Ethics of the social determinants of health

Ethical and Policy Implications of Racial and Ethnic Healthcare Disparities in Sleep Health

Despite efforts in recent years, including in policy and research, to address health disparities in the United States, many of those disparities continue to fester in marginalized racial/ethnic populations. Understanding sleep health disparities is critical in understanding the health and wellness of these groups. Using obstructive sleep apnea (OSA) in Black populations as a focus, this paper presents the role of race and ethnicity in the clinical understanding of sleep health-related issues by medical practitioners and the implications of the lack of clear policies or best practices to guide medical practitioners' attempts to meet sleep-related needs of marginalized racial/ethnic populations. Furthermore, the knowledge gap may be further complicated by the poor understanding and integration of existing evidence with the many, complex, sleep-associated co-morbidities. Policymaking in this area ought to be based on the ethical implications of disparate sleep-related health outcomes by race and ethnicity. So, we conclude by offering recommendations for developing ethically sound policies for addressing sleep problems in marginalized racial and ethnic populations.

Ethical implications of AI and robotics in healthcare: A review

Integrating Artificial Intelligence (AI) and robotics in healthcare heralds a new era of medical innovation, promising enhanced diagnostics, streamlined processes, and improved patient care. However, this technological revolution is accompanied by intricate ethical implications that demand meticulous consideration. This article navigates the complex ethical terrain surrounding AI and robotics in healthcare, delving into specific dimensions and providing strategies and best practices for ethical navigation. Privacy and data security are paramount concerns, necessitating robust encryption and anonymization techniques to safeguard patient data. Responsible data handling practices, including decentralized data sharing, are critical to preserve patient privacy. Algorithmic bias poses a significant challenge, demanding diverse datasets and ongoing monitoring to ensure fairness. Transparency and explainability in AI decision-making processes enhance trust and accountability. Clear responsibility frameworks are essential to address the accountability of manufacturers, healthcare institutions, and professionals. Ethical guidelines, regularly updated and accessible to all stakeholders, guide decision-making in this dynamic landscape. Moreover, the societal implications of AI and robotics extend to accessibility, equity, and societal trust. Strategies to bridge the digital divide and ensure equitable access must be prioritized. Global collaboration is pivotal in developing adaptable regulations and addressing legal challenges like liability and intellectual property. Ethics must remain at the forefront in the ever-evolving realm of healthcare technology. By embracing these strategies and best practices, healthcare systems and professionals can harness the potential of AI and robotics, ensuring responsible and ethical integration that benefits patients while upholding the highest ethical standards.

Unmet need for contraception among married adolescent girls and young women in Haramaya Health and demographic surveillance system, Eastern Ethiopia

Background

The prevalence of unmet need for contraception is the highest in low- and middle-income countries (LMIC). Contraceptive use among young married or unmarried women is lower than that among older women in developing countries. Previous studies generalized the findings to all women of reproductive age and have not investigated psychosocial factors that influence contraceptive use. This study aimed to identify factors associated with unmet need for contraception among young married women in the Haramaya Health and Demographic Surveillance System (HDSS), eastern Ethiopia.

Methodology

A cross-sectional, community-based study of young married women aged 15-24 years was conducted. A simple random sampling method was used to select 550 young married women. Data were collected using a pretested structured questionnaire. Using adjusted odds ratio (AOR) with a 95% confidence interval (CI), factors associated with unmet need for contraception were identified using multivariable logistic regression analysis.

Results

The overall prevalence of unmet need for contraception was 154 (30.3%). Adolescents (15-19) (AOR = 2.05, 95% CI: 1.16-3.62), husbands' negative attitude toward contraception (AOR = 2.1, 95% CI: 1.05-4.46), and no previous use of contraception (AOR = 3.9, 95% CI: 2.29-6.71) were significantly and positively associated with unmet need for contraception. On the contrary, young women with secondary education or higher (AOR = 0.55, 95% CI: 0.28-1.084) were negatively and significantly associated with unmet need for contraception.

Conclusion

The prevalence of unmet need for contraception among young women in Haramaya was high. Unmet need was affected by age, husbands' attitude toward contraceptives, the educational status of women, and previous use of contraception. This study underscored the need to improve girls' educational status to empower them in making contraceptive use decisions with their partners. Programs should also engage male partners who are perceived as key decision-makers when it comes to contraceptive use.

