Contractualist age rationing under outbreak circumstances

Age rationing is a central issue in the health care priority-setting literature, but it has become ever more salient in the light of the Covid-19 outbreak, where health authorities in several countries have given higher priority to younger over older patients. But how is age rationing different under outbreak circumstances than under normal circumstances, and what does this difference imply for ethical theories? This is the topic of this paper. The paper argues that outbreaks such as that of Covid-19 involve special circumstances that change how age should influence our prioritization decisions, and that while this shift in circumstances poses a problem for consequentialist views such as utilitarianism and age-weighted consequentialism, contractualism is better equipped to cope with it. The paper then offers a contractualist prudential account of age rationing under outbreak circumstances.

Allocation of scarce resources in Africa during COVID-19: Utility and justice for the bottom of the pyramid?

The COVID‐19 pandemic has raised important universal public health challenges. Conceiving ethical responses to these challenges is a public health imperative but must take context into account. This is particularly important in sub‐Saharan Africa (SSA). In this paper, we examine how some of the ethical recommendations offered so far in high‐income countries might appear from a SSA perspective. We also reflect on some of the key ethical challenges raised by the COVID‐19 pandemic in low‐income countries suffering from chronic shortages in health care resources, and chronic high morbidity and mortality from non‐COVID‐19 causes. A parallel is drawn between the distribution of severity of COVID‐19 disease and the classic “Fortune at the bottom of the pyramid” model that is relevant in SSA. Focusing allocation of resources during COVID‐19 on the ‘thick’ part of the pyramid in Low‐to‐Middle Income Countries (LMICs) could be ethically justified on utilitarian and social justice grounds, since it prioritizes a large number of persons who have been economically and socially marginalized. During the pandemic, importing allocation frameworks focused on the apex of the pyramid from the global north may therefore not always be appropriate. In a post‐COVID‐19 world, we need to think strategically about how health care systems can be financed and structured to ensure broad access to adequate health care for all who need it. The root problems underlying health inequity, exposed by COVID‐19, must be addressed, not just to prepare for the next pandemic, but to care for people in resource poor settings in non‐pandemic times.

Ebola vaccine? Family first! Evidence from using a brief measure on Ebola vaccine demand in a national household survey during the outbreak in Sierra Leone

BACKGROUND

Vaccination against Ebolavirus is an emerging public health tool during Ebola Virus Disease outbreaks. We examined demand issues related to deployment of Ebolavirus vaccine during the 2014-2015 outbreak in Sierra Leone.

METHODS

A cluster survey was administered to a population-based sample in December 2014 (N = 3540), before any Ebola vaccine was available to the general public in Sierra Leone. Ebola vaccine demand was captured in this survey by three Likert-scale items that were used to develop a composite score and dichotomized into a binary outcome to define high demand. A multilevel logistic regression model was fitted to assess the associations between perceptions of who should be first to receive an Ebola vaccine and the expression of high demand for an Ebola vaccine.

RESULTS

The largest proportion of respondents reported that health workers (35.1%) or their own families (29.5%) should receive the vaccine first if it became available, rather than politicians (13.8%), vaccination teams (9.8%), or people in high risk areas (8.2%). High demand for an Ebola vaccine was expressed by 74.2% of respondents nationally. The odds of expressing high demand were 13 times greater among those who said they or their families should be the first to take the vaccine compared to those who said politicians should be the first recipients (adjusted odds ratio [aOR] 13.0 [95% confidence interval [CI] 7.8-21.6]). The ultra-brief measure of the Ebola vaccine demand demonstrated acceptable scale reliability (Cronbach's α = 0.79) and construct validity (single-factor loadings > 0.50).

CONCLUSION

Perceptions of who should be the first to get the vaccine was associated with high demand for Ebola vaccine around the peak of the outbreak in Sierra Leone. Using an ultra-brief measure of Ebola vaccine demand is a feasible solution in outbreak settings and can help inform development of future rapid assessment tools.

