COVID-19 vaccine barriers and perception among rural adults: a qualitative study in Bangladesh

OBJECTIVE

The COVID-19 pandemic continues to pose challenges for global public healthcare, even with the authorisation of several vaccines worldwide. To better understand rural communities' knowledge, attitudes, perceptions and barriers towards these vaccines, we conducted a qualitative cross-sectional study with adults in rural Bangladesh.

SETTING

This cross-sectional study was conducted in the rural areas of Sylhet and Natore in Bangladesh from August 2021 to February 2022.

PARTICIPANTS

Our study involved 15 in-depth interviews with rural adults and 2 key informant interviews with health workers.

RESULTS

We analysed data thematically, resulting in four main themes: (1) knowledge and perception aspects, (2) myths and misconceptions, (3) practice and attitude and (4) barriers and challenges of COVID-19 vaccines.

CONCLUSIONS

The findings indicate that rural populations lack sufficient knowledge about COVID-19 vaccines but have a more favourable attitude towards them. Misconceptions, beliefs and personal experiences were found to be the main reasons for vaccine avoidance. To address these challenges and dispel the spread of misinformation, health education programmes play a pivotal role in improving vaccine management. Policy-makers should initiate these programmes without delay to create a well-informed and enlightened community, given that the COVID-19 is still spreading.

A Public Health Ethics Framework for Populations with Limited English Proficiency

25.6 Million people in the United States have Limited English Proficiency (LEP), defined as insufficient ability to read, write, or understand English. We will (1) Delineate the merits of approaching language as a social determinant of health, (2) highlight pertinent public health values and guidelines which are most relevant to the plight of populations with LEP and (3) Use the COVID-19 pandemic as an example of how a breakdown in public health ethics values created harm for populations and patients with LEP. We define a framework to tease out public health responsibilities given some populations' limited proficiency in a society's predominant language. The American Public Health Association (APHA) public health ethics core values serve as a framework to interrogate current practices. We use the COVID-19 case to illustrate gaps between health policy and healthcare disparities experienced by populations with LEP.

Stimulating solidarity to improve knowledge on medications used during pregnancy : A contribution from the ConcePTION project

BACKGROUND

Pregnant people have been overlooked or excluded from clinical research, resulting in a lack of scientific knowledge on medication safety and efficacy during pregnancy. Thus far, both the opportunities to generate evidence-based knowledge beyond clinical trials and the role of pregnant people in changing their status quo have not been discussed. Some scholars have argued that for rare disease patients, for whom, just like pregnant people, a poor evidence base exists regarding treatments, solidarity has played an important role in addressing the evidence gap. This paper explores whether and how the enactment of solidarity among pregnant people can be stimulated to help address the poor evidence base on medications used during pregnancy.

METHOD

We use the concept of solidarity formulated by Prainsack and Buyx and enrich their concept by providing an account for stimulating the enactment of solidarity. Then we apply this account to the case of pregnant people who use medication.

RESULTS

Solidarity means enacted commitment on the part of an individual to assisting others with whom the person recognizes a similarity in a relevant respect. Although solidarity cannot be imposed, we argue that the empowerment of people is a crucial concept in understanding how solidarity can be stimulated. Empowerment in the context of pregnant people means creating awareness about their status quo, explaining how scientific research can help close the knowledge gap, and how pregnant people can themselves contribute. In particular, how pregnant people can contribute to the collection of health data to strengthen the evidence base for medications used during pregnancy.

CONCLUSIONS

We conclude that acting in solidarity can help change the status quo for pregnant people. Furthermore, we argue that the empowerment of pregnant people and other relevant stakeholders is a way to stimulate the enactment of solidarity. The process of empowerment starts by raising awareness about the lack of evidence on medications used during prengnacy and by explaining to pregnant people how they can contribute to changing the way knowledge is being generated by, for example, sharing data on the health effects of medications.

Dogs, Epistemic Indefensibility and Ethical Denial: Don't Let Sleeping Dog Owners Lie

In this paper I use normative analysis to explore the curious and seemingly singular phenomenon whereby some dog owners deny the physical and moral facts about a situation where it is claimed their dog harmed or irritated others. I define these as epistemic and ethical denial, respectively, and offer a tentative exploration of their implications in terms of relational autonomy and responsible behaviour in public spaces.

Integrating socio-cultural value system into health services in response to Covid-19 patients' self-isolation in Indonesia

This article studies the synergistic sociocultural value system to handle COVID-19 patients in self-isolation in Indonesia, to find an effective formula in COVID-19 spread control. The problems studied here is the response carried out and the constraints faced by the Indonesian government related to the self-isolation policy. Why and how does the Indonesians' sociocultural value system contribute to COVID-19 patient response? Through the survey conducted via Google Forms, in-depth interviews, focus group discussions and literature study, it is found that the Indonesian government issued the self-isolation regulation for COVID-19 patients to mitigate the rapid and massive COVID-19 transmission. However, many constraints are found in the policy implementation, including; people's insufficient knowledge and understanding of COVID-19, leading to negative implications for the COVID-19 survivors or patients' perception, causing social stigmatisation for COVID-19 survivors or patients; COVID-19 task force's limited access to medicine, medical instrument and hospital facilities. Meanwhile, the Indonesians' strong socio-cultural values like tolerance, mutual aid, and communal work, including among the educated people in urban society, may be potentially integrated into the health service to respond to COVID-19 patients with their self-isolation. Therefore, their integration and empowerment can be a solution to mitigating COVID-19 transmission in Indonesia.

