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Mannette R. Navigating a world of genes: A conceptual analysis of gene fetishism, geneticization, genetic exceptionalism and genetic essentialism. Eur J Med Genet 2021; 64:104232. [PMID: 33974995 DOI: 10.1016/j.ejmg.2021.104232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
Genetics, as a discipline, is an essential part of the modern world. However, analyzing the interaction between genetics and society can be complex. Therefore, terminology has arisen from diverse fields to better understand genetics and its relation to other domains. Nevertheless, the diverse origins of many of these terms, as well as a lack of clarity in their definitions, have led to differences in use. This paper focuses on four such terms: genetic fetishism, geneticization, genetic essentialism, and genetic exceptionalism. By clarifying what each term means, the fields that utilize them will be helped. Furthermore, these terms can have specific value to bioethics in analyzing ethical issues that arise from genetics and the interaction with the socio-cultural world. While these terms may not always be applicable, a more careful analysis of their meaning can cultivate a more scientific and rigorous analysis of the ways genetics impacts and is understood by humanity.
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Affiliation(s)
- Ruel Mannette
- Department of Philosophy, University of Hawaii at Manoa, Honolulu, HI, USA.
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Gamboa-Antiñolo FM. Pandemic, public policy and ethics. GACETA SANITARIA 2020; 35:208. [PMID: 33239187 DOI: 10.1016/j.gaceta.2020.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 09/28/2020] [Accepted: 09/29/2020] [Indexed: 11/26/2022]
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Babich B. Ivan Illich's Medical Nemesis and the 'age of the show': On the Expropriation of Death. Nurs Philos 2017; 19. [PMID: 29271600 DOI: 10.1111/nup.12187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
What Ivan Illich regarded in his Medical Nemesis as the 'expropriation of health' takes place on the surfaces and in the spaces of the screens all around us, including our cell phones but also the patient monitors and (increasingly) the iPads that intervene between nurse and patient. To explore what Illich called the 'age of the show', this essay uses film examples, like Creed and the controversial documentary Vaxxed, and the television series Nurse Jackie. Rocky's cancer in his last film (submitting to chemo to 'fight' cancer) highlights what Illich along with Petr Skrabanek called the 'expropriation of death'. In contrast to what Illich denotes as 'Umsonstigkeit' - grace or gift, given undeservedly, i.e., gratuitously - medical science tends to be tempted by what Illich terms scientistic 'black magic', taking over (expropriating) the life and the death of the patient in increasingly technological ways, a point underscored in the concluding section on the commercial prospects of xenotransplants using factory farm or mass-produced human-pig mosaics or chimeras.
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Affiliation(s)
- Babette Babich
- Department of Philosophy, Fordham University, New York, NY, USA
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Tesser CD. Why is quaternary prevention important in prevention? Rev Saude Publica 2017; 51:116. [PMID: 29211199 PMCID: PMC5708264 DOI: 10.11606/s1518-8787.2017051000041] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 01/12/2017] [Indexed: 11/24/2022] Open
Abstract
Quaternary prevention consists in the identification of persons at risk of excessive medicalization and their protection against new unnecessary interventions, avoiding iatrogenic damages. Here, we argue about the importance of quaternary prevention in specific primary and secondary prevention. The recent great development of preventive medicine, biomedicalization of risks and their treatment as if they were diseases, and the powerful influence of the commercial interests of pharmaceutical industries on the production of medical-sanitary knowledge alter classifications, create diseases and pre-diseases, lower cutoff points, and erase the distinction between prevention and healing. This situation converts larger amounts of asymptomatic persons into sick individuals and diverts clinical attention and resources from sick persons to the healthy, from older adults to young persons, and from the poor to the rich. Quaternary prevention facilitates and induces the development and systematization of operational knowledge and guidelines to contain hypermedicalization and the damages of preventive actions in professional care, especially in primary health care.
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Affiliation(s)
- Charles Dalcanale Tesser
- Universidade Federal de Santa Catarina. Centro de Ciências da Saúde. Departamento de Saúde Pública. Florianópolis, SC, Brasil
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¿Se puede comprar la prevención? GACETA SANITARIA 2017; 31:276. [DOI: 10.1016/j.gaceta.2016.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 11/10/2016] [Indexed: 10/20/2022]
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Tesser CD, Norman AH. Differentiating clinical care from disease prevention: a prerequisite for practicing quaternary prevention. CAD SAUDE PUBLICA 2016; 32:e00012316. [PMID: 27783750 DOI: 10.1590/0102-311x00012316] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 07/20/2016] [Indexed: 11/22/2022] Open
Abstract
This article contends that the distinction between clinical care (illness) and prevention of future disease is essential to the practice of quaternary prevention. The authors argue that the ongoing entanglement of clinical care and prevention transforms healthy into "sick" people through changes in disease classification criteria and/or cut-off points for defining high-risk states. This diverts health care resources away from those in need of care and increases the risk of iatrogenic harm in healthy people. The distinction in focus is based on: (a) management of uncertainty (more flexible when caring for ill persons); (b) guarantee of benefit (required only in prevention); (c) harm tolerance (nil or minimal in prevention). This implies attitudinal differences in the decision-making process: greater skepticism, scientism and resistance towards preventive action. These should be based on high-quality scientific evidence of end-outcomes that displays a net positive harm/benefit ratio.
