Greening the poor: the trap of moralization

This article uses ethnographic data to engage a critical reflection on the tension between individual responsibility for the environment and inequality. While research has shown that the majority of sustainable consumers are middle and upper class, educated and white individuals, the study explores how the ethical injunction to ecological sustainability is being introduced to lower-income neighbourhoods in France. It draws on the observation of a national programme which aims at supporting inhabitants of public housing estates in the process of greening their lifestyle in order to fight climate change and fuel poverty. The paper analyses how environmental responsibilization is specific in that it calls upon a responsibility towards others, towards the common good. Using the Foucauldian concept of 'subjectivation', it describes and analyses the moral work implied by such behaviour change programmes. It demonstrates that a negative representation of poor households and a moral framing of the responsibility for the environment lead to a moralization of their lifestyle under the heading of 'eco-friendly behaviours'. A paradoxical result of such endeavours is that the social group with the least impactful lifestyle on the environment is the one which is moralized in the most intrusive and resolute manner. The article shows, however, that the tenants manage to resist the normalizing discourse on sustainable living, for reasons which are not anti-environmentalist. This piece thus provides interesting results for sustainability studies as well as for the sociology of the regulation of underprivileged neighbourhoods.

Universal Basic Income, Poverty, and Social Justice: A Moral and Economic Imperative for Social Workers

Modern technology threatens to dramatically alter the U.S. labor economy, but the crumbling social safety net may be insufficient for affected workers. Some advocates propose to address these converging problems through universal basic income (UBI). Authors conducted a preliminary review of social work perspectives on the topic of UBI. They found very little relevant literature, especially among American scholars. Existent social work literature frames UBI as an alternative to the neoliberal welfare state and mass unemployment. Social workers also contribute a critical social justice orientation to UBI scholarship in other disciplines. Grounded in the NASW Code of Ethics, authors argue that it is imperative for American social workers to seriously consider UBI as an answer to growing inequality and the unique expertise that social workers offer as allies of marginalized populations.

Are Patients' and Communities' Poverty Exploited to Give Health Professions Students Learning Experiences?

In clinical settings, exploitation of patients who live in poverty can be exacerbated when health professions students' educational goals are overemphasized relative to patients' and communities' needs. Continuity of care relies on health system infrastructure and its capacity to keep patients engaged. Achieving just health care delivery in domestic and international settings requires balancing students', patients', and communities' interests. This article examines how students' interests in learning should be considered relative to patients' and communities' interests in receiving quality care.

Social Work Is a Human Rights Profession

As defined by the International Federation of Social Workers, social work is a human rights profession. This is explicitly stated in the professional codes of ethics in many nations. However, the most recent version of the Code of Ethics of the National Association of Social Workers continues to exclude any mention of human rights, fitting in with the history of U.S. exceptionalism on this subject. Social workers around the world have a long history of working for the achievement of human rights, including an explicit grounding of practice in human rights principles: human dignity, nondiscrimination, participation, transparency, and accountability. Utilizing these principles, U.S. social workers can move from the deficit model of the needs-based approach to competently contextualizing individual issues in their larger human rights framework. In this way, social work can address larger social problems and make way for the concurrent achievement of human rights. This article explains these principles and provides a case example of how to apply them in practice.

How Should Clinicians Respond When Different Standards of Care Are Applied to Undocumented Patients?

A challenge in caring for patients in resource-poor settings is the ethical discomfort and discouragement clinicians might experience when they're unable to provide optimal care due to lack of resources. This case, in which a resident is faced with rationalizing substandard care for certain classes of patients, probably represents the top of a slippery slope. This article argues that physicians should identify and advocate for optimal care for each patient. Moreover, physicians should advocate to improve the health system that allows for substandard care. Physicians should disclose to patients all available evaluation and treatment options, even those that seem cost prohibitive or unrealistic for some other reason. Transparency and objectivity in the patient-clinician relationship require good communication skills and are central to avoiding harm.

Newborn health benefits or financial risk protection? An ethical analysis of a real-life dilemma in a setting without universal health coverage

INTRODUCTION

High healthcare costs make illness precarious for both patients and their families' economic situation. Despite the recent focus on the interconnection between health and financial risk at the systemic level, the ethical conflict between concerns for potential health benefits and financial risk protection at the household level in a low-income setting is less understood.

METHODS

Using a seven-step ethical analysis, we examine a real-life dilemma faced by families and health workers at the micro level in Ethiopia and analyse the acceptability of limiting treatment for an ill newborn to protect against financial risk. We assess available evidence and ethical issues at stake and discuss the dilemma with respect to three priority setting criteria: health maximisation, priority to the worse-off and financial risk protection.