Anticipating hopes, fears and expectations towards COVID-19 vaccines: A qualitative interview study in seven European countries

Vaccine uptake is essential to managing the ongoing COVID-19 pandemic, and vaccine hesitancy is a persistent concern. At the same time, both decision-makers and the general population have high hopes for COVID-19 vaccination. Drawing from qualitative interview data collected in October 2020 as part of the pan-European SolPan study, this study explores early and anticipatory expectations, hopes and fears regarding COVID-19 vaccination across seven European countries. We find that stances towards COVID-19 vaccines were shaped by personal lived experiences, but participants also aligned personal and communal interests in their considerations. Trust, particularly in expert institutions, was an important prerequisite for vaccine acceptance, but participants also expressed doubts about the rapid vaccine development process. Our findings emphasise the need to move beyond the study of factors driving vaccine hesitancy, and instead to focus on how people personally perceive vaccination in their particular social and political context.

COVID-19, the Immune System, and Organic Disability

Despite the availability of safe vaccines against SARS-CoV-2, some people will remain vulnerable because they will not be vaccinated. Who are these non-vaccinated people? We can distinguish two groups: (i) persons who cannot be vaccinated for clinical reasons and who, despite having been vaccinated, have not achieved immunity; (ii) persons who voluntarily refuse to get vaccinated. These groups have in common an immune system that will make them vulnerable to COVID-19. The reasons for their vulnerability and the ethical judgment they deserve are different; the solutions offered to them are also different. In the case of those who voluntarily avoid vaccination, States are not compromised to introduce new protective policies. In the case of people who remain involuntarily vulnerable, instead, the response should be articulated on the same rules and principles that inform the social model of disability because they will live with an organic disability.

Combatting neo-Colonialism in Health Research: What can Aboriginal Health Research Ethics and Global Health Research Ethics Teach Each Other?

The ethics of research involving Aboriginal populations and low and middle-income country populations each developed out of a long history of exploitative research projects and partnerships. Commonalities and differences between the two fields have not yet been examined. This study undertook two independent literature searches for Aboriginal health research ethics and global health research ethics. Content analysis identified shared and differently emphasised ethical principles and concepts between the two fields. Shared ethical concepts like "benefit" and "capacity development" have been developed to guide collaborations in both Aboriginal health research and global health research. However, Aboriginal health research ethics gives much greater prominence to ethical principles that assist in decolonising research practice such as "self-determination", "community-control", and "community ownership". The paper argues that global health research ethics would benefit from giving greater emphasis to these principles to guide research practice, while justice as approached in global health research ethics may inform Aboriginal health research practice. With increasing attention being drawn to the need to decolonise global health research, the lessons Aboriginal health research ethics can offer may be especially timely.

What is public health ethics for the geriatric community?

Background

A growing ageing community puts additional demands on the public health system. This will contribute to ethical consequences for the health care sector. A public health ethics framework can contribute towards addressing the ethical challenges faced by the geriatric community.

Aim

This article intends to contribute to a public health ethics framework for the geriatric community from a South African perspective.

Setting

Twenty-two participants from six geriatric institutions, two each in the three provinces, participated in the research. The provinces are the Free State, Northern Cape and North West.

Methods

Fifteen statements were rated using a five-point Likert scale questionnaire. The statements were grouped into three indexes, namely what is ethics, what is public health ethics and what is public health ethics for the geriatric community?

Results

Ethical behaviour is observable not only from person to person but also through systems, processes and practices. The need is to understand how to apply ethical principles to the working environment. A public health ethic can be understood from applied, professional and social ethics.

Conclusion

Public health ethics is the application of health care principles through a professional ethic resulting in care and relationship-building. The core of what public health is should be the basis to identify a public health ethic where the focus is on the community and improvement of the quality of health and well-being of the community.

Contribution

No evidence of a public health ethics framework for the geriatric community could be identified in South Africa.

Is the Cure Worse than the Disease? The Ethics of Imposing Risk in Public Health

Efforts to improve public health, both in the context of infectious diseases and non-communicable diseases, will often consist of measures that confer risk on some persons to bring about benefits to those same people or others. Still, it is unclear what exactly justifies implementing such measures that impose risk on some people and not others in the context of public health. Herein, we build on existing autonomy-based accounts of ethical risk imposition by arguing that considerations of imposing risk in public health should be centered on a relational autonomy and relational justice approach. Doing so better captures what makes some risk permissible and others not by exploring the importance of power and context in such deliberations. We conclude the paper by applying a relational account of risk imposition in the cases of (a) COVID-19 measures and (b) the regulation of sugar-sweetened beverages to illustrate its explanatory power.

Case for raising the minimum legal age of tobacco sale to 25

Restricting youth access to tobacco is an essential component of a comprehensive tobacco control policy. While there has been a growing movement to raise the minimum legal age (MLA) of purchasing tobacco from 18 to 21, more restrictive measures, such as raising the MLA to 25 (MLA25), have been criticised as being overly restrictive on adult's free choice. We argue that, even within a policy approach that prioritises freedom of choice, there is a strong case for MLA25 in view of neurobiological evidence which shows that, before age 25, people are neurobiologically vulnerable to developing an addiction. We discuss further considerations for an MLA25 policy, in particular its potential impact on the free choice of young adults to start or quit smoking, potential public health impact and potential effectiveness considering that most underage youth source cigarettes from older peers.

