1
|
Villalba A. Queering the genome: ethical challenges of epigenome editing in same-sex reproduction. JOURNAL OF MEDICAL ETHICS 2024:jme-2023-109609. [PMID: 38408852 DOI: 10.1136/jme-2023-109609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 02/18/2024] [Indexed: 02/28/2024]
Abstract
In this article, I explore the ethical dimensions of same-sex reproduction achieved through epigenome editing-an innovative and transformative technique. For the first time, I analyse the potential normativity of this disruptive approach for reproductive purposes, focusing on its implications for lesbian couples seeking genetically related offspring. Epigenome editing offers a compelling solution to the complex ethical challenges posed by traditional gene editing, as it sidesteps genome modifications and potential long-term genetic consequences. The focus of this article is to systematically analyse the bioethical issues related to the use of epigenome editing for same-sex reproduction. I critically assess the ethical acceptability of epigenome editing with reproductive purposes from multiple angles, considering harm perspectives, the comparison of ethical issues related to gene and epigenome editing, and feminist theories. This analysis reveals that epigenome editing emerges as an ethically acceptable means for lesbian couples to have genetically related children. Moreover, the experiments of a reproductive use of epigenome editing discussed in this article transcend bioethics, shedding light on the broader societal implications of same-sex reproduction. It challenges established notions of biological reproduction and prompts a reevaluation of how we define the human embryo, while poses some issues in the context of gender self-identification and family structures. In a world that increasingly values inclusivity and diversity, this article aims to reveal a progressive pathway for reproductive medicine and bioethics, as well as underscores the need for further philosophical research in this emerging and fertile domain.
Collapse
Affiliation(s)
- Adrian Villalba
- Department of Philosophy I, Universidad de Granada, Granada, Spain
- Institut Cochin, INSERM, CNRS, Paris, France
| |
Collapse
|
2
|
Is it possible to investigate menopausal age? A comparative cross-sectional study of five cohorts between 1968 and 2017 from the Population Study of Women in Gothenburg, Sweden. ACTA ACUST UNITED AC 2020; 27:430-436. [PMID: 31934948 DOI: 10.1097/gme.0000000000001476] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The aim of this study was to examine if the previously found trend of increasing menopausal age is continuing, taking into consideration hormonal use and surgical menopause in both 38- and 50-year-old women of today. METHODS Cohort comparisons of five generations of population-based samples of 38- and 50-year-old women from the Prospective Population Study of Women in Gothenburg with start in 1968/1969, and with follow-ups in 1980/1981, 1992/1993, 2004/2005, and 2016/2017. Across the time periods newly recruited women as well as earlier participants were included. Use of hormonal contraceptives, estrogen plus progestogen therapy (EPT), and time for menopause was registered. Changes between different generations of 38- and 50-year-old women from 1968/1969 until today were studied. The overall sample size across the time periods was 1,873 individuals. RESULTS The prevalence of oral contraceptives in 38-year-old women was about 10% in 1968/1969, increasing from 16% in 2004/2005 to almost 22% in 2016/2017. From 2004/2005 the use of hormonal intrauterine contraceptive method (the Levonorgestrel-releasing intrauterine system [LNG-IUS]) increased from about 11% to 14% in 2016/2017. The same pattern was found in 50-year-old women using LNG-IUS, increasing from 6% to 15.5% between 2004/2005 and 2016/2017. The total hormonal use, including LNG-IUS, oral contraceptives, and EPT, was 28% in 50-year-old women in 2016/2017. The total proportion of hormone use in 50-year-old women increased over the years and together with surgical menopause it reached over 37% in the 2016/2017 survey. CONCLUSIONS This study has shown an increase in the hormonal use, in both 38- and 50-year-old women, making it difficult to determine when the actual menopause occurs. Thus, the previously found increasing secular trend in menopausal age will be more complicated to assess in female generations of today and tomorrow.