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Affiliation(s)
- Charles Dalcanale Tesser
- Centro de Ciências da Saúde, Universidade Federal de Santa Catarina, Florianópolis, Brasil.,Centro de Estudos Sociais, Universidade de Coimbra, Coimbra, Portugal
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Berg JS, Powell CM. Potential Uses and Inherent Challenges of Using Genome-Scale Sequencing to Augment Current Newborn Screening. Cold Spring Harb Perspect Med 2015; 5:cshperspect.a023150. [PMID: 26438605 DOI: 10.1101/cshperspect.a023150] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Since newborn screening (NBS) began in the 1960s, technological advances have enabled its expansion to include an increasing number of disorders. Recent developments now make it possible to sequence an infant's genome relatively quickly and economically. Clinical application of whole-exome and whole-genome sequencing is expanding at a rapid pace but presents many challenges. Its utility in NBS has yet to be demonstrated and its application in the pediatric population requires examination, not only for potential clinical benefits, but also for the unique ethical challenges it presents.
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Affiliation(s)
- Jonathan S Berg
- Department of Genetics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7264
| | - Cynthia M Powell
- Departments of Pediatrics and Genetics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7264
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Royo-Bordonada MÁ, Román-Maestre B. Towards public health ethics. Public Health Rev 2015; 36:3. [PMID: 29450031 PMCID: PMC5809831 DOI: 10.1186/s40985-015-0005-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 03/12/2015] [Indexed: 12/29/2022] Open
Abstract
Health is a value, both objective and subjective, yet it is not the only value that contributes to the well-being of persons. In public health, there are different connotations of the term “public” relevant from an ethical perspective: population, government action, and collective action of the community. Ethics seeks to provide a basis for and justify moral decisions and actions. Ethics asks, why should I do it?, and the reply consists of an argument. The type of ethics that underpins applied ethics in general, and bioethics in particular, is civic ethics, a philosophical reflection on the criteria that enable the peaceful coexistence of citizens with different morals. Progress means emancipation as well as an increase of autonomy. However, more is not always better, and now we know that no health intervention, including a public health intervention, is risk-free. The false belief that undergoing a prevention intervention is always better than doing nothing explains, at least in part, that in contrast to bioethics, only recently have the ethical implications in public health practice been given the attention they deserve. Positive externalities in third parties, such as in vaccination programmes or policies to prevent harm to passive smokers, can occasionally justify the potential risks of a public health intervention. It is in such situations where a conflict might arise between the goal of improving the health of the population and the respect for the rights and freedoms of the individual that characterizes the dilemmas in public health ethics. In conclusion, it is necessary to have a public health ethics framework and a professional code of ethics applied to public health. The training of public health professionals in ethics is essential to ensure that they feel more confident when it comes to addressing the sheer range of ethical conflicts that they frequently face in the performance of their duties.
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Kreiner MJ, Hunt LM. The pursuit of preventive care for chronic illness: turning healthy people into chronic patients. SOCIOLOGY OF HEALTH & ILLNESS 2014; 36:870-84. [PMID: 24372285 PMCID: PMC4074448 DOI: 10.1111/1467-9566.12115] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Preventive health care has become prominent in clinical medicine in the US, emphasising risk assessment and control, rather than addressing the signs and symptoms of pathology. Current clinical guidelines, reinforced by evidence-based decision aids and quality of care assessment, encourage clinicians to focus on maintaining rigid test thresholds that are based on population norms. While achieving these goals may benefit the total population, this may be of no benefit or even harmful to individual patients. In order to explore how this phenomenon is manifested in clinical care and consider some factors that promote and sustain this trend, we analysed observations of over 100 clinical consultations, and open-ended interviews with 58 primary care clinicians and 70 of their patients. Both clinicians and patients equated at-risk states with illness and viewed the associated interventions not as prevention, but as treatment. This conflation of risk and disease redefines clinical success such that reducing the threat of anticipated future illness requires the acceptance of aggressive treatments and any associated adverse effects in the present. While the expanding emphasis on preventive medicine may improve the health profile of the total population, the implications of these innovations for the wellbeing of individual patients merits careful reconsideration.