Considering Quality of Life while Repudiating Disability Injustice: A Pathways Approach to Setting Priorities

This article proposes a novel strategy, one that draws on insights from antidiscrimination law, for addressing a persistent challenge in medical ethics and the philosophy of disability: whether health systems can consider quality of life without unjustly discriminating against individuals with disabilities. It argues that rather than uniformly considering or ignoring quality of life, health systems should take a more nuanced approach. Under the article's proposal, health systems should treat cases where (1) quality of life suffers because of disability-focused exclusion or injustice differently from cases where (2) lower quality of life results from laws of nature, resource scarcity, or appropriate tradeoffs. Decisionmakers should ignore quality-of-life losses that result from injustice or exclusion when ignoring them would improve the prospects of individuals with disabilities; in contrast, they should consider quality-of-life losses that are unavoidable or stem from resource scarcity or permissible tradeoffs. On this proposal, while health systems should not amplify existing injustice against individuals with disabilities, they are not required to altogether ignore the potential effects of disability on quality of life.

Ethical issues raised by cluster randomised trials conducted in low-resource settings: identifying gaps in the Ottawa Statement through an analysis of the PURE Malawi trial

The increasing use of cluster randomised trials in low-resource settings raises unique ethical issues. The Ottawa Statement on the Ethical Design and Conduct of Cluster Randomised Trials is the first international ethical guidance document specific to cluster trials, but it is unknown if it adequately addresses issues in low-resource settings. In this paper, we seek to identify any gaps in the Ottawa Statement relevant to cluster trials conducted in low-resource settings. Our method is (1) to analyse a prototypical cluster trial conducted in a low-resource setting (PURE Malawi trial) with the Ottawa Statement; (2) to identify ethical issues in the design or conduct of the trial not captured adequately and (3) to make recommendations for issues needing attention in forthcoming revisions to the Ottawa Statement Our analysis identified six ethical aspects of cluster randomised trials in low-resource settings that require further guidance. The forthcoming revision of the Ottawa Statement should provide additional guidance on these issues: (1) streamlining research ethics committee review for collaborating investigators who are affiliated with other institutions; (2) the classification of lay health workers who deliver study interventions as health providers or research participants; (3) the dilemma experienced by investigators when national standards seem to prohibit waivers of consent; (4) the timing of gatekeeper engagement, particularly when researchers face funding constraints; (5) providing ancillary care in health services or implementation trials when a routine care control arm is known to fall below national standards and (6) defining vulnerable participants needing protection in low-resource settings.

Appeal to the Rule of Rescue in health care: discriminating and not benevolent?

Thirty years of debate have passed since the term "Rule of Rescue" has been introduced into medical ethics. Its main focus was on whether or why medical treatment for acute conditions should have priority over preventive measures irrespective of opportunity costs. Recent contributions, taking account of the widespread reluctance to accept purely efficiency-oriented prioritization approaches, advance another objection: Prioritizing treatment, they hold, discriminates against statistical lives. The reference to opportunity costs has also been renewed in a distinctly ethical fashion: It has been stipulated that favoring help for identifiable lives amounts to a lack of benevolence for one's fellow creatures. The present article argues against both objections. It suggests that the debate's focus on consequences (deaths or severe ill health) should be reoriented by asking which aspects of such states of affairs are actually attributable to a decision maker who judges within a specific situation of choice.

Newborns in crisis: An outline of neonatal ethical dilemmas in humanitarian medicine

Newborn infants are among those most severely affected by humanitarian crises. Aid organisations increasingly recognise the necessity to provide for the medical needs of newborns, however, this may generate distinctive ethical questions for those providing humanitarian medical care. Medical ethical approaches to neonatal care familiar in other settings may not be appropriate given the diversity and volatility of humanitarian disasters, and the extreme resource limitations commonly faced by humanitarian aid missions.

In this paper, we first systematically review existing guidelines relating to the treatment and resuscitation of newborns in humanitarian crises, finding little substantive ethical guidance for those providing humanitarian healthcare. We next draw on paradigm cases and published literature to identify and describe some of the major ethical questions common to these settings. We divide these questions into quality of life considerations, allocation of limited resources, and conflicting cultural norms and values. We finally suggest some preliminary recommendations to guide ethical decision‐making around resuscitation of newborns and withdrawal of treatment in humanitarian settings.

