[Digital health in Latin America: current legislation and ethical aspectsSaúde digital na América Latina: legislação atual e aspectos éticos]

Objectives

Describe the current legislation on electronic medical records (EMR) and telehealth in Latin American countries and analyze the treatment of confidentiality and professional secrecy.

Methods

Between March and September 2022, a survey of the regulations in force in 21 Latin American countries was conducted at two levels: the existence of legislation on EMR and telehealth, and the treatment of confidentiality and professional secrecy in EMR and telehealth. A data extraction form was prepared for each country. Data were collected from official on-line sources. The information was analyzed qualitatively and synthesized in tables when possible.

Results

The use of EMR is legally regulated in 16 countries. Nineteen countries have legislation on telehealth. All the countries analyzed safeguard confidentiality and professional secrecy through regulations. However, confidentiality and professional secrecy are mentioned in 11 countries in the context of telehealth, and in only nine countries in the context of EMR.

Conclusions

Since the start of this century, Latin America has made progress in the legislation of digital tools for health care, such as EMR and telehealth. There is also interest in ethical issues related to the use of EMR and telehealth, particularly confidentiality and professional secrecy, aspects that should be strengthened in digital health.

Ethical research when abortion access is legally restricted

Risks and benefits of some clinical research may be altered.

Pandemic justice for and from Latin America

Introdução ao Dossiê Justiça Pandêmica Global 

Charity or empowerment? The role of COVAX for low and middle-income countries

What has the past reaction to the COVID-19 pandemic taught us? We have seen that many low and middle-income countries (LMICs) still lack access to vaccines, and it seems little progress has been made in the last few months and year. This article discusses whether the current strategies, most notably, vaccine donations by the international community and the COVID-19 global access facility COVAX, offer meaningful solutions to tackle the problem. At the centre of our analysis, we compare the concepts of "donations" and "charity" with "vaccine equity" and the "empowerment" of poorer countries. We suggest that the achievement of fair global vaccine production requires that our global approach is supportive of the idea of empowerment. We, therefore, need structural reforms, which would most importantly include capacity building, to positively impact this goal and to take the interests of the global poor seriously.

Women in Neurosurgery: Historical Path to Self-Segregation and Proposal for an Integrated Future

Despite the rising percentage of women accessing the medical profession over the last few decades, surgical specialties are still largely male-dominated; in particular, a remarkable gender disparity is evident in neurosurgery, where only 19% of practitioners are females. Although women may be reluctant to choose a challenging specialty like neurosurgery due to concerns around how to balance family and career, it must be admitted that prejudices against female neurosurgeons have been deeply rooted for long, prompting many to give up and switch track to less demanding subspecialties. Among those who have persisted, many, if not most, have experienced difficulties in career progression and received unequal treatment in comparison with their male counterparts. In 1989, a group of 8 female neurosurgeons founded Women in Neurosurgery (WINS), an organization that aimed to guarantee inclusivity in neurosurgery, encouraging a better and more egalitarian working environment. Thereafter, WINS sessions were regularly promoted at international conferences, offering female neurosurgeons a platform to report issues related to gender discrimination. Over recent years, the mission of WINS sessions in national and international conferences has taken an unexpected deviation; they have progressively become supplementary scientific sessions with only women neurosurgeons as speakers, thus paving the road to a form of self-segregation. This tendency has also resulted in the establishment of sections of only female neurosurgeons within some national societies. Although there remains a faction that fiercely supports the WINS mindset of reserved spaces for women, such segregation is an upsetting prospect for those who believe that science and professionalism have no gender; a growing part of the global neurosurgical community believes that the conception of a “female neurosurgery” and a “male neurosurgery” is misguided and counterproductive and consider the existence of the WINS as anachronistic and no longer necessary.

Vulnerability in practice: Peeling back the layers, avoiding triggers, and preventing cascading effects

The concept of vulnerability is widely used in bioethics, particularly in research ethics and public health ethics. The traditional approach construes vulnerability as inherent in individuals or the groups to which they belong and views vulnerability as requiring special protections. Florencia Luna and other bioethicists continue to challenge traditional ways of conceptualizing and applying the term. Luna began proposing a layered approach to this concept and recently extended this proposal to offer two new concepts to analyze the concept of vulnerability, namely understanding external conditions that trigger vulnerability and layers of vulnerability with cascading effects. Luna's conception of vulnerability is useful, which we demonstrate by applying her layered view and the new analyses in multiple contexts. We begin by outlining Luna's view and we use vignettes from healthcare involving transgender patients, the care of patients in psychiatric contexts, and research involving prisoners to illustrate how each part of Luna's concept elucidates important moral issues.