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McLeroy KR, Bibeau DL, McConnell TC. Ethical Issues in Health Education and Health Promotion: Challenges for the Profession. ACTA ACUST UNITED AC 2013. [DOI: 10.1080/10556699.1993.10616408] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Kenneth R. McLeroy
- a Department of Public Health Education , University of North Carolina at Greensboro , Greensboro , NC , 27412 , USA
| | - Daniel L. Bibeau
- a Department of Public Health Education , University of North Carolina at Greensboro , Greensboro , NC , 27412 , USA
| | - Terrance C. McConnell
- b Department of Philosophy , University of North Carolina at Greensboro , Greensboro , NC , 27412 , USA
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Osrin D, Azad K, Fernandez A, Manandhar DS, Mwansambo CW, Tripathy P, Costello AM. Ethical challenges in cluster randomized controlled trials: experiences from public health interventions in Africa and Asia. Bull World Health Organ 2009; 87:772-9. [PMID: 19876544 PMCID: PMC2755306 DOI: 10.2471/blt.08.051060] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Revised: 10/10/2008] [Accepted: 01/06/2009] [Indexed: 11/27/2022] Open
Abstract
Public health interventions usually operate at the level of groups rather than individuals, and cluster randomized controlled trials (RCTs) are one means of evaluating their effectiveness. Using examples from six such trials in Bangladesh, India, Malawi and Nepal, we discuss our experience of the ethical issues that arise in their conduct. We set cluster RCTs in the broader context of public health research, highlighting debates about the need to reconcile individual autonomy with the common good and about the ethics of public health research in low-income settings in general. After a brief introduction to cluster RCTs, we discuss particular challenges we have faced. These include the nature of - and responsibility for - group consent, and the need for consent by individuals within groups to intervention and data collection. We discuss the timing of consent in relation to the implementation of public health strategies, and the problem of securing ethical review and approval in a complex domain. Finally, we consider the debate about benefits to control groups and the standard of care that they should receive, and the issue of post-trial adoption of the intervention under test.
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Affiliation(s)
- David Osrin
- University College London, Institute of Child Health, London, England.
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Woolf SH, Nestle M. Do dietary guidelines explain the obesity epidemic? Am J Prev Med 2008; 34:263-5; discussion 266. [PMID: 18312816 DOI: 10.1016/j.amepre.2007.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2007] [Revised: 11/20/2007] [Accepted: 12/05/2007] [Indexed: 10/22/2022]
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Carr SV. The health of women working in the sex industry—a moral and ethical perspective. ACTA ACUST UNITED AC 2007. [DOI: 10.1080/02674659508405550] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Jepson RG, Hewison J, Thompson A, Weller D. Patient perspectives on information and choice in cancer screening: a qualitative study in the UK. Soc Sci Med 2007; 65:890-9. [PMID: 17507131 DOI: 10.1016/j.socscimed.2007.04.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Indexed: 10/23/2022]
Abstract
The principle of informed choice has been recently incorporated into cancer screening policy. However, there is limited empirical or theoretical work on informed choice in this particular context. The main aim of the study reported here was to explore the information needs of people invited for screening, and to gain insights into the relationship between the information they wanted and the choices they made. A qualitative study (nine focus groups and 15 individual interviews) was undertaken with people who had contrasting experiences (and outcomes) of either breast, cervical, or colorectal cancer screening at two locations in Scotland, UK. Findings suggest that lay people define and conceptualise informed choice differently from policy makers. The study also found that information about the disease was as important to people as information on the risks and limitations of screening. However, information may have little part to play in the choices people make. Rather, it may have more impact on outcomes such as satisfaction and anxiety. An explicit policy aim in promoting informed choice is to enhance patient autonomy and to prevent people from being deceived or coerced. However, this research shows that the provision of evidence-based information alone does not necessarily mean that an informed choice is made. People may not read, want, or understand the information, and, additionally, they may not be able to carry out their intended choice. There may be personal barriers, such as physical or mental health problems and language, or organisational barriers, such as the availability of the service/intervention and access. Therefore, the term 'informed choice' might not be useful in this context.
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Affiliation(s)
- Ruth Gillian Jepson
- Department of Nursing and Midwifery, University of Stirling, Stirling FK9 4LA, UK.