The philosophical foundations of 'health for all' and Universal Health Coverage

The WHO constitution calls for 'health for all' and Universal Health Coverage has been called "the ultimate expression of fairness", however it is not always clear how health systems can move towards equity. Should we prioritise the needs of the worst off? And if so, should we direct resources to these marginalised groups or marginalised individuals? This article provides an overview of the philosophical underpinnings of health equity and proportionate universalism, highlighting the trade-offs involved in operationalising a core tenant of global health practice.

Bioethics and COVID-19: Considering the Social Determinants of Health

In this paper, we focus on a novel bioethical approach concerning the ethical implications of the Social Determinants of Health (SDs) in the time of COVID-19, offering a fresh interpretation of our agency and responsibility in the current pandemic era. Our interpretation is grounded on the idea that our health basically depends on factors that go beyond our organism. In this sense, we stress the radical importance of circumstances to ethically assess an action, in the current pandemic context. Moreover, due the centrality of the SDs in our bioethical assessments-that implies that our health does not exclusively depend on our choices, behaviors, and lifestyle-we can affirm that we are not entirely responsible for our wellness or diseases. As health depends on economic, social, cultural, and environmental factors, we argue that the analysis of personal responsibility facing personal health status should receive further consideration. In this sense, following the "social connection model," we stress the importance of the concept of "shared responsibility" in collective decisions: if we make many decisions collectively, we are also collectively responsible of these decisions. Furthermore, to responsibly tackle the social inequalities that are the underlying cause of disparities in health outcomes, we propose two main strategies based on the Capability Approach: 1. empowering the individuals, especially the most vulnerable ones; and 2. designing preventive policies and interventions that provides an opportunity to address the disparities moving forward. This will help us going beyond the "individualistic medical ethics paradigm" and integrating our concept of health with social factors (e.g., the SDs), based on a more relational and interdependent anthropological thought.

Polity's Enduring Effect on Infant Health Outcomes

OBJECTIVES

How a nation's style of governance (polity) affects infant health is not fully understood. Here, the effects of polity on infant mortality rates (IMRs) is evaluated across 164 nations over a 28-year period.

METHODS

Variation in 2018 IMRs was examined in relation to Polity Scores from 1990 to 2017 that quantify autocratic-to-democratic propensities of governments. Regression coefficients of effect, adjusted for national differences in economic prosperity, income equity and gender parity are reported.

RESULTS

IMRs and polity was inversely related and more strongly associated with greater time between measurements. 2018 IMRs decreased by 0.12 deaths for a unitary increase in 2017 Polity Scores and 0.84 deaths when 1990 Polity Scores were examined. A similar, but more intense pattern was found when Polity Scores were aggregated to represent Autocratic, Anocratic and Democratic governance.

CONCLUSIONS FOR PRACTICE

Beyond risks associated with birthright, behavior and physical environments, a nation's form of government has a real, enduring effect on infant health. A full measure of that association requires extended time for proper evaluation.

Social justice, health equity, and mental health

There is considerable evidence to indicate that stigma and discrimination against people with mental illnesses are widely prevalent across nations. Research also shows that individuals with mental illnesses are likely to die 15–20 years younger than those who do not have these illnesses. In addition, they are more likely to experience delays in help-seeking leading to poor outcomes and are more likely to experience physical illnesses. Stigma and discrimination appear to play a major role in depriving people with mental illnesses of their basic rights. Their economic, political, social, and human rights are often ignored. In this article, we describe the capability to be healthy and basic principles of social justice related to mental health. We discuss findings of discrimination often embedded in laws of countries around the world in the context of basic human rights. We believe that clinicians have a key role as advocates for their patients. Clinicians and policymakers need to work together to bring about social and health equity.

Unhealthy lifestyles, environment, well-being and health capability in rural neighbourhoods: a community-based cross-sectional study

BACKGROUND

Non-communicable diseases are a leading cause of health loss worldwide, in part due to unhealthy lifestyles. Metabolic-based diseases are rising with an unhealthy body-mass index (BMI) in rural areas as the main risk factor in adults, which may be amplified by wider determinants of health. Changes in rural environments reflect the need of better understanding the factors affecting the self-ability for making balanced decisions. We assessed whether unhealthy lifestyles and environment in rural neighbourhoods are reflected into metabolic risks and health capability.

METHODS

We conducted a community-based cross-sectional study in 15 Portuguese rural neighbourhoods to describe individuals' health functioning condition and to characterize the community environment. We followed a qualitatively driven mixed-method design to gather information about evidence-based data, lifestyles and neighbourhood satisfaction (incorporated in eVida technology), within a random sample of 270 individuals, and in-depth interviews to 107 individuals, to uncover whether environment influence the ability for improving or pursuing heath and well-being.