Collapse
|
3
|
Harris C, Green S, Ramsey W, Allen K, King R. Sustainability in Health care by Allocating Resources Effectively (SHARE) 9: conceptualising disinvestment in the local healthcare setting. BMC Health Serv Res 2017; 17:633. [PMID: 28886735 PMCID: PMC5591535 DOI: 10.1186/s12913-017-2507-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 08/03/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This is the ninth in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The disinvestment literature has broadened considerably over the past decade; however there is a significant gap regarding systematic, integrated, organisation-wide approaches. This debate paper presents a discussion of the conceptual aspects of disinvestment from the local perspective. DISCUSSION Four themes are discussed: Terminology and concepts, Motivation and purpose, Relationships with other healthcare improvement paradigms, and Challenges to disinvestment. There are multiple definitions for disinvestment, multiple concepts underpin the definitions and multiple alternative terms convey these concepts; some definitions overlap and some are mutually exclusive; and there are systematic discrepancies in use between the research and practice settings. Many authors suggest that the term 'disinvestment' should be avoided due to perceived negative connotations and propose that the concept be considered alongside investment in the context of all resource allocation decisions and approached from the perspective of optimising health care. This may provide motivation for change, reduce disincentives and avoid some of the ethical dilemmas inherent in other disinvestment approaches. The impetus and rationale for disinvestment activities are likely to affect all aspects of the process from identification and prioritisation through to implementation and evaluation but have not been widely discussed. A need for mechanisms, frameworks, methods and tools for disinvestment is reported. However there are several health improvement paradigms with mature frameworks and validated methods and tools that are widely-used and well-accepted in local health services that already undertake disinvestment-type activities and could be expanded and built upon. The nature of disinvestment brings some particular challenges for policy-makers, managers, health professionals and researchers. There is little evidence of successful implementation of 'disinvestment' projects in the local setting, however initiatives to remove or replace technologies and practices have been successfully achieved through evidence-based practice, quality and safety activities, and health service improvement programs. CONCLUSIONS These findings suggest that the construct of 'disinvestment' may be problematic at the local level. A new definition and two potential approaches to disinvestment are proposed to stimulate further research and discussion.
Collapse
Affiliation(s)
- Claire Harris
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Centre for Clinical Effectiveness, Monash Health, Melbourne, Australia
| | - Sally Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Wayne Ramsey
- Medical Services and Quality, Monash Health, Melbourne, Australia
| | - Kelly Allen
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Centre for Clinical Effectiveness, Monash Health, Melbourne, Australia
| | - Richard King
- Medicine Program, Monash Health, Melbourne, Australia
| |
Collapse
|
4
|
Harris C, Green S, Elshaug AG. Sustainability in Health care by Allocating Resources Effectively (SHARE) 10: operationalising disinvestment in a conceptual framework for resource allocation. BMC Health Serv Res 2017; 17:632. [PMID: 28886740 PMCID: PMC5590199 DOI: 10.1186/s12913-017-2506-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 08/03/2017] [Indexed: 11/15/2022] Open
Abstract
Background This is the tenth in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. After more than a decade of research, there is little published evidence of active and successful disinvestment. The paucity of frameworks, methods and tools is reported to be a factor in the lack of success. However there are clear and consistent messages in the literature that can be used to inform development of a framework for operationalising disinvestment. This paper, along with the conceptual review of disinvestment in Paper 9 of this series, aims to integrate the findings of the SHARE Program with the existing disinvestment literature to address the lack of information regarding systematic organisation-wide approaches to disinvestment at the local health service level. Discussion A framework for disinvestment in a local healthcare setting is proposed. Definitions for essential terms and key concepts underpinning the framework have been made explicit to address the lack of consistent terminology. Given the negative connotations of the word ‘disinvestment’ and the problems inherent in considering disinvestment in isolation, the basis for the proposed framework is ‘resource allocation’ to address the spectrum of decision-making from investment to disinvestment. The focus is positive: optimising healthcare, improving health outcomes, using resources effectively. The framework is based on three components: a program for decision-making, projects to implement decisions and evaluate outcomes, and research to understand and improve the program and project activities. The program consists of principles for decision-making and settings that provide opportunities to introduce systematic prompts and triggers to initiate disinvestment. The projects follow the steps in the disinvestment process. Potential methods and tools are presented, however the framework does not stipulate project design or conduct; allowing application of any theories, methods or tools at each step. Barriers are discussed and examples illustrating constituent elements are provided. Conclusions The framework can be employed at network, institutional, departmental, ward or committee level. It is proposed as an organisation-wide application, embedded within existing systems and processes, which can be responsive to needs and priorities at the level of implementation. It can be used in policy, management or clinical contexts. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2506-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Claire Harris
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia. .,Centre for Clinical Effectiveness, Monash Health, Melbourne, Victoria, Australia.