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Allmark P, Tod A. How should public health professionals engage with lay epidemiology? JOURNAL OF MEDICAL ETHICS 2006; 32:460-3. [PMID: 16877625 PMCID: PMC2563386 DOI: 10.1136/jme.2005.014035] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
"Lay epidemiology" is a term used to describe the processes through which health risks are understood and interpreted by laypeople. It is seen as a barrier to public health when the public disbelieves or fails to act on public health messages. Two elements to lay epidemiology are proposed: (a) empirical beliefs about the nature of illness and (b) values about the place of health and risks to health in a good life. Both elements have to be dealt with by effective public health schemes or programmes, which would attempt to change the public's empirical beliefs and values. This is of concern, particularly in a context in which the lay voice is increasingly respected. Empirically, the scientific voice of standard epidemiology should be deferred to by the lay voice, provided a clear distinction exists between the measurement of risk, which is empirical, and its weighting, which is based on values. Turning to engagement with values, health is viewed to be an important value and is discussed and reflected on by most people. Public health professionals are therefore entitled and advised to participate in that process. This view is defended against some potential criticisms.
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Affiliation(s)
- P Allmark
- Samuel Fox House, Northern General Hospital, Sheffield S5 7AU, UK.
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Susanne GO, Sissel S, Ulla W, Charlotta G, Sonja OL. Pregnant women's responses to information about an increased risk of carrying a baby with Down syndrome. Birth 2006; 33:64-73. [PMID: 16499533 DOI: 10.1111/j.0730-7659.2006.00075.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fetal screening for Down syndrome by an ultrasound examination, including measurement of fetal nuchal translucency, at 12 to14 weeks' gestation is presently being evaluated in a Swedish randomized controlled trial. Women at high risk were offered an amniocentesis to obtain a definite diagnosis. The aim of this study was to explore women's reactions and responses to information about being at high risk after the scan, with a special focus on reactions to a false positive test. METHOD Interviews were conducted with 24 women within 1 week after the scan, in midpregnancy, and 2 months after the birth. The interviews were analyzed qualitatively. Down syndrome was confirmed in 4 women, who chose to terminate the pregnancy. The remaining 20 women had a false positive test. RESULTS For the majority, the risk information caused strong reactions of anxiety and worries about the future. A typical way for women to cope was to "withhold" the pregnancy, to take a "timeout," and try to live as if they were not pregnant any longer. Some weeks later, when the women received normal results from the chromosome analysis, they resumed being pregnant. Six women ages more than 35 years who had a risk score lower than their age-related risk did not express similarly strong reactions. Two months after the birth of a healthy baby, most stated they would undergo the same procedure in a subsequent pregnancy. One woman still suffered from the experience when interviewed at 2 months after the birth, and another said she regretted participating in the fetal screening program. CONCLUSIONS A false positive test of fetal screening for Down syndrome by ultrasound examination may cause strong reactions of anxiety and even rejection of the pregnancy. The prevalence of such reactions and possible long-term effects need further investigation.
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Buetow S, Docherty B. The seduction of general practice and illegitimate birth of an expanded role in population health care. J Eval Clin Pract 2005; 11:397-404. [PMID: 16011652 DOI: 10.1111/j.1365-2753.2005.00543.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
To reduce health inequalities and improve quality in health care, health policy initiatives in countries including New Zealand and the United Kingdom are expecting general practice to share responsibilities for a population approach to health care. This is giving increased emphasis to preventative care, including health promotion. Reasoned debate on this policy is overdue, not least in New Zealand, where clinicians within general practice appear to have been seduced by the lack of clarity in health policy into accepting this policy without question. They appear to disregard implications of the policy for redefining the nature and scope of their discipline (and of public health), including their own role as providers of personal care. This paper suggests that a population health approach is inappropriate in general practice when this approach weakens personal care and involves health promotion activity of unknown safety and effectiveness. The example of intentional weight loss to reduce overweight is used to illustrate these issues. We argue for a restricted range of general practice services.
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Affiliation(s)
- Stephen Buetow
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand.
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Abstract
This article claims that health promotion is best practiced in the light of an Aristotelian conception of the good life for humans and of the place of health within it.
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Affiliation(s)
- Peter Allmark
- Department of Acute and Critical Care Nursing, University of Sheffield, UK
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Abstract
This paper seeks to critically review a traditional objection to preventive medicine (which I call here the 'prevention problem'). The prevention problem is a concern about the supposedly inequitable distribution of benefits and risks of harm resulting from preventive medicine's focus on population-based interventions. This objection is potentially applicable to preventive vaccination programmes and could be used to argue that such programmes are unethical. I explore the structure of the prevention problem by focusing upon two different types of vaccination (therapeutic vaccination and preventive vaccination). I argue that the 'prevention problem' cannot be fairly applied to the case of preventive vaccination because such programmes do not just focus upon benefits at the level of populations (as is claimed by the prevention problem). Most such preventive vaccination programmes explicitly seek to create and maintain herd protection. I argue that herd protection is an important public good which is a benefit shared by all individuals in the relevant population. This fact can then be used to block the 'prevention problem' argument in relation to preventive vaccination programmes. I conclude by suggesting that whilst the future development and use of therapeutic vaccines does raise some interesting ethical issues, any ethical objections to prophylactic vaccination on the basis of the 'prevention problem' will not be overcome through the substitution of therapeutic vaccines for preventive vaccines; indeed, the 'prevention problem' fails on its own terms in relation to preventive vaccination programmes.