RESULTS

Giving priority to health maximisation and extra priority to the worse-off suggests, in this particular case, that limiting treatment is not acceptable even if the total well-being gain from reduced financial risk is taken into account. Our conclusion depends on the facts of the case and the relative weight assigned to these criteria. However, there are problematic aspects with the premise of this dilemma. The most affected parties-the newborn, family members and health worker-cannot make free choices about whether to limit treatment or not, and we thereby accept deprivations of people's substantive freedoms.

CONCLUSION

In settings where healthcare is financed largely out-of-pocket, families and health workers face tragic trade-offs. As countries move towards universal health coverage, financial risk protection for high-priority services is necessary to promote fairness, improve health and reduce poverty.

The potential exploitation of research participants in high income countries who lack access to health care

There are millions of individuals living in North America and the European Union who lack access to healthcare services. When these individuals participate in research, they are at increased risk of being exposed to the risks and burdens of clinical trials without realizing the benefits that result from them. The mechanisms that have been proposed to ensure that research participants in low- and middle-income countries are not exploited are unlikely to protect participants in high-income countries. The present manuscript argues that one way to address concerns about exploitation in high-income countries would be to require sponsors to provide targeted benefits such as medical treatment during the trial, or the study drug after the trial. The latter could be achieved through extension studies, expanded access programs, or named-patient programs. Sponsors also might provide non-medical benefits, such as education or social support. Ethical and regulatory guidance should be revised to ensure that research participants in high-income countries who lack access to healthcare services receive sufficient benefits.

Dilemmas for international mobilization around child abuse and neglect

The goal of this commentary is to articulate some issues and dilemmas raised by various efforts to mobilize international action around child abuse and neglect (CAN). We will start by proposing a typology of international mobilization strategies, noting that initiatives to promote CAN programming in new settings have tended to emphasize one of three vectors: governments, professionals, or international NGOs. There are pros and cons to each emphasis, which we discuss. We also review the debates around some of the following dilemmas: Should low-income countries be a top priority for CAN mobilization? Are there cultural and institutional capacities that need to be present in a country in order for CAN programs to work or be ethical? Are some CAN programs more likely to be internationally transferable than others and why so? Has the field adequately considered whether non-CAN programming (e.g., family planning) might actually be more effective at preventing maltreatment than CAN programming? Does the field give adequate acknowledgment that policies and practices emanating from high-resourced and Western countries may not always be the best to disseminate? Are we relying too much on a model of program transplantation over a model of local cultivation? Should we aim for modest rather than ambitious accomplishments in international mobilization? How much emphasis should be placed on the priority dissemination of evidence-based programming? We conclude with some suggestions in the service of clarifying these dilemmas and making some of these decisions more evidence based.

The Ethics of Introducing GMOs into sub-Saharan Africa: Considerations from the sub-Saharan African Theory of Ubuntu

A growing number of countries in sub-Saharan Africa are considering legalizing the growth of genetically modified organisms (GMOs). Furthermore, several projects are underway to develop transgenic crops tailored to the region. Given the contentious nature of GMOs and prevalent anti-GMO sentiments in Africa, a robust ethical analysis examining the concerns arising from the development, adoption, and regulation of GMOs in sub-Saharan Africa is warranted. To date, ethical analyses of GMOs in the global context have drawn predominantly on Western philosophy, dealing with Africa primarily on a material level. Yet, a growing number of scholars are articulating and engaging with ethical theories that draw upon sub-Saharan African value systems. One such theory, Ubuntu, is a well-studied sub-Saharan African communitarian morality. I propose that a robust ethical analysis of Africa's agricultural future necessitates engaging with African moral theory. I articulate how Ubuntu may lead to a novel and constructive understanding of the ethical considerations for introducing GMOs into sub-Saharan Africa. However, rather than reaching a definitive prescription, which would require significant engagement with local communities, I consider some of Ubuntu's broader implications for conceptualizing risk and engaging with local communities when evaluating GMOs. I conclude by reflecting on the implications of using local moral theory in bioethics by considering how one might negotiate between universalism and particularism in the global context. Rather than advocating for a form of ethical relativism, I suggest that local moral theories shed light on salient ethical considerations that are otherwise overlooked.

Universal health care and equity: evidence of maternal health based on an analysis of demographic and household survey data

INTRODUCTION

The drive toward universal health coverage (UHC) is central to the post 2015 agenda, and is incorporated as a target in the new Sustainable Development Goals. However, it is recognised that an equity dimension needs to be included when progress to this goal is monitored. WHO have developed a monitoring framework which proposes a target of 80% coverage for all populations regardless of income and place of residence by 2030, and this paper examines the feasibility of this target in relation to antenatal care and skilled care at delivery.