Acute-Phase Immune Response Involves Fever, Sickness Behavior, and an Elevated Metabolic Rate in the Subterranean Rodent Ctenomys talarum

AbstractThe acute-phase response (APR) is an induced innate response and may involve pronounced physiological and behavioral changes. One of the most common assays to study the APR involves the use of a lypopolysaccharide (LPS) from the cell wall of gram-negative bacteria. In this study, we determined the energetic costs of the APR in the subterranean rodent Ctenomys talarum, as well as the effects of the exposure to LPS on body temperature, body mass loss, and behavior in this species. Furthermore, we monitored levels of circulating endotoxin after LPS exposure. Our results suggest that in C. talarum, the APR is energetically costly, resulting in a 14% increase in metabolic rate. Animals exposed to LPS experienced a short-term thermal response, weight loss, and changes in their behavior that included more time spent resting and with their eyes totally or partially closed. However, the magnitude of the effects of LPS exposure varied between sexes and among animals. Also, there was a clear peak in circulating endotoxin levels in plasma 3 h postinjection (hpi) and a significant decrease of these levels 24 hpi, but peak endotoxin concentration values recorded were highly variable among animals. In light of these results, ecological determinants of immune function variation in tuco-tucos are discussed considering the roles of pace of life, habitat, and degree of pathogen exposure in these subterranean rodents.

Expert Views on COVAX and Equitable Global Access to COVID-19 Vaccines

Objectives: We face the impossibility of having enough COVID-19 vaccines for everyone in the near future. This study aims to contribute to the debate on equitable global access to COVID-19 vaccines, tackling key ethical discussions and policy challenges regarding early phases of COVAX, the global cooperation mechanism for supporting fair vaccine allocation.

Methods: We conducted in-depth interviews with twelve experts and a literature research on academic articles, media sources and public statements. We built a data analysis matrix and conducted a thematic analysis.

Results: Our findings show, first, that interviewed experts who hold different views on vaccine allocation, including moderate nationalist perspectives, agree on joining a global cooperation mechanism. Second, incentives to join COVAX vary greatly among countries. Third, specific barriers to COVAX emerged in the early implementation phase. And fourth, countries might be trapped in a zero-sum game regarding the global vaccine supply.

Conclusion: We present findings that enrich analyses of early phases of COVAX (April 2020–21), we introduce three ethical discussions that provide a common ground for equitable access to COVID-19 vaccines, and we highlight policy challenges.

On the Ethics of Vaccine Nationalism: The Case for the Fair Priority for Residents Framework

COVID-19 vaccines are likely to be scarce for years to come. Many countries, from India to the U.K., have demonstrated vaccine nationalism. What are the ethical limits to this vaccine nationalism? Neither extreme nationalism nor extreme cosmopolitanism is ethically justifiable. Instead, we propose the fair priority for residents (FPR) framework, in which governments can retain COVID-19 vaccine doses for their residents only to the extent that they are needed to maintain a noncrisis level of mortality while they are implementing reasonable public health interventions. Practically, a noncrisis level of mortality is that experienced during a bad influenza season, which society considers an acceptable background risk. Governments take action to limit mortality from influenza, but there is no emergency that includes severe lockdowns. This "flu-risk standard" is a nonarbitrary and generally accepted heuristic. Mortality above the flu-risk standard justifies greater governmental interventions, including retaining vaccines for a country's own citizens over global need. The precise level of vaccination needed to meet the flu-risk standard will depend upon empirical factors related to the pandemic. This links the ethical principles to the scientific data emerging from the emergency. Thus, the FPR framework recognizes that governments should prioritize procuring vaccines for their country when doing so is necessary to reduce mortality to noncrisis flu-like levels. But after that, a government is obligated to do its part to share vaccines to reduce risks of mortality for people in other countries. We consider and reject objections to the FPR framework based on a country: (1) having developed a vaccine, (2) raising taxes to pay for vaccine research and purchase, (3) wanting to eliminate economic and social burdens, and (4) being ineffective in combating COVID-19 through public health interventions.