The Case for Resource Sensitivity: Why It Is Ethical to Provide Cheaper, Less Effective Treatments in Global Health

When Dr. Hortense screens her patients in Chicago for cervical dysplasia and cancer, she conducts a pelvic exam, takes a sample of cervical cells, and sends them for Pap cytology and human papilloma virus DNA co-testing. But when she conducts cervical cancer screening in Botswana, she employs a much simpler diagnostic strategy. She applies acetic acid to highlight precancerous lesions and visually inspects the cervix-a technique known as the VIA (visual inspection with acetic acid) method. She treats suspicious lesions with cryotherapy. There are multiple reasons that Dr. Hortense uses VIA in developing countries. It requires no specialized laboratory facilities or highly trained personnel. With immediate results, there is no delay in diagnosis and treatment, ensuring that patients are not lost to follow-up. Most importantly, VIA is considerably cheaper than Pap and HPV co-testing. This difference in care between Chicago and Botswana presents an ethical dilemma in global health: is it ethically acceptable to provide some patients cheaper treatments that are less effective or more toxic than the treatments other patients receive? We argue that it is ethical to consider local resource constraints when deciding what interventions to provide. The provision of cheaper, less effective health care is frequently the most effective way of promoting health and realizing the ethical values of utility, equality, and priority to the worst off.

Against the integrative turn in bioethics: burdens of understanding

The advocates of Integrative Bioethics have insisted that this recently emerging project aspires to become a new stage of bioethical development, surpassing both biomedically oriented bioethics and global bioethics. We claim in this paper that if the project wants to successfully replace the two existing paradigms, it at least needs to properly address and surmount the lack of common moral vocabulary problem. This problem points to a semantic incommensurability due to cross-language communication in moral terms. This paper proceeds as follows. In the first part, we provide an overview of Integrative Bioethics and its conceptual building blocks: mutlidisciplinarity, interdisciplinarity, and transdisciplinarity. In the second part, we disclose the problem of semantic incommensurability. The third part gives an overview of various positions on the understanding of interdisciplinarity and integration in interdisciplinary communication, and corresponding attempts at solving the lack of common moral vocabulary problem. Here we lean mostly on Holbrook's three theses regarding the character of interdisciplinary communication. Finally, in the fourth part, we discuss a particular bioethical case-that of euthanasia-to demonstrate the challenge semantic incommensurability poses to dialogues in Integrative Bioethics. We conclude that Integrative Bioethics does not offer a methodological toolset that would warrant optimism in its advocates' predictions of surpassing current modes of doing bioethics. Since Integrative Bioethics leaves controversial methodological questions unresolved on almost all counts and shows no attempts at overcoming the critical stumbling points, we argue for its rejection.

Fair Resource Allocation to Health Research: Priority Topics for Bioethics Scholarship

This article draws attention to the limited amount of scholarship on what constitutes fairness and equity in resource allocation to health research by individual funders. It identifies three key decisions of ethical significance about resource allocation that research funders make regularly and calls for prioritizing scholarship on those topics - namely, how health resources should be fairly apportioned amongst public health and health care delivery versus health research, how health research resources should be fairly allocated between health problems experienced domestically versus other health problems typically experienced by disadvantaged populations outside the funder's country, and how domestic and non-domestic health research funding should be further apportioned to different areas, e.g. types of research and recipients. These three topics should be priorities for bioethics research because their outcomes have a substantial bearing on the achievement of health justice. The proposed agenda aims to move discussion on the ethics of health research funding beyond its current focus on the mismatch between worldwide basic and clinical research investment and the global burden of disease. Individual funders' decision-making on whether and to what extent to allocate resources to non-domestic health research, health systems research, research on the social determinants of health, capacity development, and recipients in certain countries should also be the focus of ethical scrutiny.