METHODOLOGY

We analyse the coverage gap between the poorest and richest groups within the population for antenatal care and presence of a skilled attendant at birth for countries grouped by overall coverage of each maternal health service. Average annual rates of improvement needed for each grouping (disaggregated by wealth quintile and urban/rural residence) to reach the goal are also calculated, alongside rates of progress over the past decades for comparative purposes.

FINDINGS

Marked inequities are seen in all groups except in countries where overall coverage is high. As the monitoring framework has an absolute target countries with currently very low coverage are required to make rapid and sustained progress, in particular for the poorest and those living in rural areas. The rate of past progress will need to be accelerated markedly in most countries if the target is to be achieved, although several countries have demonstrated the rate of progress required is feasible both for the population as a whole and for the poorest.

CONCLUSIONS

For countries with currently low coverage the target of 80% essential coverage for all populations will be challenging. Lessons should be drawn from countries who have achieved rapid and equitable progress in the past.

Transnational gestational surrogacy: does it have to be exploitative?

This article explores the controversial practice of transnational gestational surrogacy and poses a provocative question: Does it have to be exploitative? Various existing models of exploitation are considered and a novel exploitation-evaluation heuristic is introduced to assist in the analysis of the potentially exploitative dimensions/elements of complex health-related practices. On the basis of application of the heuristic, I conclude that transnational gestational surrogacy, as currently practiced in low-income country settings (such as rural, western India), is exploitative of surrogate women. Arising out of consideration of the heuristic's exploitation conditions, a set of public education and enabled choice, enhanced protections, and empowerment reforms to transnational gestational surrogacy practice is proposed that, if incorporated into a national regulatory framework and actualized within a low income country, could possibly render such practice nonexploitative.

Financial compensation for deceased organ donation in China

In March 2010, China launched a pilot programme of deceased donor organ donation in 10 provinces and cities. However, the deceased donor donation rate in China remains significantly lower than in Spain and other Western countries. In order to provide incentive for deceased donor organ donation, five pilot provinces and cities have subsequently launched a financial compensation policy. Financial compensation can be considered to include two main forms, the 'thank you' form and the 'help' form. The 'thank you' form is an expression of gratitude on behalf of the Red Cross Society of China for consenting to donation. The 'help' form is social welfare support for needy families.

Indian hospitals and government in the colonial Andes

This article examines the reception of the early modern hospital among the indigenous people of the Andes under Spanish colonial rule. During the period covered by this study (sixteenth to mid-eighteenth centuries), the hospital was conceived primarily as a manifestation of the sovereign’s paternalistic concern for his subjects’ spiritual well being. Hospitals in the Spanish American colonies were organised along racial lines, and those catering to Indians were meant to complement the missionary endeavour. Besides establishing hospitals in the main urban centres, Spanish colonial legislation instituted hospitals for Indians in provincial towns and in small rural jurisdictions throughout the Peruvian viceroyalty. Indian hospitals often met with the suspicion and even hostility of their supposed beneficiaries, especially indigenous rulers. By conceptualising the Indian hospital as a tool of colonial government, this article investigates the reasons behind its negative reception, the work of adaptation that allowed a few of them to thrive, and the eventual failure of most of these institutions.

[Precariousness, DRG's and health planning: pilot study at the Lariboisière hospital in Paris]

OBJECTIVES

This paper considers the specific administrative procedures set up by managers of public healthcare establishments and those responsible for health and welfare policies to care for low-income pregnant women for whom 100% of the "price per act" (T2A) is refunded. What are the limitations and what improvements can be suggested?

PATIENTS AND METHOD

The results are based on an analysis of data from semi-structured interviews, legislation and documents.

RESULTS

The State, health insurance systems, public health establishments, local authorities, charities and outpatient services are involved in handling low-income parturients in different services and different establishments, both locally and regionally. A health and welfare policy comprising specific, coordinated actions and measures has been developed. The T2A "price per act" system may threaten its survival: the limited number of front-line facilities is often saturated and demand is increasing, treatment is often reduced to reactive management leading to unwanted readmissions, ethics are sometimes called into question and there is a risk of patient selection.

DISCUSSION AND CONCLUSION

This pilot study provided some encouraging information but also indicated the limitations of the approach adopted. However, it was still of interest to see whether it was possible to use this approach, which did not require considerable resources, to reveal useful markers. This appeared to be the case. Regional Health Agencies (ARS) and local authorities could support the system. Additional funding is needed.