RESULTS

Men showed to have a 75% higher probability of being overweight than women (p-value = 0.0954); and the reporting of health loss risks was higher in women (RR: 1.48; p-value = 0.122), individuals with larger waist circumference (RR: 2.21; IC: 1.19; 4.27), overweight and obesity (RR: 1.38; p-value = 0.293) and aged over 75 years (RR: 1.78; p-value = 0.235; when compared with participants under 40 years old). Metabolic risks were more associated to BMI and physical activity than diet (or sleeping habits). Overall, metabolic risk linked to BMI was higher in small villages than in municipalities. Seven dimensions, economic development, built (and natural) environment, social network, health care, demography, active lifestyles, and mobility, reflected the self-perceptions in place affecting the individual ability to make healthy choices. Qualitative data exposed asymmetries in surrounding environments among neighbourhoods and uncovered the natural environment and natural resources specifies as the main value of rural well-being.

CONCLUSIONS

Metabolic risk factors reflect unhealthy lifestyles and can be associated with environment contextual-dependent circumstances. People-centred approaches highlight wider socioeconomic and (natural) environmental determinants reflecting health needs, health expectations and health capability. Our community-based program and cross-disciplinary research provides insights that may improve health-promoting changes in rural neighbourhoods.

Don't Downplay "Play": Reasons Why Health Systems Should Protect Childhood Play

Much research has studied the importance of play for children's development. However, questions of its political importance and our public institutions' duties to protect it have been largely neglected. This article argues that childhood play is politically important due to having both intrinsic and instrumental value, and it suggests that the duty to protect the capability for play in childhood falls especially on the public health system. If this argument succeeds, it follows that we have stronger duties toward our children than we currently believe.

Synthesising the shifting terminology of community health: A critiquing review of agent-based approaches

The field of community health promotion encompasses a wide range of approaches, including bottom-up approaches that recognise and build on the agency and strengths of communities to define and pursue their health goals. Momentum towards agent-based approaches to community health promotion has grown in recent years, and several related but distinct conceptual and methodological bodies of work have developed largely in isolation from each other. The lack of a cohesive collection of research, practice, and policy has made it difficult to learn from the innovations, best practices, and shortcomings of these approaches, which is exacerbated by the imprecise and inconsistent use of related terms. This article provides a review of three agent-based approaches to promoting community health: asset-based approaches, capacity building, and capabilities approaches, noting the theoretical origins and fundamental concepts, applications and methodologies, and limitations and critiques of each. This article discusses their commonalities and differences in terms of how they conceptualise and approach the promotion of community health, including a critical consideration of their limitations and where they may prove to be counterproductive. This article argues that agent-based approaches to community health must be met with meaningful opportunities to disengage from the structures that constrain their health.

Bringing ethical thinking to social change initiatives: Why it matters

Norms-shifting interventions (NSI) seek to improve people's well-being by facilitating the transformation of harmful social norms, the shared rules of acceptable actions in a group that prop up harmful health behaviours. Community-based NSI aim for incremental normative change and complement other social and behaviour change strategies, addressing gender, other inequalities, and the power structures that hold inequalities in place. Consequently, they demand that designers and implementers-many who are outsiders-grapple with power, history, and community agency operating in complicated social contexts. Ethical questions include whose voices and values, at which levels, should inform intervention design; who should be accountable for managing resistance that arises during implementation? As interest and funding for NSI increases in lower and middle-income countries, their potential to yield sustained change is balanced by unintentionally reinforcing inequities that violate human rights and social justice pillars guiding health promotion efforts. A review of 125 articles on ethical considerations in public health, social justice, and human rights-where NSI actions intersect-indicated little guidance on practice. To begin to address this gap, we propose ten ethical values and practical ways to engage ethically with the social complexities of NSI and the social change they seek, and a way forward.

Commercial determinants of health: an ethical exploration

OBJECTIVES

This paper seeks to contribute toward a better understanding of commercial determinants of health by proposing a set of ethical principles that can be used by researchers and other health actors in understanding and addressing Commercial Determinants of Health (CDoH).