Leashes, Litterboxes, and Lifelines: Exploring Volunteer-Based Pet Care Assistance Programs for Older Adults

At the convergence of population aging and pet-ownership, community stakeholders are well-positioned to support older adults' relationships with companion animals through age-related transitions in health and living arrangements. In this study's setting, a volunteer-based pet care assistance program launched in 2017 to provide practical assistance with pet care for socially disadvantaged, community-dwelling older adults. This case study explored the impacts and feasibility of this and similar programs via (i) an Internet-based environmental scan to compare similar programs and (ii) qualitative interviews with a sampling of diverse community stakeholders (n = 9). A small number of comparable international programs (n = 16) were found. Among these, programs were delivered using a range of funding models; fewer than half involved collaborations across human social services and animal welfare sectors; and none addressed all dimensions of support offered by our local program. Analysis of qualitative interviews highlighted five major themes confirming the value of the volunteer-based approach and the importance of cross-sectoral collaborations in addressing older adults' under-recognized pet care-related needs. Taken together, the findings confirmed the effectiveness of our local program model. Collaborative, cross-sectoral programs that target both human and companion animal well-being hold promise to reduce barriers to pet ownership that many disadvantaged older adults face. This unique approach leverages the health-promoting potential of human-animal relationships in ways that enhance quality of life for individuals, animal welfare, and age-friendliness of communities.

Compliance to Public Health Advisory amid COVID-19 Scare: The Communication Conundrum and Public Health Ethics

Discussion of ethics in the public health arena has primarily focused on the practices of public health doctors and professionals. The community could not get the required attention in terms of their role in compliance with the communication in the form of public health advisory in times of public health crisis. Even though public health is the societal approach to protecting and promoting health, ethics in public health have prioritised behaviours of and moral dilemmas faced by public health professionals only. Leaving out the community’s responsibility makes the entire gamut of public health efforts incomplete and deficient. Amid the COVID-19 pandemic, non-compliance to the public health advisory raised an important aspect of expectation of ethical behaviour by the community and what could facilitate and hinder compliance of ethical behaviour ensuring the safety of self and others. Public health ought to consider the community as not only an important but also responsible stakeholder in its pursuit of promotion of health and prevention of disease.

Ethical issues experienced by persons with rheumatoid arthritis in a wearable-enabled physical activity intervention study

Introduction

Using wearables to self‐monitor physical activity is a promising approach to support arthritis self‐management. Little is known, however, about the context in which ethical issues may be experienced when using a wearable in self‐management. We used a relational ethics lens to better understand how persons with rheumatoid arthritis (RA) experience their use of a wearable as part of a physical activity counselling intervention study involving a physiotherapist (PT).

Methods

Constructivist grounded theory and a relational ethics lens guided the study design. This conceptual framework drew attention to benefits, downsides and tensions experienced in a context of relational settings (micro and macro) in which participants live. Fourteen initial and eleven follow‐up interviews took place with persons with RA in British Columbia, Canada, following participation in a wearable‐enabled intervention study.

Results

We created three main categories, exploring how experiences of benefits, downsides and tensions when using the intervention intertwined with shared moral values placed on self‐control, trustworthiness, independence and productivity: (1) For some, using a wearable helped to ‘do something right’ by taking more control over reaching physical activity goals. Some, however, felt ambivalent, believing both there was nothing more they could do and that they had not done enough to reach their goal; (2) Some participants described how sharing wearable data supported and challenged mutual trustworthiness in their relationship with the PT; (3) For some, using a wearable affirmed or challenged their sense of self‐respect as an independent and productive person.

Conclusion

Participants in this study reported that using a wearable could support and challenge their arthritis self‐management. Constructing moral identity, with qualities of self‐control, trustworthiness, independence and productivity, within the relational settings in which participants live, was integral to ethical issues encountered. This study is a key step to advance understanding of ethical issues of using a wearable as an adjunct for engaging in physical activity from a patient's perspective.

Patient or Public Contribution

Perspectives of persons with arthritis (mostly members of Arthritis Research Canada's Arthritis Patient Advisory Board) were sought to shape the research question and interpretations throughout data analysis.

One Health Animal Disaster Management: An Ethics of Care Approach

In this article, we consider the One Health framework for orienting guidance for animal disaster management through an ethics of care approach. While One Health was created at the beginning of the 21st century in response to the persistence of emerging infectious diseases and the view that the health of humans and other animals are contiguous, it can be a useful tool for promoting animal welfare and considering animals' experiences during a disaster. However, implementing One Health strategies into animal disaster management is not without its challenges, since ethical judgments are implicit in all decisions and recommendations made about how to conceptualize a "disaster" and their impact on animals and their welfare. Our discussion is divided into three sections. First, we consider the significance of a One Health framework for animal disaster management. Here, we highlight how One Health strategies can be employed in disaster health and natural disaster. Next, we use an ethics of care approach to lay the contours for an interspecies account of relational solidarity, thus offering a vision for how One Health strategies can reimagine the ethical dilemmas involving human-animal conflicts during a disaster. Lastly, we consider the textured nature of our relationship with animals, the moral weight of common vulnerability and interdependency and illuminating insights from animal welfare science.

Building blocks for a public health ethics framework for the geriatric community

Background

The elderly population is steadily growing in South Africa. However, there is limited strategic planning or policy initiatives to address this group’s vulnerability resulting in several public health ethical issues that need to be considered and addressed. This article aims to develop a public health ethics framework for the geriatric community with the purpose to review ethical implications when working with the geriatric community.

Methods

The Q-methodology was selected for data collection. Fifteen statements were ranked by means of a five-point Likert-scale questionnaire. Twenty-two participants from six geriatric institutions participated in the ranking of the statements.

Results

The ranking of the statements confirmed the need for a public health ethics framework to provide guidance when working with the geriatric community and to evaluate decisions about geriatric care. Such a framework should be application-based and practice-oriented which can assist in addressing unfamiliarity with public health ethics in general and can extend the capacity for decision-making. The ranking of these statements contributed to the scope of the planned framework, by considering the vulnerability of healthcare practitioners (as community of practitioners) and the geriatric community as a basis from which to promote justice in public health programmes.

Conclusion

Based on the ranking of statements, eight building blocks for a public health ethics framework were identified. The building blocks are imbedded in professional ethics and care ethics. The proposed framework can give rise to social justice in public health and the ability to evaluate what the ethical implications are for public health policies, programmes and interventions aimed at the geriatric community.