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Affiliation(s)
- Angus Dawson
- Centre for Professional Ethics, Keele Hall, Keele University, Staffs ST5 5BG, UK.
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Roberts H, Curtis K, Liabo K, Rowland D, DiGuiseppi C, Roberts I. Putting public health evidence into practice: increasing the prevalence of working smoke alarms in disadvantaged inner city housing. J Epidemiol Community Health 2004; 58:280-5. [PMID: 15026437 PMCID: PMC1732727 DOI: 10.1136/jech.2003.007948] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
STUDY OBJECTIVES The UK government recommends that local authorities install battery operated smoke alarms to prevent fire related injury. However, a randomised controlled trial of smoke alarm installation in local authority housing found a low level of working alarms at follow up. Qualitative work, which accompanied the trial explored barriers and levers to the use of this public health intervention. DESIGN Semi-structured group and individual interviews were conducted with a sample of the adult participants in a randomised controlled trial of free smoke alarm installation. Group interviews and "draw and write" exercises were conducted with children at a local primary school. PARTICIPANTS A sample of trial participants and primary school children in the trial neighbourhood. SETTING An inner city housing estate in central London. MAIN RESULTS The main barrier to smoke alarm use was the distress caused by false alarms. Although trial participants considered themselves to be at high risk for fires and would recommend smoke alarms to others, respondents' reports on the distress caused by false alarms suggest that people balance immediate and longer term risks to their health and wellbeing when they disable alarms. CONCLUSIONS This study identified some of the reasons for the low level of functioning smoke alarms, and problems experienced with alarms. The results have implications for the implementation of this public health intervention. The effectiveness of smoke alarm installation could be improved if alarm manufacturers and those responsible for implementation programmes considered ways of tackling the issues raised in this study.
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Affiliation(s)
- H Roberts
- Child Health Research and Policy Unit, City University, London, UK
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Sheikh A, Cook A, Ashcroft R. Making cycle helmets compulsory: ethical arguments for legislation. J R Soc Med 2004; 97:262-265. [PMID: 15173325 PMCID: PMC1079487 DOI: 10.1258/jrsm.97.6.262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Affiliation(s)
- Aziz Sheikh
- Division of Community Health Sciences, University of Edinburgh, UK.
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Sheikh A, Cook A, Ashcroft R. Making Cycle Helmets Compulsory: Ethical Arguments for Legislation. Med Chir Trans 2004; 97:262-5. [PMID: 15173325 PMCID: PMC1079487 DOI: 10.1177/014107680409700602] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Aziz Sheikh
- Division of Community Health Sciences, University of Edinburgh, UK.
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Abstract
The terrorist attacks launched on September 11, 2001, ignited fear of further aggression with biological weapons, leading to a discourse and allocation of resources for both defensive and dissuasive/ offensive use in order to counteract such threats. Many such measures involved the investigation and production of biological agents, and the public health field has been called upon to participate in these strategic efforts. Participation by health programs is in moral contradiction with military tactics and should be limited to protecting the health of the purportedly threatened population, in itself a difficult task due to the numerous imponderable factors. The additional resources being made available to public health are largely conditioned on their strategic military application, leaving traditional public health care in its chronic state of insufficient funding and non-egalitarian allocation.
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Affiliation(s)
- Miguel Kottow
- Escuela de Salud Pública, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile.
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Abstract
Genetics research has shown enormous developments in recent decades, although as yet with only limited clinical application. Bioethical analysis has been unable to deal with the vast problems of genetics because emphasis has been put on the principlism applied to both clinical and research bioethics. Genetics nevertheless poses its most complex moral dilemmas at the public level, where a social brand of ethics ought to supersede the essentially interpersonal perspective of principlism. A more social understanding of ethics in genetics is required to unravel issues such as research and clinical explorations, ownership and patents, genetic manipulation, and allocation of resources. All these issues require reflection based on the requirements of citizenry, consideration of common assets, and definition of public policies in regulating genetic endeavors and protecting the society as a whole Bioethics has privileged the approach to individual ethical issues derived from genetic intervention, thereby neglecting the more salient aspects of genetics and social ethics.