METHODS

The paper is mainly based on a systematic review and qualitative analysis of the existing literature on CDoH and public health ethics frameworks. We conducted searches using selected search engines (Google Scholar and Pubmed). For ethical challenges relating to CDOH, our searches in Google Scholar yielded 17 papers that discussed ethical challenges that affect CDoH. For ethical frameworks relevant for CDOH, our searches in Google Scholar and Pubmed yielded 15 papers that clearly described bioethical models including relevant ethical principles. Additionally, we consulted eight experts working on CDoH. Through these two methods, we were able to identify ethical challenges as well as norms and values related to CDoH that we offer as candidates to comprise a foundational ethics framework for CDoH.

RESULTS

Discussing risk factors associated with CDH frequently brings public health into conflict with the interests of industry actors in the food, automobile, beverage, alcohol, ammunition, gaming and tobacco industries including conflict between profit-making and public health. We propose the following candidate ethical principles that can be used in addressing CDoH: moral responsibility, nonmaleficence, social justice and equity, consumer sovereignty, evidence-informed actions, responsiveness, accountability, appropriateness, transparency, beneficence and holism.

CONCLUSIONS

We hope that this set of guiding principles will generate wider global debate on CDoH and help inform ethical analyses of corporate actions that contribute to ill health and policies aimed at addressing CDoH. These candidate principles can guide researchers and health actors including corporations in addressing CDoH.

Positive Public Health Ethics: Toward Flourishing and Resilient Communities and Individuals

The COVID-19 pandemic is a global contagion of unprecedented proportions and health, economic, and social consequences. As with many health problems, its impact is uneven. This article argues the COVID-19 pandemic is a global health injustice due to moral failures of national governments and international organizations to prepare for, prevent and control it. Global and national health communities had a moral obligation to act in accordance with the current state of knowledge of pandemic preparedness. This obligation-a positive duty to develop and implement systems to reduce threats to and safeguard individuals' and, communities' abilities to flourish-stems from theories of global health justice and governance. The COVID-19 pandemic revealed and amplified the fragility and deficiencies in our global and domestic health institutions and systems. Moving forward, positive public health ethics is needed to set ethical standards for building and operating robust public health systems for resilient individuals and communities.

Reconceptualizing Psychosis: The Hearing Voices Movement and Social Approaches to Health

The Hearing Voices Movement is an international grassroots movement that aims to shift public and professional attitudes toward experiences-such as hearing voices and seeing visions-that are generally associated with psychosis. The Hearing Voices Movement identifies these experiences as having personal, relational, and cultural significance. Incorporating this perspective into mental health practice and policy has the potential to foster greater understanding and respect for consumers/survivors diagnosed with psychosis while opening up valuable avenues for future research. However, it is important that a focus on individual experiences of adversity not supersede attention to larger issues of social and economic injustice. Access to appropriate mental health care is a human right; this article will argue that the right to health additionally extends beyond individual-level interventions.

A logic framework for evaluating social determinants of health interventions in primary care

Background

Increasing efforts have been made in primary care settings to screen for a broad array of social determinants of health including inadequate food and nutrition, lack of education, unemployment, and inadequate housing, and to refer patients to community resources. Core tenets of primary care include integration with community resources.

Methods

In the course of designing a randomized controlled trial of the effectiveness of a social determinants of health intervention aimed at adult, at-risk, African American primary care clinic patients, our research team developed a logic model to assist with the evaluation of the intervention.

Results

In this article, we describe the logic model including elements of the intervention, mediator variables, and outcome variables.

Conclusions

The proposed logic framework is likely to be helpful for planning, conducting, and evaluating social determinants of health interventions in primary care settings.

Health Impact Assessment of Transportation Projects and Policies: Living Up to Aims of Advancing Population Health and Health Equity?

Health impact assessment (HIA) is a forward-looking, evidence-based tool used to inform stakeholders and policy makers about the potential health effects of proposed projects and policies and to identify options for maximizing potential health benefits and minimizing potential harm. This review examines how health equity, a core principle of health impact assessment (HIA), has been operationalized in HIAs conducted in the United States in one sector, transportation. Two perspectives on promoting health equity appear in the broader public health research literature; one aims at reducing disparities in health determinants and outcomes in affected populations, whereas the other focuses on facilitating community participation and self-determination. Variations in how these perspectives are applied in HIA informed our typology of five ways of addressing health equity in HIA. Transportation HIAs commonly included two of these—selecting vulnerable populations for the focus of the HIA and stakeholder engagement, seen in more than 70% of the 96 HIAs reviewed. Fewer than half of the HIAs assessed current health disparities or changes in their distribution. Only 15% of HIAs addressed equity by focusing on capabilities development or empowerment. Routinely assessing and reporting how an HIA aims to address health equity might better manage expectations and could make HIA practitioners and users more conscious of how an HIA can realistically be used to advance health equity.