Navigating conflicting value systems: a grounded theory of the process of public health equity work in the context of mental health promotion and prevention of harms of substance use

BACKGROUND

Promoting health equity and reducing heath inequities is a foundational aim and ethical imperative in public health. There has been limited attention to and research on the ethical issues inherent in promoting health equity and reducing health inequities that public health practitioners experience in their work. The aim of the study was to explore how public health providers identified and navigated ethical issues and their management related to promoting health equity within services focused on mental health promotion and preventing harms of substance use.

METHODS

Semi-structured individual interviews and focus groups were conducted with 32 public health practitioners who provided public-health oriented services related to mental health promotion and prevention of substance use harms (e.g. harm reduction) in one Canadian province.

RESULTS

Participants engaged in the basic social process of navigating conflicting value systems. In this process, they came to recognize a range of ethically challenging situations related to health equity within a system that held values in conflict with health equity. The extent to which practitioners recognized, made sense of, and acted on these fundamental challenges was dependent on the degree to which they had developed a critical public health consciousness. Ethically challenging situations had impacts for practitioners, most importantly, the experiences of responding emotionally to ethical issues and the experience of living in dissonance when working to navigate ethical issues related to promoting health equity in their practice within a health system based in biomedical values.

CONCLUSIONS

There is an immediate need for practice-oriented tools for recognizing ethical dilemmas and supporting ethical decision making related to health equity in public health practice in the context of mental health promotion and prevention of harms of substance use. An increased focus on understanding public health ethical issues and working collaboratively and reflexively to address the complexity of equity work has the potential to strengthen equity strategies and improve population health.

Chronic Pain and Opioid Prescribing: Three Ways for Navigating Complexity at the Clinical‒Population Health Interface

Clinically focused interventions for people living with pain, such as health professional education, clinical decision support systems, prescription drug monitoring programs, and multidisciplinary care to support opioid tapering, have all been promoted as important solutions to the North American opioid crisis. Yet none have so far delivered substantive beneficial opioid-related population health outcomes. In fact, while total opioid prescribing has leveled off or reduced in many jurisdictions, population-level harms from opioids have continued to increase dramatically. We attribute this failure partly to a poor recognition of the epistemic and ethical complexities at the interface of clinical and population health. We draw on a framework of knowledge networks in wicked problems to identify 3 strategies to help navigate these complexities: (1) designing and evaluating clinically focused interventions as complex interventions, (2) reformulating evidence to make population health dynamics apparent, and (3) appealing to the inseparability of facts and values to support decision-making in uncertainty. We advocate that applying these strategies will better equip clinically focused interventions as complements to structural and public health interventions to achieve the desired beneficial population health effects. (Am J Public Health. 2022;112(S1):S56-S65. https://doi.org/10.2105/AJPH.2021.306500).

Structural Discrimination in Pandemic Policy: Essential Protections for Essential Workers

An inordinate number of low wage workers in essential industries are Black, Hispanic, or Latino, immigrants or refugees - groups beset by centuries of discrimination and burdened with disproportionate but preventable harms during the COVID-19 pandemic.

Noisy Autonomy: The Ethics of Audible and Silent Noise

In this paper, I summarize the medical evidence regarding the auditory and non-auditory effects of noise and analyse the ethics of noise and personal autonomy in the social environment using a variety of case studies. Key to this discussion is the fact that, contrary to the traditional definition of noise, sound can be noise without being annoying, as the evidence shows that some sounds can harm without being perceived. Ultimately, I develop a theory of 'noisy autonomy' with which to guide us in discussing the public health ethics of noise and other sounds.

Unmasking the Ethics of Public Health Messaging in a Pandemic

Uncertainty is inherent in new and unexpected viral outbreaks such as the current COVID-19 pandemic. It imposes challenges for health officials in soliciting cooperative behavioural changes based on incomplete information. In this paper, we use evolving mask recommendations in the United States as an example to analyse the ethical importance and practical demonstration of trustworthiness in pandemic messaging and decision-making. We argue that responsible public health interventions in the time of uncertainties requires explicit intersecting ethical considerations both in action and in communication to promote trustworthiness. First, as public health decisions have to be made in the face of incomplete and evolving data, health officials need to exhibit competence while committing to epistemic humility. They can explain the methods used in making and updating mask recommendations as well as explicitly acknowledge the need to incorporate sociocultural and other contextual considerations in translating scientific data into mask recommendations. Second, officials and agencies must uphold and communicate decisional transparency as part of their effort to demonstrate accountability and promote the public's understanding of the evolving pandemic. Third, especially since both the pandemic and mask recommendations may have disparate impact on different populations, officials should start with the fair implementation of the least restrictive measures that can help reduce harm.

Face mask uptake in the absence of mandates during the COVID-19 pandemic: a qualitative interview study with Swiss residents

Background

In the COVID-19 pandemic, Switzerland introduced broad nationwide face mask mandates only by October 2020, later than other Western European countries. This study aims to assess the underlying values and considerations of individuals to wear face masks in the absence of face mask mandates in the COVID-19 pandemic in German-speaking Switzerland.

Methods

As part of the “Solidarity in times of a pandemic” (SolPan) research commons, we interviewed 31 participants living in the German-speaking part of Switzerland in April 2020 and 25 of them again in October 2020. Qualitative inductive thematic analysis was applied for data analysis and interpretation. Public health ethics principles guided the interpretation and organization of findings.

Results

Five themes were identified: Trust and governmental policy; perceived benefits of mask-wearing; perceived risks of mask-wearing; social exclusion and prejudice; and decision-making in the absence of mandates. In light of increasing infection rates in October 2020, many participants started to consider the benefits higher than the risks and were willing to accept face mask mandates in that context, despite earlier reservations.