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Maycock B, Howat P, Slevin T. A decision-making model for health promotion advocacy: the case for advocacy of drunk driving control measures. PROMOTION & EDUCATION 2002; 8:59-64. [PMID: 11475038 DOI: 10.1177/102538230100800202] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This paper presents a decision-making model which can help public health professionals justify their decision to advocate for a particular intervention. The model is demonstrated by a case study related to advocacy of Random Breath Testing (RBT). For the purpose of this paper advocacy is a "catch-all word for the set of skills used to create a shift in public opinion and mobilise the necessary resources and forces to support an issue, policy, or constituency..." (Wallack, Dorfman, Jernigan & Themba, 1994).
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Affiliation(s)
- B Maycock
- Western Australian Centre for Health Promotion Research, Curtin University, Perth, Western Australia, GPO Box U1987, WA 6845.
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Abstract
We propose to analyze the specificity of ethical problems in public health issues and to elucidate the applicability of principlism as a problem-solving strategy in this realm. Although well-established in clinical ethics, principlism is not an adequate model to be used in public health, since it is basically intended to serve as a moral guide in the physician-patient encounter. We discuss the possible adequacy of principles like "solidarity", "ontic responsibility" (as proposed by Jonas), and "caring or diaconal responsibility" as presented by Lévinas. Solidarity appears to be insufficiently specified, whereas the other two perspectives may be adapted to public health issues by bringing together Jonas' ontological and Lévinas' transcendental concerns to form a principle of protection that might better serve the purposes of such an ethics. This principle would help to identify more clearly the goals and agents involved in the implementation of public policies that are expected to be both morally correct and pragmatically effective.
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Affiliation(s)
- F R Schramm
- Departamento de Ciências Sociais, Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, 21041-210, Brasil.
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Abstract
Cluster randomized trials are increasingly used in research into health care and health services. Ethics of individual patient randomized trials have been elucidated in a number of different codes, but less attention has been given to the ethical issues raised by cluster randomized trials. I assess the challenges raised by cluster randomized controlled trials by considering three questions: What are the essential elements of ethical medical research, particularly experiments on people? What are the features which distinguish cluster randomized controlled trials from ordinary RCTs? Do the distinctive features of cluster randomized trials entail new ethical principles, or careful application of existing principles? I conclude that cluster randomized controlled trials raise new issues on the nature and practice of informed consent, because of the levels at which consent can be sought, and for which it can be sought. In addition, careful consideration of the principles relating to the quality of the scientific design and analysis, balance of risk and benefit, liberty to leave a trial, early stopping of a trial and the power to exclude people from potential benefits is required.
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Affiliation(s)
- J L Hutton
- Department of Statistics, The University of Newcastle, Newcastle upon Tyne, NE1 7RU, UK. J.L.
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Dunn AS, Shridharani KV, Lou W, Bernstein J, Horowitz CR. Physician-patient discussions of controversial cancer screening tests. Am J Prev Med 2001; 20:130-4. [PMID: 11165455 PMCID: PMC4848038 DOI: 10.1016/s0749-3797(00)00288-9] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Screening mammography for younger women and prostate-specific antigen (PSA) measurement have controversial benefits and known potential adverse consequences. While providing informed consent and eliciting patient preference have been advocated for these tests, little is known about how often these discussions take place or about barriers to these discussions. METHODS We administered a survey to medical house staff and attending physicians practicing primary care. The survey examined physicians' likelihood of discussing screening mammography and PSA testing, and factors influencing the frequency and quality of these discussions. RESULTS For the three scenarios, 16% to 34% of physicians stated that they do not discuss the screening tests. The likelihood of having a discussion was significantly associated with house staff physicians' belief that PSA screening is advantageous; house staff and attending physicians' intention to order a PSA test, and attending physicians' intention to order a mammogram; and a controversial indication for screening. The most commonly identified barriers to discussions were lack of time, the complexity of the topic, and a language barrier. CONCLUSIONS Physicians report they often do not discuss cancer screening tests with their patients. Our finding that physicians' beliefs and intention to order the tests, and extraneous factors such as time constraints and a language barrier, are associated with discussions indicates that some patients may be inappropriately denied the opportunity to choose whether to screen for breast and prostate cancer.
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Affiliation(s)
- A S Dunn
- Departments of Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA.