Right to health and social justice in Bangladesh: ethical dilemmas and obligations of state and non-state actors to ensure health for urban poor

Background

The world is urbanizing rapidly; more than half the world’s population now lives in urban areas, leading to significant transition in lifestyles and social behaviours globally. While offering many advantages, urban environments also concentrate health risks and introduce health hazards for the poor. In Bangladesh, although many public policies are directed towards equity and protecting people’s rights, these are not comprehensively and inclusively applied in ways that prioritize the health rights of citizens. The country is thus facing many issues that raise moral and ethical concerns.

Methods

A narrative literature review was conducted between October 2016 and November 2017 on issues related to social justice, health, and human rights in urban Bangladesh. The key questions discussed here are: i) ethical dilemmas and inclusion of the urban poor to pursue social justice; and ii) the ethical obligations and moral responsibilities of the state and non-state sectors in serving Bangladesh’s urban poor. Using a Rawlsian theory of equality of opportunity to ensure social justice, we identified key health-related ethical issues in the country’s rapidly changing urban landscape, especially among the poor.

Results

We examined ethical dilemmas in Bangladesh’s health system through the rural–urban divide and the lack of coordination among implementing agencies. The unregulated profusion of the private sector and immoral practices of service providers result in high out-of-pocket expenditures for urban poor, leading to debt and further impoverishment. We also highlight policy and programmatic gaps, as well as entry points for safeguarding the right to health for Bangladeshi citizens.

Conclusions

The urban health system in Bangladesh needs a reform in which state and non-state actors should work together, understanding and acknowledging their moral responsibilities for improving the health of the urban poor by engaging multiple sectors. The social determinants of health should be taken into account when formulating policies and programs to achieve universal health coverage and ensure social justice for the urban poor in Bangladesh.

Making the Case for Addressing Health Disparities: What Drives Providers and Payers?

Purpose: The creation of the Centers for Medicare & Medicaid Services Office of Minority Health placed increased emphasis on federal efforts to address health disparities. Although the literature establishes a social justice case for addressing health disparities, there is limited evidence of this case being sufficient for businesses to invest in such initiatives. The purpose of this study was to better understand the “business case” behind an organization's investment in health disparity reduction work.

Methods: We conducted six case studies (44 on-site interviews) with diverse private-sector provider and payer organizations.

Results: While providers and payers cited business rationales for initiating disparity-focused efforts, their motivations differed.

Conclusion: As federal entities address health disparities, and payment models shift from volume to value, engaging private stakeholders with the leverage to move the health disparities needle is of principal importance.

Using sustainability as a collaboration magnet to encourage multi-sector collaborations for health

The World Health Organization Commission on Social Determinants of Health (SDH) places great emphasis on the role of multi-sector collaboration in addressing SDH. Despite this emphasis on this need, there is surprisingly little evidence for this to advance health equity goals. One way to encourage more successful multi-sector collaborations is anchoring SDH discourse around 'sustainability', subordinating within it the ethical and empirical importance of 'levelling up'. Sustainability, in contrast to health equity, has recently proved to be an effective collaboration magnet. The recent adoption of the Sustainable Development Goals (SDGs) provides an opportunity for novel ways of ideationally re-framing SDH discussions through the notion of sustainability. The 2030 Agenda for the SDGs calls for greater policy coherence across sectors to advance on the goals and targets. The expectation is that diverse sectors are more likely and willing to collaborate with each other around the SDGs, the core idea of which is 'sustainability'.

Governance of Transnational Global Health Research Consortia and Health Equity

Global health research partnerships are increasingly taking the form of consortia of institutions from high-income countries and low- and middle-income countries that undertake programs of research. These partnerships differ from collaborations that carry out single projects in the multiplicity of their goals, scope of their activities, and nature of their management. Although such consortia typically aim to reduce health disparities between and within countries, what is required for them to do so has not been clearly defined. This article takes a conceptual approach to explore how the governance of transnational global health research consortia should be structured to advance health equity. To do so, it applies an account called shared health governance to derive procedural and substantive guidance. A checklist based on this guidance is proposed to assist research consortia determine where their governance practices strongly promote equity and where they may fall short.