Preparing students for the ethical challenges on international health electives: A systematic review of the literature on educational interventions

International health electives pose specific ethical challenges for students travelling from to low and middle income countries. We undertook a systematic review of the literature on interventions to prepare students to identify ethical issues addressed, educational approaches and to collate evidence on the effectiveness of different strategies. We searched nine electronic databases of peer-reviewed literature and identified grey literature through key word searches; supplemented through citation mapping and expert consultation. Articles that described ethical training conducted by universities or professional bodies were included for review. We reviewed forty-four full text articles. Ten sources of published literature and seven sources of grey literature met our inclusion criteria. We identified thirteen ethical situations that students should be prepared to manage and eight generic skills to support this process. Most interventions were delivered before the elective, used case studies or guidelines. Some suggested ethical principles or a framework for analysis of ethical issues. Only two papers evaluated the intervention described. Our paper collates a small but growing body of work on education to prepare students to manage ethical issues. Ethical training should have elements that are delivered before, during and after the elective. Interventions should include case studies covering thirteen ethical issues identified here, linked to ethical principles and a process for responding to ethical issues. We suggest that evaluations of interventions are an important area for future research.

Ethical Questions about Platelet Transfusions at the End of Life

This case of platelet transfusion in palliative care illustrates a common dilemma in transfusion medicine: approval of the use of a scarce, yet potentially life-saving, resource. As in this case, these decisions often involve seriously ill patients with acute needs and evolving goals of care. The use of resources to treat the patient at hand must be balanced against maintaining adequate resources to treat future patients. In this setting, the ethical principles of beneficence and social justice are in conflict.

Reexamining Healthcare Justice in the Light of Empirical Data

This article discusses the notion of justice from a capabilities approach. We undertake an empirical analysis of the concepts of justice held by healthcare personnel, gleaned from a qualitative analysis of interviews on the subject of ethical dilemmas in everyday practice. The article states that Justice undoubtedly presents a work in progress, which implicates the link between justice as capability and human dignity. We empirically found a contrast between the views of justice based on the patient's own perceptions and those based on the perceptions of healthcare personnel. We establish the kind of actions, communication skills and justice required to build a stronger relationship between patients and healthcare professionals, which would improve prognosis, treatment efficiency and therapeutic adhesion.

Evaluation of the work of hospital districts' research ethics committees in Finland

The main task of research ethics committees (RECs) is to assess research studies before their start. In this study, 24 RECs that evaluate medical research were sent questionnaires about their structure and functions. The RECs were divided into two separate groups: those working in university hospital districts (uRECs) and those in central hospital districts (non-uRECs). The two groups were different in many respects: the uRECs were bigger in size, covered a wider range of disciplines (both medical and non-medical), had better resources and more frequent and regular meetings. After the survey was performed and analysed, the Medical Research Act was amended so that only hospital districts with a medical faculty in their region had a duty to establish ethics committees. After the amendment, the number of RECs evaluating medical research in Finland decreased from 25 to 9. The ethics committees that remained had wider expertise and were better equipped already by the time of this survey. Only one non-uREC was continuing its work, and this was being done under the governance of a university hospital district. Simple measures were used for qualitative analysis of the work of RECs that evaluate medical research. These showed differences between RECs. This may be helpful in establishing an ethics committee network in a research field or administrational area.

Justifying community benefit requirements in international research

It is widely agreed that foreign sponsors of research in low- and middle-income countries (LMICs) are morally required to ensure that their research benefits the broader host community. There is no agreement, however, about how much benefit or what type of benefit research sponsors must provide, nor is there agreement about what group of people is entitled to benefit. To settle these questions, it is necessary to examine why research sponsors have an obligation to benefit the broader host community, not only their subjects. Justifying this claim is not straightforward. There are three justifications for an obligation to benefit host communities that each apply to some research, but not to all. Each requires a different amount of benefit, and each requires benefit to be directed toward a different group. If research involves significant net risk to LMIC subjects, research must provide adequate benefit to people in LMICs to avoid an unjustified appeal to subjects' altruism. If research places significant burdens on public resources, research must provide fair compensation to the community whose public resources are burdened. If research is for profit, research sponsors must contribute adequately to the upkeep of public goods from which they benefit in order to avoid the wrong of free-riding, even if their use of these public goods is not burdensome.