Conclusions

The absence of face mask mandates underline individual autonomy but may also suppress personal responsibility due to social influence. Face masks are only temporarily acceptable in liberal Western societies and face mask mandates should be enforced only when epidemiologically necessary.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12215-4.

"The health equity curse": ethical tensions in promoting health equity

BACKGROUND

Public health (PH) practitioners have a strong moral commitment to health equity and social justice. However, PH values often do not align with health systems values, making it challenging for PH practitioners to promote health equity. In spite of a growing range of PH ethics frameworks and theories, little is known about ethical concerns related to promotion of health equity in PH practice. The purpose of this paper is to examine the ethical concerns of PH practitioners in promoting health equity in the context of mental health promotion and prevention of harms of substance use.

METHODS

As part of a broader program of public health systems and services research, we interviewed 32 PH practitioners.

RESULTS

Using constant comparative analysis, we identified four systemic ethical tensions: [1] biomedical versus social determinants of health agenda; [2] systems driven agendas versus situational care; [3] stigma and discrimination versus respect for persons; and [4] trust and autonomy versus surveillance and social control.

CONCLUSIONS

Naming these tensions provides insights into the daily ethical challenges of PH practitioners and an opportunity to reflect on the relevance of PH frameworks. These findings highlight the value of relational ethics as a promising approach for developing ethical frameworks for PH practice.

What do we mean by critical and ethical global engagement? Questions from a research partnership between universities in Canada and Rwanda

Language - the words we use - can play a key role in enabling or limiting transformation of inequalities in the field of global health. At the same time, given the interdisciplinary, intersectoral, and international nature of much global health work, intended meanings, commitments, and underlying values for words used cannot be taken for granted. This commentary sets out to clarify, and in this manner render available for further discussion and debate, the phrase 'critical and ethical global engagement' (CEGE). It derives from discussions between scholars and partners in research, education, and healthcare practice based at one Canadian and two Rwanda institutions. Initially, our aim was to conceptualise the term 'critical and ethical global engagement' in order to guide our own practices. As the complexity of the values, commitments, and considerations underlying our use of this phrase emerged, however, we realised these discussions merited being captured and shared, to facilitate further exploration and exchange on this phrase.

Sharing power in global health research: an ethical toolkit for designing priority-setting processes that meaningfully include communities

To promote social justice and equity, global health research should meaningfully engage communities throughout projects: from setting agendas onwards. But communities, especially those that are considered disadvantaged or marginalised, rarely have a say in the priorities of the research projects that aim to help them. So far, there remains limited ethical guidance and resources on how to share power with communities in health research priority-setting. This paper presents an "ethical toolkit" for academic researchers and their community partners to use to design priority-setting processes that meaningfully include the communities impacted by their projects. An empirical reflective equilibrium approach was employed to develop the toolkit. Conceptual work articulated ethical considerations related to sharing power in g0l0o0bal health research priority-setting, developed guidance on how to address them, and created an initial version of the toolkit. Empirical work (51 in-depth interviews, 1 focus group, 2 case studies in India and the Philippines) conducted in 2018 and 2019 then tested those findings against information from global health research practice. The final ethical toolkit is a reflective project planning aid. It consists of 4 worksheets (Worksheet 1- Selecting Partners; Worksheet 2- Deciding to Partner; Worksheet 3- Deciding to Engage with the Wider Community; Worksheet 4- Designing Priority-setting) and a Companion Document detailing how to use them. Reflecting on and discussing the questions in Worksheets 1 to 4 before priority-setting will help deliver priority-setting processes that share power with communities and projects with research topics and questions that more accurately reflect their healthcare and system needs.

Developing an ethical framework for asymptomatic COVID-19 testing programmes in higher education institutions

Background: Mass asymptomatic COVID-19 testing programmes are being introduced in a range of settings, including in higher education institutions (HEIs). We aimed to produce an ethical framework to identify the range of ethical considerations relevant to HEI testing programmes and to support organisational decision-making. Methods: We conducted a mixed-method consultation (survey and semi-structured interviews) with students and staff at a case study university that was running a student testing programme. Survey data were analysed descriptively; data analysis for interviews was based on the Framework method. The findings of the consultation were combined with literature review, legal/ethical analysis and expert views to produce an ethical framework. Results: A total of 239 people took part in the consultation: 213 completed surveys (189 students, 24 staff) and 26 (16 students, 7 staff) participated in interviews. The survey identified clear support (99% of survey respondents) for the testing programme. Around two-thirds (62%) supported non-mandatory participation. Over half (54%) felt that the programme would need to be at least moderately effective to be acceptable. Over three-quarters (76%) felt the university had some responsibility to run a testing programme. Synthesis of consultation findings and further analysis identified nine areas of ethical consideration for HEIs looking to implement mass asymptomatic testing programmes: design and operation; goals; properties of the test; enabling isolation; choices about participation; benefits, harms and opportunity costs; responsibilities between students and institutions; privacy, confidentiality and data-sharing; and communication. The ethical framework includes recommendations in each of these areas, with illustrative examples of how they might be put into practice. Conclusions: By identifying ethical considerations relevant to university student testing programmes using analysis and consultation, the framework we developed has potential to facilitate deliberation about ethical aspects of such programmes, as well as informing decision-making about their introduction, design and delivery.