| | - Sally Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Adam G Elshaug
- Menzies Centre for Health Policy, Sydney School of Public Health, University of Sydney, Sydney, Australia.,Lown Institute, Brookline, Massachusetts, USA
| |
Collapse
|
5
|
Harris C, Ko H, Waller C, Sloss P, Williams P. Sustainability in health care by allocating resources effectively (SHARE) 4: exploring opportunities and methods for consumer engagement in resource allocation in a local healthcare setting. BMC Health Serv Res 2017; 17:329. [PMID: 28476155 PMCID: PMC5420096 DOI: 10.1186/s12913-017-2212-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/31/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This is the fourth in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. Healthcare decision-makers have sought to improve the effectiveness and efficiency of services through removal or restriction of practices that are unsafe or of little benefit, often referred to as 'disinvestment'. A systematic, integrated, evidence-based program for disinvestment was being established within a large Australian health service network. Consumer engagement was acknowledged as integral to this process. This paper reports the process of developing a model to integrate consumer views and preferences into an organisation-wide approach to resource allocation. METHODS A literature search was conducted and interviews and workshops were undertaken with health service consumers and staff. Findings were drafted into a model for consumer engagement in resource allocation which was workshopped and refined. RESULTS Although consumer engagement is increasingly becoming a requirement of publicly-funded health services and documented in standards and policies, participation in organisational decision-making is not widespread. Several consistent messages for consumer engagement in this context emerged from the literature and consumer responses. Opportunities, settings and activities for consumer engagement through communication, consultation and participation were identified within the resource allocation process. Sources of information regarding consumer values and perspectives in publications and locally-collected data, and methods to use them in health service decision-making, were identified. A model bringing these elements together was developed. CONCLUSION The proposed model presents potential opportunities and activities for consumer engagement in the context of resource allocation.
Collapse
Affiliation(s)
- Claire Harris
- School of Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia. .,Centre for Clinical Effectiveness, Monash Health, Clayton, VIC, Australia.
| | - Henry Ko
- Centre for Clinical Effectiveness, Monash Health, Clayton, VIC, Australia.,NHMRC Clinical Trials Centre, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Cara Waller
- Centre for Clinical Effectiveness, Monash Health, Clayton, VIC, Australia
| | - Pamela Sloss
- Consumer Representative, Monash Health, Clayton, VIC, Australia
| | - Pamela Williams
- Consumer Representative, Monash Health, Clayton, VIC, Australia
| |
Collapse
|
6
|
Milazzo A, Mnatzaganian G, Elshaug AG, Hemphill SA, Hiller JE. Depression and Anxiety Outcomes Associated with Failed Assisted Reproductive Technologies: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0165805. [PMID: 27835654 PMCID: PMC5106043 DOI: 10.1371/journal.pone.0165805] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 10/18/2016] [Indexed: 11/18/2022] Open
Abstract
Objective Our study examined the psychological outcomes associated with failed ART treatment outcomes in men and women. Search Strategy A systematic search for studies published between January 1980 and August 2015 was performed across seven electronic databases. Inclusion Criteria Studies were included if they contained data on psychosocial outcomes taken pre and post ART treatment. Data Extraction and Synthesis A standardised form was used to extract data and was verified by two independent reviewers. Studies were meta-analysed to determine the association of depression and anxiety with ART treatment outcomes. Narrative synthesis identified factors to explain variations in the size and directions of effects and relationships explored within and between the studies. Main Results Both depression and anxiety increased after a ART treatment failure with an overall pooled standardised mean difference (SMD) of 0.41 (95% CI: 0.27, 0.55) for depression and 0.21 (95% CI: 0.13, 0.29) for anxiety. In contrast, depression decreased after a successful treatment, SMD of -0.24 (95% CI: -0.37,-0.11). Both depression and anxiety decreased as time passed from ART procedure. Nonetheless, these remained higher than baseline measures in the group with the failed outcome even six months after the procedure. Studies included in the narrative synthesis also confirmed an association with negative psychological outcomes in relation to marital satisfaction and general well-being following treatment failure. Conclusion Linking ART failure and psychosocial outcomes may elucidate the experience of treatment subgroups, influence deliberations around recommendations for resource allocation and health policy and guide patient and clinician decision making.