Ethical considerations in targeted paediatric neurosurgery missions

Within the context of global health development approaches, surgical missions to provide care for underserved populations remain the least studied interventions with regard to their methodology. Because of the unique logistical needs of delivering operative care, surgical missions are often described solely in terms of cases performed, with a paucity of discourse on medical ethics. Within surgery, subspecialties that serve patients on a non-elective basis should, it could be argued, create mission strategies that involve a didactic approach and the propagation of sustainable surgical care. The ethical considerations have yet to be described for paediatric neurosurgical outreach missions. We present here the perspectives of neurosurgeons who have participated in surgical outreach missions in Central America, South America, Eastern Europe and sub-Saharan Africa from the vantage point of both the visiting mission team and the host team that accommodates the mission efforts.

Health researchers' ancillary care obligations in low-resource settings: how can we tell what is morally required?

Health researchers working in low-resource settings often encounter serious unmet health needs among participants. What is the nature and extent of researchers' obligations to respond to such needs? Competing accounts have been proposed, but there is no independent standard by which to assess them or to guide future inquiry. I propose an independent standard and demonstrate its use. In conclusion I recommend two areas of focus for future inquiry: what makes an account of researchers' obligations reasonable from the standpoint of both participants and researchers and how general duties of rescue apply to researchers' resource-allocation decision making in low-resource settings.

Sufficiency of care in disasters: ventilation, ventilator triage, and the misconception of guideline-driven treatment

This essay examines the management of ventilatory failure in disaster settings where clinical needs overwhelm available resources. An ethically defensible approach in such settings will adopt a "sufficiency of care" perspective that is: (1) adaptive, (2) resource-driven, and (3) responsive to the values of populations being served. Detailed, generic, antecedently written guidelines for "ventilator triage" or other management issues typically are of limited value, and may even impede ethical disaster response if they result in rescuers' clumsily interpreting events through the lens of the guideline, rather than customizing tactics to the actual context. Especially concerning is the tendency of some expert planners to mistakenly assume that medical treatment of respiratory failure: (1) always requires full-feature mechanical ventilators, (2) will always occur in hospitals, and (3) can be planned in advance without sophisticated public consultation about likely ethical dilemmas.

Holding services to account

BACKGROUND

Recently, the frequency of audit inspections of health services for people with intellectual disability (ID) in the UK has increased, from occasional inquiries to a systematic audit of all services. From 2008, a process of continuous audit 'surveillance' of specialist health services is to be introduced. Similar regimes of inspection are in place for social care services.

AIM

To explore the conceptual positions which inform audit, through detailed examination of the investigation into the learning disability service at Sutton and Merton.

FINDINGS

Audit is distinct from evaluation because it neither provides opportunities for service staff to give an account of their work nor represents a search for knowledge. Audit investigates adherence to government policy. In ID, audits measure aspirations derived from normalisation, despite research showing that some of these aspirations have not been achieved by any service. As audit consumes significant public resource, it is questionable whether the dominant finding of the Healthcare Commission's investigation into Sutton and Merton, that the ID service was chronically under-funded, represents value for money.

DISCUSSION AND CONCLUSIONS

While basic checks on minimum standards will always be necessary, service excellence requires not audit but research-driven evaluation. Audits inhibit rather than open-up debate about improving support to people with ID. They impose an ideology, squander resource, and demoralise carers and staff. Evaluations challenge the implicit management-versus-professional binary enacted by audit, and can inform new care systems which make effective use of all those engaged with people with ID.

Ethical considerations in pandemic influenza planning

Although the timing and severity of the next influenza pandemic is impossible to predict, there is broad agreement that one will occur. Preparation is vital to mitigating its effects. A severe influenza pandemic like that which began in 1918 would be unlike other disasters in nature, scale, and duration. It could cripple normal business operations and disrupt global distribution of essential goods and services. It could force ethical decisions that many in a country accustomed to relative abundance are poorly prepared to make. Although sound evidence and clinical and public health expertise are needed to make informed decisions, so is an understanding of our common and diverse values. This article outlines some of the challenges the state would face during a pandemic, especially concerning the rationing of resources and care. It also describes a process currently underway to develop guidelines for how the state should approach the ethical questions that would arise.