In Defense of Patient Autonomy in Kidney Failure Care When Treatment Choices Are Limited

Respect for patient autonomy is a primary ethical obligation of health care providers. In kidney health care, clinical practice recommendations commonly include strategies to promote shared decision making with patients and their families about treatment options to promote patient autonomy and improve patient outcomes. However, for many people with kidney failure, treatment options may be unavailable or inaccessible. In these circumstances some clinicians may act paternalistically and withhold information from patients because of a fear of causing harm or because clinicians believe that patient autonomy is not a relevant consideration. In this article, we reflect on the concept of autonomy in the context of clinical decision making in kidney failure care, with particular attention to resource-constrained settings and the disclosure of information to patients for whom treatment may be inaccessible. We examine and address key concerns that patient autonomy may be impossible, irrelevant, or harmful in the context of limited treatment choices, and discuss factors that may influence paternalistic practices in such settings. We conclude that respect for autonomy is intrinsically and instrumentally valuable, and argue that in neglecting patient autonomy in resource-constrained settings, clinicians may exacerbate and entrench the structural inequalities and health inequities they are committed to addressing.

Addressing the dark matter of gene therapy: technical and ethical barriers to clinical application

Gene therapies for genetic diseases have been sought for decades, and the relatively recent development of the CRISPR/Cas9 gene-editing system has encouraged a new wave of interest in the field. There have nonetheless been significant setbacks to gene therapy, including unintended biological consequences, ethical scandals, and death. The major focus of research has been on technological problems such as delivery, potential immune responses, and both on and off-target effects in an effort to avoid negative clinical outcomes. While the field has concentrated on how we can better achieve gene therapies and gene editing techniques, there has been less focus on when and why we should use such technology. Here we combine discussion of both the technical and ethical barriers to the widespread clinical application of gene therapy and gene editing, providing a resource for gene therapy experts and novices alike. We discuss ethical problems and solutions, using cystic fibrosis and beta-thalassemia as case studies where gene therapy might be suitable, and provide examples of situations where human germline gene editing may be ethically permissible. Using such examples, we propose criteria to guide researchers and clinicians in deciding whether or not to pursue gene therapy as a treatment. Finally, we summarize how current progress in the field adheres to principles of biomedical ethics and highlight how this approach might fall short of ethical rigour using examples in the bioethics literature. Ultimately by addressing both the technical and ethical aspects of gene therapy and editing, new frameworks can be developed for the fair application of these potentially life-saving treatments.

Real-World Ethical Dilemmas in Laboratory Safety for Microbiology Under-Resourced and Outreach Teaching

With modernization of safety standards for microbiology outreach teaching laboratories, ethical challenges arise in teaching microbiology for the public good without short-changing students in under-resourced situations, or when institutional support is subpar. Still, educators want students to engage using applied skills for inquiry, research-based microbial learning activities – safely. Following several United States microbial outbreaks, federal investigation traced sources back to teaching laboratories. Policy discussions ensued. The American Society for Microbiology (ASM) Task Force provides recommended but not mandated guidelines; however, guidelines are not amenable by all. Here, a real-world, ethical scenario of a university-level outreach microbiology laboratory course hosted at several locations provides context for under-resourced challenges in safety compliance. In this example of biomedical and public health ethical considerations, upper administration puts the onus on instructors to assure safe labs for their students and the general public. Temporarily hired instructors without curriculum or sufficient institutional support are put in precarious positions with often egregious practices to get the job done. This scenario is examined with different public health ethical frameworks and principles: non-maleficence, beneficence, health maximization, efficiency of policy regulations, respect for institutional and instructor autonomy, justice, and proportionality balancing stakeholder concerns. Sample curricular strategies are employed to mitigate these challenges. Taking a utilitarianism framework of the greatest good for the most benefit, this paper advocates for social justice supporting access to education as a moral duty. Administrations should ensure instructors are supported sufficiently to provide safe, authentic learning experiences. Solutions for under-resourced outreach teaching are needed for public trust.

Using community engagement to implement evidence-based practices for opioid use disorder: A data-driven paradigm & systems science approach

Community-driven responses are essential to ensure the adoption, reach and sustainability of evidence-based practices (EBPs) to prevent new cases of opioid use disorder (OUD) and reduce fatal and non-fatal overdoses. Most organizational approaches for selecting and implementing EBPs remain top-down and individually oriented without community engagement (CE). Moreover, few CE approaches have leveraged systems science to integrate community resources, values and priorities. This paper provides a novel CE paradigm that utilizes a data-driven and systems science approach; describes the composition, functions, and roles of researchers in CE; discusses unique ethical considerations that are particularly salient to CE research; and provides a description of how systems science and data-driven approaches to CE may be employed to select a range of EBPs that collectively address community needs. Finally, we conclude with scientific recommendations for the use of CE in research. Greater investment in CE research is needed to ensure contextual, equitable, and sustainable access to EBPs, such as medications for OUD (MOUD) in communities heavily impacted by the opioid epidemic. A data-driven approach to CE research guided by systems science has the potential to ensure adequate saturation and sustainability of EBPs that could significantly reduce opioid overdose and health inequities across the US.

Relational solidarity and COVID-19: an ethical approach to disrupt the global health disparity pathway

While the effects of COVID-19 are being felt globally, the pandemic disproportionately affects lower- and middle-income countries (LMICs) by exacerbating existing global health disparities. In this article, we illustrate how intersecting upstream social determinants of global health form a disparity pathway that compromises LMICs' ability to respond to the pandemic. We consider pre-existing disease burden and baseline susceptibility, limited disease prevention resources, and unequal access to basic and specialized health care, essential drugs, and clinical trials. Recognizing that ongoing and underlying disparity issues will require long-term correction efforts, this pathway approach is nonetheless helpful to inform ethical responses to this global pandemic. It can facilitate international cooperation during the pandemic to reduce the disparate burdens among different regions without imposing significant burden on any particular contributor. The pathway approach allows international stakeholders in various social positions to respond to different components of the pathway based on their respective strengths and resources to help break the cycle of global health inequity. Guided by the ethical principles of relational and pragmatic solidarity, we argue for a coordinated global division of labor such that different stakeholders can collaborate to foster equitable healthcare access during this pandemic.