Practical Strategies for Providing Culturally Sensitive, Ethical Care in Developing Nations

Providing health care in developing nations results in cultural and ethical challenges for health care professionals. The authors’ intent is to raise readers’ awareness of how to maintain an ethical and culturally sensitive approach to practice in developing nations. Four practical approaches to ethical decision-making, developed from the literature and praxis, in conjunction with traditional moral theory and guidelines from professional and international organizations are discussed. Ethical multiculturalism, a view that combines universalism and multiculturalism undergirds culturally appropriate and ethically responsive decisions.

Environmental justice and health practices: understanding how health inequities arise at the local level

While empirical evidence continues to show that people living in low socio-economic status neighbourhoods are less likely to engage in health-enhancing behaviour, our understanding of why this is so remains less than clear. We suggest that two changes could take place to move from description to understanding in this field; (i) a move away from the established concept of individual health behaviour to a contextualised understanding of health practices; and (ii) a switch from focusing on health inequalities in outcomes to health inequities in conditions. We apply Pierre Bourdieu's theory on capital interaction but find it insufficient with regard to the role of agency for structural change. We therefore introduce Amartya Sen's capability approach as a useful link between capital interaction theory and action to reduce social inequities in health-related practices. Sen's capability theory also elucidates the importance of discussing unequal chances in terms of inequity, rather than inequality, in order to underscore the moral nature of inequalities. We draw on the discussion in social geography on environmental injustice, which also underscores the moral nature of the spatial distribution of opportunities. The article ends by applying this approach to the 'Interdisciplinary study of inequalities in smoking' framework.

Understanding the social factors that contribute to diabetes: a means to informing health care and social policies for the chronically ill

Social determinants of health are the conditions in which individuals are born, grow, live, work, and age. Increasingly, they are being recognized for their relationship to the soaring incidence of Type 2 diabetes in the US, as well as the opportunities they present for us to counter it. Many current Type 2 diabetes interventions focus on biologic and behavioral factors, such as symptoms, diet, and physical activity. However, it is equally important to address the influence of physical and social environments, which may include low income, employment insecurity, low educational attainment, and poor living conditions, on health outcomes. Section 4302 of the Patient Protection and Affordable Care Act of 2010 offers an opportunity to improve data collection and policy development to more effectively identify populations at high risk for developing Type 2 diabetes and to proactively refer them to appropriate social support services that may ultimately support reduction of health disparities. Expanding the scope of this legislation to include data that incorporate social determinants would improve the ability of clinicians and health systems to engage and to treat patients with chronic conditions, such as Type 2 diabetes, while expanding policymakers' ability to conform to the legislation's intent of shaping efforts to reduce chronic conditions nationwide.

Health capabilities and diabetes self-management: the impact of economic, social, and cultural resources

While the "social determinants of health" view compels us to explore how social structures shape health outcomes, it often ignores the role individual agency plays. In contrast, approaches that focus on individual choice and personal responsibility for health often overlook the influence of social structures. Amartya Sen's "capabilities" framework and its derivative the "health capabilities" (HC) approach attempts to accommodate both points of view, acknowledging that individuals function under social conditions over which they have little control, while also acting as agents in their own health and well-being. This paper explores how economic, social, and cultural resources shape the health capability of people with diabetes, focusing specifically on dietary practices. Health capability and agency are central to dietary practices, while also being shaped by immediate and broader social conditions that can generate habits and a lifestyle that constrain dietary behaviors. From January 2011 to December 2012, we interviewed 45 people with diabetes from a primary care clinic in Ontario (Canada) to examine how their economic, social, and cultural resources combine to influence dietary practices relative to their condition. We classified respondents into low, medium, and high resource groups based on economic circumstances, and compared how economic resources, social relationships, health-related knowledge and values combine to enhance or weaken health capability and dietary management. Economic, social, and cultural resources conspired to undermine dietary management among most in the low resource group, whereas social influences significantly influenced diet among many in the medium group. High resource respondents appeared most motivated to maintain a healthy diet, and also had the social and cultural resources to enable them to do so. Understanding the influence of all three types of resources is critical for constructing ways to enhance health capability, chronic disease self-management, and health.