The diverse ethics of translational research

Commentators on the ethics of translational research find it morally problematic. Types of translational research are said to involve questionable benefits, special risks, additional barriers to informed consent, and severe conflicts of interest. Translational research conducted on the global poor is thought to exploit them and increase international disparities. Some commentators support especially stringent ethical review. However, such concerns are grounded only in pre-approval translational research (now called T1). Whether or not T1 has these features, translational research beyond approval (T2: phase IV, health services, and implementation research) is unlikely to and, when conducted on the global poor, may support development. Therefore, insofar as T1 is morally problematic, and no independent objections to T2 exist, the ethics of translational research is diverse: while some translational research is problematic, some is not. Funding and oversight should reflect this diversity, and T2 should be encouraged, particularly when conducted among the global poor.

Obtaining informed consent: observations from community research with refugee and impoverished youth

This paper presents challenges facing researchers in applying basic ethical principles while conducting research with youth in a developing country context. A discussion of the cultural and social challenges to adherence to the elements of informed consent: disclosure, comprehension, capacity, voluntariness and consent is presented. The authors argue that the current institutional review board requirements that guide research reflect values and stem from western contexts that may not be fully applicable to non-western contexts. More dialogue is needed among researchers in developing world contexts on challenges of and possible revisions to requirements that maintain respect for persons, beneficence, autonomy and justice, particularly when working with youth.

Just palliative care: responding responsibly to the suffering of the poor

The disproportionate suffering of the world's poor from AIDS and cancer has generated efforts to promote palliative care as an affordable alternative to expensive disease-modifying therapies. These well-intentioned efforts stem from a wish to respond to the suffering of the poor as quickly and widely as possible and from the view that only inexpensive interventions are feasible in poor settings. Such efforts also may be informed by the cautious attitude of palliative care in rich countries toward disease-modifying treatments for patients with advanced life-threatening illnesses. Yet, acceptance of unequal access for the poor to life-saving medical services that are badly needed and potentially feasible is unjust. Although palliative interventions to relieve the disproportionate physical, psychological, and social suffering of the poor are essential, they should be integrated with preventive and disease-modifying interventions for major killers, such as acquired immunodeficiency syndrome and cancer.

The ethics of poverty and the poverty of ethics: the case of Palestinian prisoners in Israel seeking to sell their kidneys in order to feed their children

Bioethical arguments conceal the coercion underlying the choice between poverty and selling ones organs.

Clinical research with economically disadvantaged populations

Concerns about exploiting the poor or economically disadvantaged in clinical research are widespread in the bioethics community. For some, any research that involves economically disadvantaged individuals is de facto ethically problematic. The economically disadvantaged are thought of as "vulnerable" [corrected] to exploitation, impaired decision making, or both, thus requiring either special protections or complete exclusion from research. A closer examination of the worries about vulnerabilities among the economically disadvantaged reveals that some of these worries are empirically or logically untenable, while others can be better resolved by improved study designs than by blanket exclusion of poorer individuals from research participation. The scientific objective to generate generalisable results and the ethical objective to fairly distribute both the risks and benefits of research oblige researchers not to unnecessarily bar economically disadvantaged subjects from clinical research participation.

Unconditional compensation: reducing the costs of disagreement about compensation for research subjects

A central requirement of research involving humans is that people who participate as subjects should do so voluntarily. We argue that disagreements about the effect of offers of compensation on subjects' ability to participate voluntarily are likely to persist and to have high social costs. We propose a novel compensation practice--to pay potential subjects whether or not they participate--and argue that its implementation in some regions, including the Eastern Mediterranean Region, may reduce disagreement and thus mitigate such costs. We outline a research programme for assessing the potential of this practice to reduce costs.

Who's in the Business of Saving Lives?

There are individuals, including children, dying needlessly in poverty-stricken third world countries. Many of these deaths could be prevented if pharmaceutical companies provided the drugs needed to save their lives. Some believe that because pharmaceutical companies have the power to save lives, and because they can do so with little effort, they have a special obligation. I argue that there is no distinction, with respect to obligations and responsibilities, between pharmaceutical companies and other types of companies. As a result, to hold pharmaceutical companies especially responsible for saving lives in third world countries is unjustified.

Feminism and public health ethics

This paper sketches an account of public health ethics drawing upon established scholarship in feminist ethics. Health inequities are one of the central problems in public health ethics; a feminist approach leads us to examine not only the connections between gender, disadvantage, and health, but also the distribution of power in the processes of public health, from policy making through to programme delivery. The complexity of public health demands investigation using multiple perspectives and an attention to detail that is capable of identifying the health issues that are important to women, and investigating ways to address these issues. Finally, a feminist account of public health ethics embraces rather than avoids the inescapable political dimensions of public health.