Teaching medical students about fair distribution of healthcare resources

Healthcare package decisions are complex. Different judgements about effectiveness, cost-effectiveness and disease burden influence the decision-making process. Moreover, different concepts of justice generate different ideas about fair distribution of healthcare resources. This paper presents a decision model that is used in medical school in order to familiarise medical students with the different concepts of justice and the ethical dimension of making concrete choices. The model is based on the four-stage decision model developed in the Netherlands by the Dunning Committee and the discussion that followed its presentation in 1991. Having to deal with 10 medical services, students working with the model learn to discern and integrate four different ideas of distributive justice that are integrated in a flow chart: libertarian, communitarian, egalitarian and utilitarian.

Ethical triage and scarce resource allocation during public health emergencies: tenets and procedures

Public health emergencies may result in mass casualties and a surge in demand for hospital-based care. Healthcare standards may need to be altered to respond to an imbalance between demands for care and resources. Clinical decisions that involve triage and scarce resource allocation may present unique ethical challenges. To address these challenges, the authors detailed tenets and procedures to guide triage and scarce resource allocation during public health emergencies. The authors propose health care organizations deploy a Triage and Scarce Resource Allocation Team to over-see and guide ethically challenging clinical decision-making during a crisis period. The authors' goal is to help healthcare organizations and clinicians balance public health responsibilities and their duty to individual patients during emergencies in as equitable and humane a manner as possible.

Resource allocation in healthcare: implications of models of medicine as a profession

For decades, the problem of how to allocate healthcare resources in a just and equitable fashion has been the subject of concerted discussion and analysis, yet the issue has stubbornly resisted resolution. This article suggests that a major reason for this is that the discussion has focused exclusively on the nature and status of the material resources, and that the nature and role of the medical profession have been entirely ignored. Because physicians are gatekeepers to healthcare resources, their role in allocation is central from a process perspective. This article identifies 3 distinct interpretations of the nature of medicine, shows how each mandates a different method of allocation, and argues that unless an appropriate model of medicine is developed that acknowledges the valid points contained in each of the 3 approaches, the allocation problem will remain unsolvable.

A proposed rural healthcare ethics agenda

The unique context of the rural setting provides special challenges to furnishing ethical healthcare to its approximately 62 million inhabitants. Although rural communities are widely diverse, most have the following common features: limited economic resources, shared values, reduced health status, limited availability of and accessibility to healthcare services, overlapping professional-patient relationships and care giver stress. These rural features shape common healthcare ethical issues, including threats to confidentiality, boundary issues, professional-patient relationship and allocation of resources. To date, there exists a limited focus on rural healthcare ethics shown by the scarcity of rural healthcare ethics literature, rural ethics committees, rural focused ethics training and research on rural ethics issues. An interdisciplinary group of rural healthcare ethicists with backgrounds in medicine, nursing and philosophy was convened to explore the need for a rural healthcare ethics agenda. At the meeting, the Coalition for Rural Health Care Ethics agreed to a definition of rural healthcare ethics and a broad-ranging rural ethics agenda with the ultimate goal of enhancing the quality of patient care in rural America. The proposed agenda calls for increasing awareness and understanding of rural healthcare ethics through the development of evidence--informed, rural-attuned research, scholarship and education in collaboration with rural healthcare professionals, healthcare institutions and the diverse rural population.

[Organ donation: scarce and fragile resources]

Organ transplantation, the gold standard therapy for end-stage organ failures, has become a victim of its success. Indeed, the number of patients listed for transplantation has been increasing faster than that of available grafts. The number of brain-dead donors, the primary source of organ donation in France, is limited, but this figure is becoming more and more comprehensive, thanks to the work carried out by hospital transplant coordination units. The room for manoeuvre is limited: to increase the transplantation rate in this respect, the only possibility would be to reduce the rate of donation refusals, which still accounts for more than 30 percent of all identified brain deaths. It is thus more and more critical to resort to other donor sources: living donors and non-heart-beating donors. Each donor source is associated with different constraints and limitations in terms of available resources, removal organization and ethics. For cadaver donors, the key ethical issues are the acceptance of presumed consent, the difficulty in diagnosing the exact time of death and the notion of body integrity. For living donors, the ethical issues are related to the quality of the consent and the assessment of the risk undertaken by the donor, when no personal benefit is expected.