Brief communication International cooperation in a non-ideal world: the example of COVAX

The world witnessed one of the fasted responses in history to a new disease in terms of drug and vaccine development. However, despite the fact that safe and effective vaccines for COVID-19 were developed at a remarkable pace, international cooperation seems to have failed regarding the global equitable allocation of vaccines. This article explores challenges to international cooperation in global health and specifically to the fair allocation of vaccines at a global scale. We will present major obstacles to cooperative efforts and an interesting answer such as the COVAX facility, a cooperative redistribution scheme that has recently been launched by WHO, CEPI and Gavi. Considering COVAX a laudable and necessary first step to improve international cooperation in health, we nevertheless argue that the facility needs to identify key areas of potential improvement.

HIV prevention research and COVID-19: putting ethics guidance to the test

BACKGROUND

Critical public health measures implemented to mitigate the spread of the novel coronavirus disease (COVID-19) pandemic have disrupted health research worldwide, including HIV prevention research. While general guidance has been issued for the responsible conduct of research in these challenging circumstances, the contours of the dueling COVID-19 and HIV/AIDS pandemics raise some critical ethical issues for HIV prevention research. In this paper, we use the recently updated HIV Prevention Trials Network (HPTN) Ethics Guidance Document (EGD) to situate and analyze key ethical challenges related to the conduct of HIV prevention research during the COVID-19 pandemic as well as identify potential areas for refinement of the guidance document based on this unprecedented state of affairs.

MAIN BODY

Necessary actions taken for HIV prevention research studies due to the COVID-19 pandemic involve an array of ethical issues including those related to: (1) risk mitigation; (2) behavior change; (3) compounding vulnerability; (4) community engagement; (5) trial reopening; and 6) shifting research priorities.

CONCLUSIONS

In the context of the dueling HIV and COVID-19 global pandemics, research teams and sponsors must be nimble in responding to the rapidly changing environment by being sensitive to the associated ethical issues. The HTPN EGD provides a rich set of tools to help identify, analyze and address many of these issues. At the same time, future refinements of the HPTN EGD and other research ethics guidance could be strengthened by providing explicit advice regarding the ethical issues associated with disrupted research and the reopening of studies. In addition, additional consideration should be given to appropriately balancing domains of risk (e.g., physical versus social), addressing the vulnerability of research staff and community partners, and responding to un-anticipatable ancillary care needs of participants and communities. Appropriately addressing these issues will necessitate conceptual work, which would benefit from the careful documentation of the actual ethical issues encountered in research, the strategies implemented to overcome them, and their success in doing so. Throughout all of these efforts, it is critical to remember that the HIV pandemic not be forgotten in the rush to deal with the COVID-19 pandemic.

Pregnant women & vaccines against emerging epidemic threats: Ethics guidance for preparedness, research, and response

Zika virus, influenza, and Ebola have called attention to the ways in which infectious disease outbreaks can severely - and at times uniquely - affect the health interests of pregnant women and their offspring. These examples also highlight the critical need to proactively consider pregnant women and their offspring in vaccine research and response efforts to combat emerging and re-emerging infectious diseases. Historically, pregnant women and their offspring have been largely excluded from research agendas and investment strategies for vaccines against epidemic threats, which in turn can lead to exclusion from future vaccine campaigns amidst outbreaks. This state of affairs is profoundly unjust to pregnant women and their offspring, and deeply problematic from the standpoint of public health. To ensure that the needs of pregnant women and their offspring are fairly addressed, new approaches to public health preparedness, vaccine research and development, and vaccine delivery are required. This Guidance offers 22 concrete recommendations that provide a roadmap for the ethically responsible, socially just, and respectful inclusion of the interests of pregnant women in the development and deployment of vaccines against emerging pathogens. The Guidance was developed by the Pregnancy Research Ethics for Vaccines, Epidemics, and New Technologies (PREVENT) Working Group - a multidisciplinary, international team of 17 experts specializing in bioethics, maternal immunization, maternal-fetal medicine, obstetrics, pediatrics, philosophy, public health, and vaccine research and policy - in consultation with a variety of external experts and stakeholders.

An ethical framework for global vaccine allocation

The Fair Priority Model offers a practical way to fulfill pledges to distribute vaccines fairly and equitably

Why have Non-communicable Diseases been Left Behind?