Collapse
Affiliation(s)
- Adriana Milazzo
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - George Mnatzaganian
- College of Science, Health and Engineering, La Trobe Rural Health School, La Trobe University, Victoria, Australia
| | - Adam G. Elshaug
- Menzies Centre for Health Policy, The University of Sydney, Sydney, New South Wales, Australia
| | - Sheryl A. Hemphill
- Learning Sciences Institute Australia, Faculty of Education and Arts, Australian Catholic University, Melbourne, Victoria, Australia
- School of Psychology, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia
| | - Janet E. Hiller
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
- School of Health Sciences, Swinburne University of Technology, Melbourne, Victoria Australia
- * E-mail:
| | | |
Collapse
|
7
|
Carter D, Gordon J, Watt AM. Competing Principles for Allocating Health Care Resources. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2016; 41:558-83. [DOI: 10.1093/jmp/jhw017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
8
|
Brown RCH, Rogers WA, Entwistle VA, Bhattacharya S. Reframing the Debate Around State Responses to Infertility: Considering the Harms of Subfertility and Involuntary Childlessness. Public Health Ethics 2016. [DOI: 10.1093/phe/phw005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
9
|
Hodgetts K, Hiller JE, Street JM, Carter D, Braunack-Mayer AJ, Watt AM, Moss JR, Elshaug AG. Disinvestment policy and the public funding of assisted reproductive technologies: outcomes of deliberative engagements with three key stakeholder groups. BMC Health Serv Res 2014; 14:204. [PMID: 24885716 PMCID: PMC4016640 DOI: 10.1186/1472-6963-14-204] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 04/25/2014] [Indexed: 11/10/2022] Open
Abstract
Background Measures to improve the quality and sustainability of healthcare practice and provision have become a policy concern. In addition, the involvement of stakeholders in health policy decision-making has been advocated, as complex questions arise around the structure of funding arrangements in a context of limited resources. Using a case study of assisted reproductive technologies (ART), deliberative engagements with a range of stakeholder groups were held on the topic of how best to structure the distribution of Australian public funding in this domain. Methods Deliberative engagements were carried out with groups of ART consumers, clinicians and community members. The forums were informed by a systematic review of ART treatment safety and effectiveness (focusing, in particular, on maternal age and number of treatment cycles), as well as by international policy comparisons, and ethical and cost analyses. Forum discussions were transcribed and subject to thematic analysis. Results Each forum demonstrated stakeholders’ capacity to understand concepts of choice under resource scarcity and disinvestment, and to countenance options for ART funding not always aligned with their interests. Deliberations in each engagement identified concerns around ‘equity’ and ‘patient responsibility’, culminating in a broad preference for (potential) ART subsidy restrictions to be based upon individual factors rather than maternal age or number of treatment cycles. Community participants were open to restrictions based upon measures of body mass index (BMI) and smoking status, while consumers and clinicians saw support to improve these factors as part of an ART treatment program, as distinct from a funding criterion. All groups advocated continued patient co-payments, with measures in place to provide treatment access to those unable to pay (namely, equity of access). Conclusions Deliberations yielded qualitative, socially-negotiated evidence required to inform ethical, accountable policy decisions in the specific area of ART and health care more broadly. Notably, reductionist, deterministic characterizations of stakeholder ‘self-interest’ proved unfounded as each group sought to prioritise universal values (in particular, ‘equity’ and ‘responsibility’) over specific, within-group concerns. Our results - from an emotive case study in ART - highlight that evidence-informed disinvestment decision-making is feasible, and potentially less controversial than often presumed.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Adam G Elshaug
- Menzies Centre for Health Policy, Sydney School of Public Health, Sydney Medical School, The University of Sydney, Coppleson Building D02, Sydney, NSW 2006, Australia.
| | | |
Collapse
|