Parenteral nutrition: ethical and legal considerations

Parenteral nutrition is an expensive therapeutic modality that is used to treat patients with intestinal failure. The benefit it offers in terms of life prolongation needs to be weighed against its risks and burdens. Through the use of descriptive clinical vignettes, this article illustrates the ethical and legal principles that underpin decisions to administer and, more importantly, to withhold or withdraw parenteral nutrition.

Ethical issues of resuscitation: an American perspective

Challenging issues confront emergency physicians routinely when performing cardiopulmonary resuscitation. Ethical issues surrounding resuscitation may include issues of futility, withholding or withdrawing interventions, advance directives, family presence, practising procedures on the newly dead, palliative care, and communication. Principles of bioethics can be valuable in assessing and debating ethical dilemmas. In many cases where curative care is not possible or is not desired, the goal of medical care at the end of life is to provide comfort to the patient and family, rather than initiating technological interventions that are unlikely to benefit the patient.

The challenges and ethical dilemmas of a military medical officer serving with a peacekeeping operation in regard to the medical care of the local population

Medical Officers serving with their national contingents in peacekeeping operations are faced with difficult ethical decisions in regard to their obligations to the local civilian population. Such populations may be under-resourced in regard to medical care, and vulnerable to abuse and exploitation. Though the medical officer may support the local medical services, he/she should never undermine these resources. Adopting a human rights approach and observing the requirements of ethical medicine, aids the doctor in prioritising his/her duties. At times there may be conflict with one's own military superiors. It is wise to discuss potential difficulties prior to setting out on the mission. Human rights abuses cannot be ignored. The medical officer has a duty to do his/her best to report their observations so as to prevent abuse or to bring it to an end.

Capabilities and health

Sen's capabilities approach offers a radical generalisation of the conventional approach to welfare economics. It has been highly influential in development and many researchers are now beginning to explore its implications for health care. This paper contributes to the emerging debate by discussing two examples of such applications: first, at the individual decision making level, namely the right to die, and second, at the social choice level. For the first application, which draws on Nussbaum's list of capabilities, it is argued that many capabilities are ambiguously or indirectly related to the right to die, but the ability to form a concept of the good life and plan one's own life provides a direct justification for such a right. In the second application, the focus is specifically on healthcare rationing and it is argued that, although not committed to age based rationing, the capabilities approach provides a more natural justification of age related access to health care than the fair innings argument, which is often used to justify the alleged ageism inherent in quality adjusted life years (QALY) maximisation.

A necessária frugalidade dos idosos

O artigo pretende refletir sobre a pertinência e a legitimidade moral de basear na variável idade a alocação de recursos públicos para a saúde, considerada do ponto de vista da teoria da justiça como eqüidade, formulada por John Rawls. Depois de caracterizar o problema da alocação de recursos públicos para a saúde, confrontada com o desafio representado pelo envelhecimento populacional, e apresentar, brevemente, a concepção de eqüidade adotada neste trabalho, assim como discutir a abordagem de Norman Daniels e Daniel Callahan para a alocação de recursos entre os diferentes grupos de idade, concluiremos que basear a alocação de recursos na variável idade pode ser considerado eticamente adequado se concebermos a vida do indivíduo como um ciclo limitado de existência formado por diferentes estágios (infância, adolescência, maturidade, velhice e morte), nos quais variam as necessidades, devendo a distribuição de recursos entre os diferentes grupos de idade estar baseada numa ética de proteção.

Helping medical students to find their moral compasses: ethics teaching for second and third year undergraduates

The paper describes a two week course that has been offered as a special study module to intermediate level (second and third year) undergraduate medical students at Dundee University Medical School for the past five years. The course requires students to research the various aspects of ethical dilemmas that they have identified themselves, and to "teach" these issues to their colleagues in a short PowerPoint presentation as well as to prepare an extended 3000 word essay discussion. The course specifically asks students not to disclose their own ethical positions, as these are probably still in formation and the objective is to promote critical thinking capacity in ethical and moral issues as a prelude to the development of practical skills in dealing with clinical problems. The course is easy to resource for the school and has received universally high evaluations from the students since its inception.