Non-communicable diseases are no longer largely limited to high-income countries and the elderly. The burden of non-communicable diseases is rising across all country income categories, in part because these diseases have been relatively overlooked on the global health agenda. Historically, communicable diseases have been prioritized in many countries as they were perceived to constitute the greatest disease burden, especially among vulnerable and poor populations, and strategies for prevention and treatment, which had been successful in high-income settings, were considered feasible and often affordable in low-income settings. This prioritization has reduced the communicable diseases burden globally but has left non-communicable diseases largely neglected. A new approach is urgently needed to tackle non-communicable diseases. Based on an analysis of potential features which may have underlain the different approaches to non-communicable diseases and communicable diseases until now, including acuity of disease, potential for control or cure, cost, infectiousness, blaming of individuals and logistical barriers, little ethical or rational justification can be found to support continued neglect of non-communicable diseases. Justice demands access to quality and affordable care for all. An equitable approach to non-communicable diseases is therefore strongly mandated on medical, ethical, economic, and public health grounds. Funding must not however be diverted away from communicable diseases, which continue to require attention-but concomitantly, funding for non-communicable diseases must be increased. International and multi-sectoral action is required to accelerate progress towards true universal health coverage and towards achievement of all of the sustainable development goals, such that prevention and access to care for non-communicable disease can become a global reality.

Ethical challenges in global health-related stigma research

BACKGROUND

It is critically important to conduct research on stigmatized conditions, to include marginalized groups that experience stigma, and to develop interventions to reduce stigma. However, such research is ethically challenging. Though superficial reference is frequently made to these widely acknowledged challenges, few publications have focused on ethical issues in research on stigmatized groups or conditions. In fact, a brief literature review found only two such publications.

MAIN TEXT

At a recent Science of Stigma Reduction workshop comprising 60 stigma researchers from the USA and low and middle-income countries, the need for more robust and critical discussion of the ethics of the research was highlighted. In this paper we describe, illustrate through cases, and critically examine key ethical challenges that are more likely to arise because a research study focuses on health-related stigma or involves stigmatized groups or conditions. We examine the ethics of this research from two perspectives. First, through the lens of overprotection, where we discuss how the perception of stigma can impede ethical research, disrespect research participants, and narrow the research questions. Second, through the lens of research risks, where we consider how research with stigmatized populations can unintentionally result in harms. Research-related harms to participants include potential breaches of confidentiality and the exacerbation of stigma. Potential harms also extend to third parties, including families and populations who may be affected by the dissemination of research results.

CONCLUSIONS

Research with stigmatized populations and on stigmatized conditions should not be impeded by unnecessary or inappropriate protective measures. Nevertheless, it may entail different and greater risks than other health research. Investigators and research ethics committees must be particularly attentive to these risks and how to manage them.

From the Middle Ages to the 21st Century. Abortion, Assisted Reproduction Technologies and LGBT Rights in Argentina

Despite "progressive" legislative changes concerning the LGBT collective and assisted reproductive technologies (ARTs) in Argentina, women and their sexual and reproductive rights have been overlooked. This article presents a critical perspective of some of these legislative modifications in the country. It addresses why some legislators and society are prepared to challenge a conservative or traditional approach for certain groups while ignoring others. Several factors are at play. There is no all-inclusive explanation. I stress that a striking double standard prevails in Argentina with respect to women and their sexual and reproductive rights. I also contend that powerful discrimination exists, in particular against poor women, who continue to suffer and are "punished" by the criminalization of abortion.

Identifying and evaluating layers of vulnerability - a way forward

“Vulnerability” is a key concept for research ethics and public health ethics. This term can be discussed from either a conceptual or a practical perspective. I previously proposed the metaphor of layers to understand how this concept functions from the conceptual perspective in human research. In this paper I will clarify how my analysis includes other definitions of vulnerability. Then, I will take the practical‐ethical perspective, rejecting the usefulness of taxonomies to analyze vulnerabilities. My proposal specifies two steps and provides a procedural guide to help rank layers. I introduce the notion of cascade vulnerability and outline the dispositional nature of layers of vulnerability to underscore the importance of identifying their stimulus condition. In addition, I identify three kinds of obligations and some strategies to implement them.

This strategy outlines the normative force of harmful layers of vulnerability. It offers concrete guidance. It contributes substantial content to the practical sphere but it does not simplify or idealize research subjects, research context or public health challenges.