Mental wellbeing in a pandemic: the role of solidarity and care

COVID-19 deeply affects many spheres of life. Lockdown measures implemented worldwide have accentuated mental wellbeing changes in the population from the perspectives of space and social relations. These changes leave lasting imprints on individuals and communities. This article draws upon solidarity and care ethics in exploring their role in rebuilding mental wellbeing in the light of constraints arising from lockdown. The diversity of responses to physical and social isolation during the pandemic illuminates the distinctly relational nature of human beings, offering the opportunity for care and solidarity to respond to mental wellbeing challenges in an inclusive and context-sensitive way.

Shaming and Stigmatizing Healthcare Workers in Japan During the COVID-19 Pandemic

Stigmatization and sharming of healthcare workers in Japan during the coronavirus 2019 (COVID-19) pandemic reveal uniquely Japanese features. Seken, usually translated as ‘social appearance or appearance in the eyes of others,’ is a deep undercurrent woven into the fabric of Japanese life. It has led to providers who become ill with the SARS-CoV-2 virus feeling ashamed, while concealing their conditions from coworkers and public health officials. It also has led to healthcare providers being perceived as polluted and their children being told they were not welcome in schools. Although such experiences are not isolated to Japan and have appeared in other parts of the world, the cultural forces driving them in Japan are unique. Overcoming stigmatization and shaming of Japanese healthcare providers will require concerted efforts to understand cultural barriers and to view such practices as raising human rights issues affecting the safety and well-being of all.

Social justice in pandemic immunization policy: We're all in this together

Policy decisions regarding immunization during a pandemic are informed by the ethical understandings of policy makers. With the possibility that a vaccine might soon be available to mitigate the deadly COVID-19 pandemic, policy makers can consider learnings from past pandemic immunization campaigns. This critical analysis of three policy decisions made in Alberta, Canada, during the 2009 H1N1 influenza pandemic demonstrates the predominance of distributive justice principles and the problems that this created for vulnerable groups. Vulnerable groups identified in Alberta include rural and First Nations populations. We propose a social justice approach as a viable alternative to inform pandemic immunization policy and invite debate.

Emergency Basic Income during the Pandemic

This paper focuses on an emergency basic income (EBI) as a tool for avoiding financial insecurity during the time of pandemic. The authors argue that paying each resident a monthly cash amount for the duration of the crisis would serve to protect them from the economic fallout.They suggest three reasons why the EBI proposal is particularly well-suited to play an important role in a comprehensive public health response to COVID-19: it offers an immediate and agile response; it prioritizes the most vulnerable in the affected population; and it promotes a solidaristic response to the pandemic crisis. To go beyond the need to shut down and restart an EBI assistance scheme each time a pandemic hits, the authors propose considering turning the program into a permanent feature.

A Partial Defense of the Non-Commercialization of Surrogacy

Canada’s Assisted Human Reproduction Act justifies its non-commercialization approach to surrogacy on the grounds that commercial payments for surrogacy commodify women and are exploitative. However, empirical evidence suggests that payments in surrogacy are not exploitative, at least not to an extent that would warrant criminalizing payments. Given skepticism about the connection between exploitation and commodification, I explore whether commodification critiques can ground an alternative justification for the non-commercialization of surrogacy. First, I examine Vida Panitch’s argument that commodification critiques are flawed for being absolutist, that is, they cannot identify what makes some surrogacy transactions better or worse than others. Second, I examine Anne Phillips’ rearticulation of a commodification critique: Commercial surrogacy is problematic because it undermines equality in a democratic society. I argue that Phillips’ revision can escape absolutism and provide a better justification for Canada’s non-commercialization stance. However, it also entails that the preference for criminalizing payments is weakened, as other policy solutions might be effectively implemented to protect equality. As a result, I propose a shift in how commodification is appealed to: Less attention should be paid to abstract values and more attention should be given to how those values are enacted relationally between members of a political community. I also tentatively suggest that commodification critiques might provide a normative basis in Canadian policy for a self-sufficiency regulatory framework, which centres on values such as solidarity and the public good.

Perspectives of HIV-positive and -negative people who use drugs regarding the criminalization of HIV non-disclosure in Canada: a qualitative study

Background

While previous research has identified how criminalization of HIV non-disclosure can have deleterious effects on those living with HIV, the perspectives of people who use drugs – a population disproportionately affected by HIV– should be more meaningfully considered in these discussions.

Methods

Using constant comparative techniques, data from 60 interviews with men and women living with and without HIV and who use drugs in Vancouver were analyzed to explore their perceptions about Canada’s HIV non-disclosure legal framework.

Results

Participants’ perspectives on the framework involved three themes: understandings of HIV risk; HIV-related stigma; and their own experiences with HIV. While several participants favored the punitive character of the legal framework, these arguments were premised on misinformed and stigmatized assumptions regarding HIV.

Conclusions

The paper concludes by discussing the challenges and opportunities for resisting HIV stigma and misconceptions about HIV within the context of personal accounts that, at times, support criminalization of non-disclosure.

Relational Autonomy as a Theoretical Lens for Qualitative Health Research

As scholars integrate empirical approaches to ethical questions in healthcare, relational autonomy theory must inform research design and change practice. Qualitative approaches are well suited to issues where patient values play a central role, and they can be combined with relational autonomy theory to investigate the factors influencing autonomy-rich experiences. This paper draws upon my experience conducting bioethics research related to clinical trial decision-making to develop a systematic method for applying relational autonomy as a theoretical lens to qualitative health research. The resultant practical guide utilizes Susan Sherwin’s theory of relational autonomy and presents an empirical method responsive to autonomy-relevant questions.

