access the Internet because of disabilities associated with age. Current legal interpretations of the ADA, however, do not consider the Internet to be an entity covered by law. In this article, we examine the current state of Internet accessibility protection in the United States through the lens of the ADA, sections 504 and 508 of the Rehabilitation Act, state laws and industry guidelines. We then compare U.S. rules to those of OECD (Organisation for Economic Co-Operation and Development) countries, notably in the European Union, Canada, Japan, Australia, and the Nordic countries. Our policy recommendations follow from our analyses of these laws and guidelines, and we conclude that the biggest challenge in bridging the age- and disability-based digital divide is the need to extend accessibility requirements to private, not just governmental, entities and organizations.

The best argument against kidney sales fails

Simon Rippon has recently argued against kidney markets on the grounds that introducing the option to vend will result in many people, especially the poor, being subject to harmful pressure to vend. Though compelling, Rippon's argument fails. What he takes to be a single phenomenon-social and legal pressure to vend-is actually two. Only one of these forms of pressure is, by Rippon's own account, harmful. Further, an empirically informed view of the regulated market suggests that this harmful pressure is easily avoided. Thus, the harm that is the lynchpin of Rippon's opposition is neither a necessary feature of the market nor is it likely to play a significant role in its operation.

What would an environmentally sustainable reproductive technology industry look like?

Through the use of assisted reproductive technologies (ARTs), multiple children are born adding to worldwide carbon emissions. Evaluating the ethics of offering reproductive services against its overall harm to the environment makes unregulated ARTs unjustified, yet the ART business can move towards sustainability as a part of the larger green bioethics movement. By integrating ecological ethos into the ART industry, climate change can be mitigated and the conversation about consumption can become a broader public discourse. Although the impact of naturally made children on the environment is undeniable, I will focus on the ART industry as an anthropogenic source of carbon emissions which lead to climate change. The ART industry is an often overlooked source of environmental degradation and decidedly different from natural reproduction as fertility centres provide a service for a fee and therefore can be subject to economic, policy and bioethical scrutiny. In this article, I will provide a brief background on the current state of human-driven climate change before suggesting two conservationist strategies that can be employed in the ART business. First, endorsing a carbon capping programme that limits the carbon emissions of ART businesses will be proposed. Second, I will recommend that policymakers eliminate funded ARTs for those who are not biologically infertile. I will conclude the article by urging policymakers and all those concerned with climate change to consider the effects of the reproductive technologies industry in light of climate change and move towards sustainability.

The neoliberal political economy and erosion of retirement security

The origins and trajectory of the crisis in the United States retirement security system have slowly become part of the discussion about the social, political, and economic impacts of population aging. Private sources of retirement security have weakened significantly since 1980 as employers have converted defined benefits precisions to defined contribution plans. The Center for Retirement Research (CRR) now estimates that over half of boomer generation retirees will not receive 70-80% of their wages while working. This erosion of the private retirement security system will likely increase reliance on the public system, mainly Social Security and Medicare. These programs, however, have increasingly become the targets of critics who claim that they are not financially sustainable in their current form and must be significantly modified. This article will focus on an analysis of these trends in the erosion of the United States retirement security system and their connection to changes in the United States political economy as neoliberal, promarket ideology, and policies (low taxes, reduced spending, and deregulation) have become dominant in the private and public sectors. The neoliberal priority on reducing labor costs and achieving maximum shareholder value has created an environment inimical to maintain the traditional system of pension and health care benefits in both the private and public sectors. This article explores the implications of these neoliberal trends in the United States economy for the future of retirement security.