Public health agencies' obligations and the case of Zika

This article focuses on the initial reactions to the Zika epidemic by national and international public health agencies. It presents and analyzes some responses public officials made about sexual and reproductive health at the inception of the epidemic. It also describes the different challenges and obligations faced by local and international public health agencies, as these have not been clearly outlined. The article argues that these agencies have different obligations and should fulfill them despite existing obstacles. While international agencies should honor their leadership role and make recommendations at a meta-level, local agencies should provide, in the case of Zika, a framework for empowerment and grant women the freedom to achieve sexual and reproductive health so that they can avoid the consequences of this epidemic.

Straightforward method to measure optomechanically induced transparency

We demonstrate a simple method to measure optomechanically induced transparency (OMIT) in a Fabry-Perot based system using a trampoline resonator. In OMIT, the transmitted intensity of a weak probe beam in the presence of a strong control beam is modified via the optomechanical interaction, leading to an ultra-narrow optical resonance. To retrieve both the magnitude and the phase of the probe beam, a homodyne detection technique is typically used. We have greatly simplified this method by using a single acousto-optical modulator to create a control and two probe beams. The beat signal between the transmitted control and probe beams shows directly the typical OMIT characteristics. This method therefore demonstrates an elegant solution when a homodyne field is needed but experimentally not accessible.

Globalization and Global Health

Globalization shrinks the world. The world watches on television people dying of hunger or in extreme poverty conditions. Every year, 8 million children die before they reach the age of 5 from preventable diseases. "Exotic illnesses" cease to be so exotic, they can cross borders easily. Ebola, originally an African worry, in 2014 was an international threat. The revolution in information technologies enables us witness the emergence of transnational epistemic communities exhibiting, measuring and explaining health and disease. Presently, the authors are more aware than ever of the health problems of people from far away countries, which decades ago were unknown and distant. The transparency and availability of this information exhibits, in a quasi-obscene way, an unacceptable world. A world that is willing to rescue banks and ignores the worst off - those people whose unlucky birth seals a never ending cycle of misery with almost no possibility of breaking it. This paper address the situation just described by asking: Are these new empiric circumstances reflected in the authors' moral understanding of the issues? How should the world think of global health and their obligations towards people living in deprivation? How can the new empiric possibilities the global world offers be related to the implementation of such obligations? What are some of the challenges to the translation of new obligations to the present world? In addressing these questions, the paper argues that if the world seriously wants to address the obligations towards those in need, even if they are far away from the places they may need to work not only with ideal proposals such as the "new obligations" pointed by Singer and Pogge, but also with different transitional theories and non-ideal strategies in order to solve some of the big challenges the real world impose to theories.

Medical ethics and more: ideal theories, non-ideal theories and conscientious objection

Doing 'good medical ethics' requires acknowledgment that it is often practised in non-ideal circumstances! In this article I present the distinction between ideal theory (IT) and non-ideal theory (NIT). I show how IT may not be the best solution to tackle problems in non-ideal contexts. I sketch a NIT framework as a useful tool for bioethics and medical ethics and explain how NITs can contribute to policy design in non-ideal circumstances. Different NITs can coexist and be evaluated vis-à-vis the IT. Additionally, I address what an individual doctor ought to do in this non-ideal context with the view that knowledge of NITs can facilitate the decision-making process. NITs help conceptualise problems faced in the context of non-compliance and scarcity in a better and more realistic way. Deciding which policy is optimal in such contexts may influence physicians' decisions regarding their patients. Thus, this analysis-usually identified only with policy making-may also be relevant to medical ethics. Finally, I recognise that this is merely a first step in an unexplored but fundamental theoretical area and that more work needs to be done.

Twelve years of Fogarty-funded bioethics training in Latin America and the Caribbean: achievements and challenges

The landscape in research ethics has changed significantly in Latin America and the Caribbean over the past two decades. Research ethics has gone from being a largely foreign concept and unfamiliar practice to an integral and growing feature of regional health research systems. Four bioethics training programs have been funded by the Fogarty International Center (FIC) in this region in the past 12 years. Overall, they have contributed significantly to changing the face of research ethics through the creation of locally relevant training materials and courses (including distance learning), academic publications, workshops, and conferences in Spanish, and strengthening ethics review committees and national systems of governance. This paper outlines their achievements and challenges, and reflects on current regional needs and what the future may hold for research ethics and bioethics training in Latin America and the Caribbean.