Ethical issues of obesity surgery--a health technology assessment

New surgical technologies may challenge societal values, and their adoption may lead to ethical challenges. Despite proven cost-effectiveness, obesity (bariatric) surgery and its public funding have been questioned on ethical arguments relating to, for example, the self-inflicted or non-disease nature of obesity. Our aim was to analyze the ethical issues relevant to bariatric surgery. A comprehensive health technology assessment was conducted on bariatric surgery for morbid obesity using the EUnetHTA method, including a fully integrated ethical analysis. The ethical arguments suggesting that obesity should not be surgically treated because it is self-inflicted were rejected. Medicalization of obesity may have both positive and negative effects that impact the various stakeholders differently, thus being difficult to balance. Informing bariatric surgery patients and actively supporting their autonomy is exceptionally important, as the benefits and harms of both obesity and bariatric surgery are complex, and the outcome depends on how well the patient understands and adheres to the life-long changes in eating habits required. Justice considerations are important in organizing surgical treatment of obesity, as the obese are discriminated against in many ways and obesity is more common in socioeconomically disadvantaged populations who might have problems of access to treatments. Obesity should be treated like other diseases in health care, and obesity surgery rationed like other cost-effective treatments. Positive actions to ensure patient autonomy and just access to surgical treatments may be warranted.

Global Health Governance at a Crossroads

This review takes stock of the global health governance (GHG) literature. We address the transition from international health governance (IHG) to global health governance, identify major actors, and explain some challenges and successes in GHG. We analyze the framing of health as national security, human security, human rights, and global public good, and the implications of these various frames. We also establish and examine from the literature GHG's major themes and issues, which include: 1) persistent GHG problems; 2) different approaches to tackling health challenges (vertical, horizontal, and diagonal); 3) health's multisectoral connections; 4) neoliberalism and the global economy; 5) the framing of health (e.g. as a security issue, as a foreign policy issue, as a human rights issue, and as a global public good); 6) global health inequalities; 7) local and country ownership and capacity; 8) international law in GHG; and 9) research gaps in GHG. We find that decades-old challenges in GHG persist and GHG needs a new way forward. A framework called shared health governance offers promise.

Capability and clinical success

Better outcomes for chronic diseases remain elusive because success depends on events outside the control of the health care system: patients' ability to mange their health behaviors and chronic diseases. Among the most powerful influences on self-management are the social and environmental constraints on healthy living, yet the clinical response to these environmental determinants is poorly developed. A potential approach for addressing social determinants in practice, as well as planning and evaluating community responses, is the capability framework. Defined as the real opportunity to achieve a desired lifestyle, capability focuses attention on the material conditions that constrain real opportunity and how opportunity emerges from the interaction between personal resources and the social environment. Using examples relevant to chronic disease and behavior change, we discuss the clinical application of the capability framework.

The ideal of equal health revisited: definitions and measures of inequity in health should be better integrated with theories of distributive justice

The past decade witnessed great progress in research on health inequities. The most widely cited definition of health inequity is, arguably, the one proposed by Whitehead and Dahlgren: "Health inequalities that are avoidable, unnecessary, and unfair are unjust." We argue that this definition is useful but in need of further clarification because it is not linked to broader theories of justice. We propose an alternative, pluralist notion of fair distribution of health that is compatible with several theories of distributive justice. Our proposed view consists of the weak principle of health equality and the principle of fair trade-offs. The weak principle of health equality offers an alternative definition of health equity to those proposed in the past. It maintains the all-encompassing nature of the popular Whitehead/Dahlgren definition of health equity, and at the same time offers a richer philosophical foundation. This principle states that every person or group should have equal health except when: (a) health equality is only possible by making someone less healthy, or (b) there are technological limitations on further health improvement. In short, health inequalities that are amenable to positive human intervention are unfair. The principle of fair trade-offs states that weak equality of health is morally objectionable if and only if: (c) further reduction of weak inequality leads to unacceptable sacrifices of average or overall health of the population, or (d) further reduction in weak health inequality would result in unacceptable sacrifices of other important goods, such as education, employment, and social security.

The Global Role of the World Health Organization

The 21^st century global health landscape requires effective global action in the face of globalization of trade, travel, information, human rights, ideas, and disease. The new global health era is more plural, comprising a number of key actors, and requiring more coordination of effort, priorities and investments. The World Health Organization (WHO) plays an essential role in the global governance of health and disease; due to its core global functions of establishing, monitoring and enforcing international norms and standards, and coordinating multiple actors toward common goals. Global health governance requires WHO leadership and effective implementation of WHO's core global functions to ensure better effectiveness of all health actors, but achieving this global mission could be hampered by narrowing activities and budget reallocations from core global functions.