Social justice issues related to uneven distribution of resources

This article examines the social justice issues resulting from the uneven distribution of resources. In this article, justice theories are discussed in relation to two of these issues: lack of adequate food and shelter and inequitable access to an appropriate continuum of health care. Public health nurses have the obligation to deal with the results of poverty and the uneven distribution of resources, which pose a threat to the common good in the United States and throughout the global community.

[Hunger, solidarity, and ethics: discourse analysis of the movement Citizen's Action against Hunger and Poverty and for Life]

The article analyzes the discourse of Citizen's Action against Hunger and Poverty and for Life, a social movement led by sociologist Herbert de Souza (Betinho) that was at its peak between 1993 and 1994. From the perspective of certain concepts and principles introduced and disseminated by so-called bio-ethics, the present study identifies within this campaign an attempt to construct a social movement in Brazil displaying characteristics quite similar to those associated with 'practical ethics'. These features are apparent in the three major principles that the movement applied as strategies for fighting hunger and poverty - to wit, solidarity, partnership, and decentralization.

[Basic ethical aspects of living organ donation]

A characteristic feature of transplanting organs from living donors is that not only patients in need for treatment but also healthy individuals are submitted to medical interventions. Ethical considerations in this field have to deal with the question of property attributes of the human body and conflicts with traditional medical principles. Altruistic organ donation, appreciated by Christianity as a sign of charity, is indeed contradictory to the classic maxim of medical ethics "primum nihil nocere, " meaning "first of all, do not harm." The autonomous choice of a potential donor has to be balanced thoroughly against his personal physical and psychological risks. Apart from organ donation with altruistic motives, commercial incentives or payment for organ donation, which are increasingly under discussion in many nations, need profound ethical reflection. Organ selling does not lead to long-term economic benefit for individual donors in developing countries and is associated with a decline in health. A market system of organ sales would foster exploitation of the poor, and it is substantially doubtful whether autonomy and self determination are valid under circumstances of poverty and coercion. Commodification of the human body risks viewing persons as marketable objects. The human body,however, is an integral element of an individual's personality and not a resource to be removed. It is therefore fundamental that the social good of altruism is preserved as the major principle in organ donation.

Defining equity in health

STUDY OBJECTIVE

To propose a definition of health equity to guide operationalisation and measurement, and to discuss the practical importance of clarity in defining this concept.

DESIGN

Conceptual discussion. Setting, Patients/Participants, and Main results: not applicable.

CONCLUSIONS

For the purposes of measurement and operationalisation, equity in health is the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage-that is, wealth, power, or prestige. Inequities in health systematically put groups of people who are already socially disadvantaged (for example, by virtue of being poor, female, and/or members of a disenfranchised racial, ethnic, or religious group) at further disadvantage with respect to their health; health is essential to wellbeing and to overcoming other effects of social disadvantage. Equity is an ethical principle; it also is consonant with and closely related to human rights principles. The proposed definition of equity supports operationalisation of the right to the highest attainable standard of health as indicated by the health status of the most socially advantaged group. Assessing health equity requires comparing health and its social determinants between more and less advantaged social groups. These comparisons are essential to assess whether national and international policies are leading toward or away from greater social justice in health.

Vulnerable women and neo-liberal globalization: debt burdens undermine women's health in the global South

Contemporary processes of globalization have been accompanied by a serious deterioration in the health of many women across the world. Particularly disturbing is the drastic decline in the health status of many women in the global South, as well as some women in the global North. This paper argues that the health vulnerability of women in the global South is inseparable from their political and economic vulnerability. More specifically, it links the deteriorating health of many Southern women with the neo-liberal economic policies that characterize contemporary economic globalization and argues that this structure is sustained by the heavy burden of debt repayments imposed on many Southern countries. In conclusion, it argues that many Southern debt obligations are not morally binding because they are not democratically legitimate.

‘A future not of riches but of comfort’: The emigration of pauper children from Bristol to Canada, 1870–1915

This article examines the emigration of orphan and deserted children from Bristol to Canada in the late nineteenth and early twentieth centuries. This emigration was organised and financed by the local Boards of Guardians and, as such, raises important questions about the way in which state agencies cared for dependent children. The emigration of Poor Law children is explored in relation to debates about childcare, poverty, racial degeneration and imperialism. Of particular interest is the role played by women in promoting child emigration and the article considers the women's contribution to discourse and practice, both locally and nationally. The dynamics of emigration are analysed by using both British and Canadian sources and the tensions associated with pauper emigration are examined in some detail.