An analysis of online courses in research ethics in the Fogarty-sponsored bioethics training programs

Several training programs sponsored by the NIH/Fogarty International Center's International Research Ethics Education and Curriculum Development Program offer online graduate-level courses in research ethics to participants in lowand middle-income countries. This paper describes the evaluation of four of these online courses and recommendations for improvements to achieve the highest-quality design and delivery. We used an evaluation matrix consisting of 95 criteria based on recommended best practices in eLearning. Our results showed that these courses are developing or meeting nearly 73% of the criteria, while they are not meeting approximately 21% of the criteria. Together, one or more of the courses are developing or meeting 89 of the 95 criteria. These results suggest that the necessary skills and expertise exist in these programs to bring all of the eLearning courses close to 100% proficiency by sharing a common set of best practices. This paper is part of a collection of articles analyzing the Fogarty International Center's International Research Ethics Education and Curriculum Development Program.

Challenges for assisted reproduction and secondary infertility in Latin America

This essay explores a new way to think about Assisted Reproductive Technologies (ARTs) in the Latin American context. The infertility caused by inadequately treated sexually transmitted diseases and by unsafe or illegal abortions is preventable, reflects the neglect of women’s sexual health, and disproportionally affects the region’s poorest women. I suggest a new logic that revisits ARTs, to do justice to the relevance of this type of infertility. I propose utilizing these technologies so as to transform the care of women and open a new discourse. I also suggest that we be more strategic and seek new alliances.

Not the usual suspects: addressing layers of vulnerability

This paper challenges the traditional account of vulnerability in healthcare which conceptualizes vulnerability as a list of identifiable subpopulations. This list of 'usual suspects', focusing on groups from lower resource settings, is a narrow account of vulnerability. In this article we argue that in certain circumstances middle-class individuals can be also rendered vulnerable. We propose a relational and layered account of vulnerability and explore this concept using the case study of cord blood (CB) banking. In the first section, two different approaches to 'vulnerability' are contrasted: categorical versus layered. In the second section, we describe CB banking and present a case study of CB banking in Argentina. We examine the types of pressure that middle-class pregnant women feel when considering CB collection and storage. In section three, we use the CB banking case study to critique the categorical approach to vulnerability: this model is unable to account for the ways in which these women are vulnerable. A layered account of vulnerability identifies several ways in which middle-class women are vulnerable. Finally, by utilizing the layered approach, this paper suggests how public health policies could be designed to overcome vulnerabilities.

Mounting a specific immune response increases energy expenditure of the subterranean rodent Ctenomys talarum (tuco-tuco): implications for intraspecific and interspecific variation in immunological traits

It was recently hypothesised that specific induced defences, which require substantial time and resources and are mostly beneficial against repeated infections, are more likely to be favoured in ‘slow-living-pace’ species. Therefore, understanding how different types of immune defences might vary with life history requires knowledge of the costs and benefits of defence components. Studies that have explored the energetic costs of immunity in vertebrates have done so with a focus primarily on birds and less so on mammals, particularly surface-dwelling rodents. In this study, we evaluated whether an experimental induction of the immune system with a non-pathogenic antigen elevates the energetic expenditure of a subterranean rodent: Ctenomys talarum (tuco-tucos). In both seasons studied, a significant increase in oxygen consumption was verified in immune-challenged tuco-tucos injected with sheep red blood cells (SRBC) compared with control animals. The increase in oxygen consumption 10 days after the exposure to SRBC was lower for female tuco-tucos monitored in the breeding season compared with females in the non-breeding season. Interestingly, antibody titres of female tuco-tucos did not decrease during the breeding season. Our results add new insight into the role of other factors such as basal metabolic rate or degree of parasite exposure besides ‘pace of life’ in modulating the interspecific immunological variation observed in natural populations of mammals.

Prenatal diagnosis and abortion for congenital abnormalities: is it ethical to provide one without the other?

This target article considers the ethical implications of providing prenatal diagnosis (PND) and antenatal screening services to detect fetal abnormalities in jurisdictions that prohibit abortion for these conditions. This unusual health policy context is common in the Latin American region. Congenital conditions are often untreated or under-treated in developing countries due to limited health resources, leading many women/couples to prefer termination of affected pregnancies. Three potential harms derive from the provision of PND in the absence of legal and safe abortion for these conditions: psychological distress, unjust distribution of burdens between socio-economic classes, and financial burdens for families and society. We present Iran as a comparative case study where recognition of these ethical issues has led to the liberalization of abortion laws for fetuses with thalassemia. We argue that physicians, geneticists and policymakers have an ethical and professional duty of care to advocate for change in order to ameliorate these harms.