Rethinking equal access: agency, quality, and norms

In 2005 the Global Health Council convened healthcare providers, community organizers, policymakers and researchers at Health Systems: Putting Pieces Together to discuss health from a systems perspective. Its report and others have established healthcare access and quality as two of the most important issues in health policy today. Still, there is little agreement about what equal access and quality mean for health system development. At the philosophical level, few have sought to understand why differences in healthcare quality are morally so troubling. While there has been considerable work in medical ethics on equal access, these efforts have neglected health agency (individuals' ability to work toward health goals they value) and health norms, both of which influence individuals' ability to be healthy. This paper argues for rethinking equal access in terms of an alternative ethical aim: to ensure the social conditions in which all individuals have the capability to be healthy. This perspective requires that we examine injustices not just by the level of healthcare resources, but by the: (1) quality of those resources and their capacity to enable effective health functioning; (2) extent to which society supports health agency so that individuals can convert healthcare resources into health functioning; and (3) nature of health norms, which affect individuals' efforts to achieve functioning.

Ethics in American health 2: an ethical framework for health system reform

I argue that an ethical vision resting on explicitly articulated values and norms is critical to ensuring comprehensive health reform. Reform requires a consensus on the public good transcending self-interest and narrow agendas and underpinning collective action for universal coverage. In what I call shared health governance, individuals, providers, and institutions all have essential roles in achieving health goals and work together to create a positive environment for health. This ethical paradigm provides (1) reasoned consensus through a joint scientific and deliberative approach to judge the value of a health care intervention; (2) a method for achieving consensus that differs from aggregate tools such as a strict majority vote; (3) combined technical and ethical rationality for collective choice; (4) a joint clinical and economic approach combining efficiency with equity, but with economic solutions following and complementing clinical progress; and (5) protection for disabled individuals from discrimination.

Ethics in American health 1: ethical approaches to health policy

I trace the evolution of ethical approaches to health policy in the United States and examine a number of critical unresolved issues pertaining to the current set of frameworks. Several themes emerge. First, fair procedures claim more attention than substantive and procedural principles. Second, in the case of public deliberation, more focus has been placed on factors such as procedural mechanisms than on understanding how individuals and groups value different aspects of health and agree on health-related decisions. Third, the nation needs workable frameworks to guide collective choices about valuable social ends and their trade-offs; purely procedural strategies are limited in illuminating overarching health policy and ethics questions. There is a need to integrate consequential and procedural approaches to health ethics and policy.

[Bioethics and Brazilian health policies]

In Brazil, bioethics has developed within specific social circumstances taking into account public health issues. In addition, this article analyses the ethical principles of the Brazilian healthcare system issued from the 1988 Federal Constitution which made healthcare a universal right for all citizens. The goal of this system is to provide universal care through an equity policy pertaining to the distribution of resources.

Conceptualising health: insights from the capability approach

This paper suggests the adoption of a 'capability approach' to key concepts in healthcare. Recent developments in theoretical approaches to concepts such as 'health' and 'disease' are discussed, and a trend identified of thinking of health as a matter of having the capability to cope with life's demands. This approach is contrasted with the WHO definition of health and Boorse's biostatistical account. We outline the 'capability approach', which has become standard in development ethics and economics, and show how existing work in those areas can profitably be adapted to healthcare. Cases are used to illustrate the value of adopting a capability approach.

Health, health care, and incompletely theorized agreements: a normative theory of health policy decision making

The years 2003-2004 marked the tenth anniversary of the rapid rise and demise of the Clinton administration's health reform efforts. Health reform may again be a political issue in the 2008 congressional and presidential elections. However, analysts still disagree over why large-scale health reform efforts continue to fail in the American political landscape. This article presents a normative theory for analyzing federal health policy decision making in the United States. This theory states that values and norms, particularly their level of generality, and the social agreement or lack thereof around them have a central role in understanding health policy reform. This theory does not attempt to arrive at a single unified framework for explaining health policy reform, and it recognizes the complementary roles of political science and economic explanations. Nonetheless, it argues that unarticulated values and norms have a critical role to play in health-policy making and reform; this role has been inadequately studied and has lacked a theoretical framework. Within this perspective, this article argues that policy goals, which require individuals to make financial commitments (e.g., tax contributions) in the form of redistributing resources for implementation (e.g., universal health insurance), should be analyzed within a normative framework that evaluates individuals' ethical commitments to making such sacrifices that are beyond their self-interest. The distribution of pub-lic moral norms, their degree of internalization, and the social consensus, or lack thereof, that applies to them must be objects of study in the effort to better understand health policy reform. By emphasizing these factors, this approach offers findings distinct from those provided by existing analyses, and the article concludes with prescriptions for future health reform efforts.