Relational ethical approaches to the COVID-19 pandemic

Key ethical challenges for healthcare workers arising from the COVID-19 pandemic are identified: isolation and social distancing, duty of care and fair access to treatment. The paper argues for a relational approach to ethics which includes solidarity, relational autonomy, duty, equity, trust and reciprocity as core values. The needs of the poor and socially disadvantaged are highlighted. Relational autonomy and solidarity are explored in relation to isolation and social distancing. Reciprocity is discussed with reference to healthcare workers' duty of care and its limits. Priority setting and access to treatment raise ethical issues of utility and equity. Difficult ethical dilemmas around triage, do not resuscitate decisions, and withholding and withdrawing treatment are discussed in the light of recently published guidelines. The paper concludes with the hope for a wider discussion of relational ethics and a glimpse of a future after the pandemic has subsided.

Prioritising access to pandemic influenza vaccine: a review of the ethics literature

Background

The world is threatened by future pandemics. Vaccines can play a key role in preventing harm, but there will inevitably be shortages because there is no possibility of advance stockpiling. We therefore need some method of prioritising access.

Main text

This paper reports a critical interpretative review of the published literature that discusses ethical arguments used to justify how we could prioritise vaccine during an influenza pandemic. We found that the focus of the literature was often on proposing different groups as priorities (e.g. those with pre-existing health conditions, the young, the old, health care workers etc.). Different reasons were often suggested as a means of justifying such priority groupings (e.g. appeal to best overall outcomes, fairness, belonging to a vulnerable or ‘at risk’ group etc.). We suggest that much of the literature, wrongly, assumes that we are able to plan priority groups prior to the time of a particular pandemic and development of a particular vaccine. We also point out the surprising absence of various issues from the literature (e.g. how vaccines fit within overall pandemic planning, a lack of specificity about place, issues of global justice etc.).

Conclusions

The literature proposes a wide range of ways to prioritise vaccines, focusing on different groups and ‘principles’. Any plan to use pandemic vaccine must provide justifications for its prioritisation. The focus of this review was influenza pandemic vaccines, but lessons can be learnt for future allocations of coronavirus vaccine, if one becomes available.

Justice: a key consideration in health policy and systems research ethics

Health policy and systems research (HPSR) is increasingly being funded and conducted worldwide. There are currently no specific guidelines or criteria for the ethical review and conduct of HPSR. Academic debates on HPSR ethics in the scholarly literature can inform the development of guidelines. Yet there is a deficiency of academic bioethics work relating to justice in HPSR. This gap is especially problematic for a field like HPSR, which can entail studies that intervene in ways affecting the social and health system delivery structures of society. In this paper, we call for interpreting the principle of justice in a more expansive way in developing and reviewing HPSR studies (relative to biomedical research). The principle requires advancing health equity and social justice at population or systems levels. Drawing on the rich justice literature from political philosophy and public health ethics, we propose a set of essential justice considerations to uphold this principle. These considerations are relevant for research funders, researchers, research ethics committees, policymakers, community organisations and others who are active in the HPSR field.

The Dilemma of When to Stop Disease-Modifying Therapy in Multiple Sclerosis: A Narrative Review and Canadian Regional Reimbursement Policies

BACKGROUND

Disease-modifying therapy (DMT) has changed the landscape of multiple sclerosis (MS) care. However, there is lack of consensus on the duration of treatment and the selection of individuals most likely to benefit from continued treatment. Current evidence, practice guidelines, health policy, and ethical considerations presented together may further inform challenging clinical decision making and future directions. The objectives of this study were to conduct a narrative review of original research and practice guideline recommendations on discontinuation of DMTs in MS; to collect information regarding Canadian regional reimbursement policies for DMT coverage in MS; and to present ethical considerations applicable to such decision making.

METHODS

A literature review was conducted of the MEDLINE/PubMed, OneFile (GALE), Scopus (Elsevier), and ProQuest Biological Science Collection databases. Data regarding Canadian regional reimbursement policies for DMT coverage in MS were collected from the ministry/government websites. Ethical considerations were reviewed in the context of the identified evidence, guidelines, and policies.

RESULTS

The literature lacks evidence from prospective randomized controlled trials that directly addresses the issue of discontinuation of DMTs in MS. Current practice guidelines advocate the vital role of patient choice in decision making. There are regional variations in Expanded Disability Status Scale criteria scores for continuing MS DMT coverage among Canadian provinces/territories.

CONCLUSIONS

In the absence of strong evidence on discontinuation of DMTs, shared decision making and consideration of the ethical complexities could help in the decision-making process.

Analysis of engagement between ethics and return-to-work discourses in respective academic literature

BACKGROUND

Return-to-work (RTW)/back-to-work (BTW) interventions that are designed to rehabilitate individuals impaired from fulfilling employment roles are facing challenges. Ethics discourses, including ethics theories, principles and concepts, are meant to give guidance on what one ought to do or not to do and RTW professionals could use them to respond to their challenges.

OBJECTIVE

A scoping review was performed to investigate to what extent 33 ethics concepts, theories, and principles are employed in RTW/BTW academic literature, and to what extent RTW/BTW is engaged with in ethics linked academic journals.

METHODS

Three academic databases were searched, and 147 article results were extracted from our literature review to be thematically analyzed.

RESULTS

Searches with n = 11 ethics concepts and n = 4 ethics theories generated results. The content of 20 RTW/BTW article results demonstrated conceptual engagement between RTW and ethics discourses. Only one article in ethics-related journals conceptually engaged with RTW/BTW.

CONCLUSION

Ethics theories and principles were not used extensively in RTW/BTW academic literature and RTW/BTW is a topic under-engaged within ethics-related journals. Our findings indicate opportunities for further research, like conducting interviews, to better understand our findings and how to respond to them.