Elucidating the concept of vulnerability: Layers not labels

In this article I examine several criticisms of the concept of vulnerability. Rather than rejecting the concept, however, I argue that a sufficiently rich understanding of vulnerability is essential to bioethics. The challenges of international research in developing countries require an understanding of how new vulnerabilities arise from conditions of economic, social and political exclusion. A serious shortcoming of current conceptions of vulnerability in research ethics is the tendency to treat vulnerability as a label fixed on a particular subpopulation. My paper examines the role of this “label” metaphor in current statements of research ethics. In contrast to this prevailing “label” metaphor, my own positive account of vulnerability develops a dynamic way of understanding the structure of the concept of vulnerability based on the idea of “layers of vulnerability.” I examine several cases involving women, as they are sometimes labeled as a vulnerable population and sometimes not. My analysis demonstrates the essential role of this revised concept of vulnerability in bioethics and research ethics.

Single-point acupuncture and physiotherapy for the treatment of painful shoulder: a multicentre randomized controlled trial

OBJECTIVE

Evaluate the efficacy of acupuncture associated with physiotherapy for patients with painful shoulder.

METHODS

In a multicentre controlled randomized study, participants were recruited with a clinical diagnosis of unilateral subacromial syndrome from six rehabilitation medicine departments belonging to the Public Health System in two Spanish regions. All participants received 15 sessions of physiotherapy during the 3 weeks that the treatment lasted and were randomized to additionally receive, once a week, acupuncture or mock TENS (transcutaneous electrical nerve stimulation). The primary outcome measure was the change in the Constant-Murley Score (CMS) for functional assessment of the shoulder, at 4 weeks after randomization. This study is registered as an International Standard Randomized Controlled Trial, number ISRCTN28687220.

RESULTS

A total of 425 patients were recruited. The mean score (s.d.) on the CMS had increased by 16.6 (15.6) points among the acupuncture group, compared with 10.6 (13.5) points in the control group, and the mean difference between the two groups was statistically significant (6.0 points; 95% CI 3.2, 8.8 points; P < 0.001). By the end of the treatment, 53% of the patients in the acupuncture group had decreased their consumption of analgesics, compared with a corresponding 30% among the control group (P < 0.001).

CONCLUSIONS

Single-point acupuncture in association with physiotherapy improves shoulder function and alleviates pain, compared with physiotherapy as the sole treatment. This improvement is accompanied by a reduction in the consumption of analgesic medicaments.

In silico analysis identifies a C3HC4-RING finger domain of a putative E3 ubiquitin-protein ligase located at the C-terminus of a polyglutamine-containing protein

Almost identical polyglutamine-containing proteins with unknown structures have been found in human, mouse and rat genomes (GenBank AJ277365, AF525300, AY879229). We infer that an identical new gene (RING) finger domain of real interest is located in each C-terminal segment. A three-dimensional (3-D) model was generated by remote homology modeling and the functional implications are discussed. The model consists of 65 residues from terminal position 707 to 772 of the human protein with a total length of 796 residues. The 3-D model predicts a ubiquitin-protein ligase (E3) as a binding site for ubiquitin-conjugating enzyme (E2). Both enzymes are part of the ubiquitin pathway to label unwanted proteins for subsequent enzymatic degradation. The molecular contact specificities are suggested for both the substrate recognition and the residues at the possible E2-binding surface. The predicted structure, of a ubiquitin-protein ligase (E3, enzyme class number 6.3.2.19, CATH code 3.30.40.10.4) may contribute to explain the process of ubiquitination. The 3-D model supports the idea of a C3HC4-RING finger with a partially new pattern. The putative E2-binding site is formed by a shallow hydrophobic groove on the surface adjacent to the helix and one zinc finger (L722, C739, P740, P741, R744). Solvent-exposed hydrophobic amino acids lie around both zinc fingers (I717, L722, F738, or P765, L766, V767, V733, P734). The 3-D structure was deposited in the protein databank theoretical model repository (2B9G, RCSB Protein Data Bank, NJ).