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Beaulieu MD, Hudon E, Roberge D, Pineault R, Forté D, Légaré J. Practice guidelines for clinical prevention: do patients, physicians and experts share common ground? CMAJ 1999; 161:519-23. [PMID: 10497607 PMCID: PMC1230580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND Clinical practice guidelines, such as those of the Canadian Task Force on Preventive Health Care, although based on sound evidence, may conflict with the perceived needs and expectations of patients and physicians. This may jeopardize the implementation of such guidelines. This study was undertaken to explore patients' and family physicians' acceptance of the task force's recommendations and the values and criteria upon which the opinions of these 2 groups are based. METHODS Focus groups were used to collect study data. In total, 35 physicians (in 7 groups) and 75 patient representatives (in 9 groups) participated in the focus groups. An inductive approach was used to develop coding grids and to generate themes from the transcripts of the interviews. RESULTS Physicians expressed resistance to discontinuing the annual check-up, which they viewed as an organizational strategy to counteract the many barriers to preventive care that they encounter. They reported difficulties in explaining to their patients the recommendations of the Canadian Task Force on Preventive Health Care, which they found complex and inconsistent with popular wisdom. Both patients and physicians attributed high value to the detection of insidious diseases, even in the absence of proof of the effectiveness of such activity. INTERPRETATION The patients and family physicians who participated in this study shared many opinions on the value of preventive activities that depart from the values used by "prevention experts" such as the Canadian Task Force on Preventive Health Care in establishing their recommendations. A better understanding of the values of patients and physicians would help guideline developers to create better targeted communication strategies to take these discrepancies into account.
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Affiliation(s)
- M D Beaulieu
- Department of Family Medicine, Université de Montréal, Que
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33
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Affiliation(s)
- D L Weed
- Preventive Oncology Branch, National Cancer Institute, Bethesda, MD 20892-7105, USA
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Foster P, Anderson CM. Reaching targets in the national cervical screening programme: are current practices unethical? JOURNAL OF MEDICAL ETHICS 1998; 24:151-7. [PMID: 9650108 PMCID: PMC1377516 DOI: 10.1136/jme.24.3.151] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The principle of informed consent is now well established within the National Health Service (NHS) in relation to any type of medical treatment. However, this ethical principle appears to be far less well established in relation to medical screening programmes such as Britain's national cervical screening programme. This article will critically examine the case for health care providers vigorously pursuing women to accept an invitation to be screened. It will discuss the type of information which women would need in order to make an informed decision about whether or not to be screened. The lack of such information in current patient leaflets on the "smear test" will then be documented. Finally, the article will explore possible ways of maximising women's autonomy in relation to the cervical screening programme without sacrificing any of its main benefits.
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Science, gender, and women's liberation: an argument against postmodernism. WOMENS STUDIES INTERNATIONAL FORUM 1998. [DOI: 10.1016/s0277-5395(98)00005-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Marshall KG. Prevention. How much harm? How much benefit? 4. The ethics of informed consent for preventive screening programs. CMAJ 1996; 155:377-83. [PMID: 8752062 PMCID: PMC1488063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Preventive interventions may have few or unproven benefits, or they may even be harmful. Since three of the fundamental precepts of Western biomedical ethics are beneficence, non-maleficence and respect for individual autonomy, failure to obtain truly informed consent for many current preventive interventions may be unethical. However, there are many impediments to obtaining such consent. Physicians need to be aware of an immense amount of up-to-date, complex information. It may be difficult for patients to assimilate this information, and there is rarely time for physicians to become informed and to inform their patients. Clinical practice guidelines may be helpful, but not all are based on evidence, and recommendations are often conflicting. Medical institutions, as well as individual clinicians, can help solve these dilemmas. Authors and journal editors can make a commitment to report and publish well-referenced evidence-based guidelines. Organizations such as the Canadian Task Force on the Periodic Health Examination and the US Preventive Services Task Force can develop balanced, evidence-based patient-information material. Faculty at all levels of medical education can increase their emphasis on the ethics of prevention. Individual clinicians should avoid making clinical decisions on the basis of relative reductions of morbidity or mortality, should use evidence-based clinical practice guidelines rather than those based on authority whenever possible, should make use of patient-information material and, most important, should have a consistent policy of obtaining informed consent from patients before they participate in potentially harmful preventive programs.
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Abstract
This paper brings together ideas from two perspectives on ethics and health promotion. A discussion of the ethical dimension of the health promotion practice of community nurses is set in the wider context of health policy, with particular reference to health gain and individual responsibility. It is widely held that nurses have a key role to play in health promotion and that this is particularly the case for nurses working in primary health care. This assumption is reinforced by policy documents from the World Health Organization, the Department of Health and statutory bodies such as the United Kingdom Central Council for Nursing, Midwifery and Health Visiting. The approach of many nurses to health promotion has tended on the one hand to be somewhat naive and on the other to be authoritarian and didactic; there has been little discussion in the nursing literature of the ethical aspects of health promotion. However, recent developments in nurse education, such as Project 2000 and the consequent changes to preregistration programmes, have resulted in increased attention to both ethics and health promotion within the curriculum.
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Affiliation(s)
- J McCormick
- Department of Community Health and General Practice, Trinity College, University of Dublin, Ireland
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Abstract
The issue of mandatory cycle helmets is highly contentious. The aim of this paper is not to argue for or against legislation but to suggest criteria on which the debate should focus. This is done by attempting to answer the question: 'What criteria must be met before cycle helmet wearing is enforced?' Consideration is given to principles, precedents and consequences and four criteria are suggested. The criteria are to do with effectiveness, personal liberty, public acceptability and the promotion of the public health benefits of cycling.
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Stone DH. The pros and cons of immunisation -- Paper three: the difference between ideological and intellectual dissent. HEALTH CARE ANALYSIS 1995; 3:111-5. [PMID: 11645302 DOI: 10.1007/bf02198212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
The mass childhood immunization programme has traditionally been viewed as a safe and effective preventative measure by health promoters, primary health care professionals and governments. This consensus has meant that immunization has rarely been viewed as ethically problematic. A number of recent changes in the context of the delivery of health care, particularly the emphasis on consumerism and the effect of the marketization of services, makes timely an examination of ethical, social and political issues. This article examines four main grounds for problematizing the mass childhood immunization programme. These are: clinical research evidence about the safety and efficacy of vaccines; the masking of wider social and political determinants of ill health; the contradictory strictures about collective and individual rights in relation to immunization; and the uniqueness of childhood immunization as a physical intrusion into a healthy body. The implications of these ethical issues are discussed in relation to informed consent and the need for a 'greenfield' review that includes the views of dissenting parents, lawyers and moral philosophers, as well as health professionals.
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Abstract
Searches in MEDLINE databases show a rapid increase in the number of articles with the term 'risk(s)' in the title and/or abstract in the period from 1967 to 1991. This trend is found in medical journals giving a general coverage of medicine and journals covering obstetrics and gynaecology in U.S.A., Britain and Scandinavia. The most rapid increase is, however, found in epidemiological journals. Comparisons of the developments in the occurrence of such terms as risk, hazard, danger and uncertainty show that the increasing frequency of the term risk in the medical literature can not be explained as a change in terminology alone. It is hypothesized that the ongoing trend, which resembles an epidemic, is a result of developments in science and technology, that has changed our beliefs about the locus of control from factors outside human control to factors inside our control. The origins of the epidemic may be traced to the development of such disciplines as probability statistics, increased focus on risk management and health promotion, with recent developments in computer technology as the factor responsible for the escalation seen in the past decade. With the cultural selection of risks in mind, the social construction of risk is discussed. Potentially harmful effects of such an epidemic are discussed, exemplified through controversies over current epidemiological risk construction and strategies for coronary risk reduction. It is finally argued that the risk epidemic reflects the social constructions of a particular culture at a particular time in history.
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Affiliation(s)
- J A Skolbekken
- Institute of Psychology, University of Oslo, Blindern, Norway
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Davison C, Macintyre S, Smith GD. The potential social impact of predictive genetic testing for susceptibility to common chronic diseases: a review and proposed research agenda. SOCIOLOGY OF HEALTH & ILLNESS 1994; 16:340-371. [PMID: 11660089 DOI: 10.1111/1467-9566.ep11348762] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Shickle D, Chadwick R. The ethics of screening: is 'screeningitis' an incurable disease? JOURNAL OF MEDICAL ETHICS 1994; 20:12-18. [PMID: 8035433 PMCID: PMC1376367 DOI: 10.1136/jme.20.1.12] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Screening programmes are becoming increasingly popular since prevention is considered 'better than cure'. While earlier diagnosis may result in more effective treatment for some, there will be consequent harm for others due to anxiety, stigma, side-effects etc. A screening test cannot guarantee the detection of all 'abnormal' cases, therefore there will be false reassurance for some. A proper consideration of the potential benefit and harm arising from screening may lead to the conclusion that the programme should not be offered. A modified utilitarian approach may be used for allocation of scarce resources in health care. Ethics has an important role in this evaluation.
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Affiliation(s)
- D Shickle
- Centre for Applied Public Health Medicine, University of Wales College of Medicine, Cardiff
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49
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Affiliation(s)
- Bruce G Charlton
- Department of Epidemiology and Public Health, University of Newcastle upon Tyne, Newcastle NE2 4HH
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50
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Charlton BG. Public health medicine--a different kind of ethics? J R Soc Med 1993; 86:194-5. [PMID: 8505723 PMCID: PMC1293945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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