Ethics as ritual: smoothing over moments of dislocation in biomedicine

Applications of biomedical R&D currently imply substantial societal concerns. This paper explores, based on semi-structured interviews with scientists in Norway, how biomedical researchers experience and tackle such concerns in their daily work. It shows how ritualised routine responses to dislocatory moments help maintain order in the daily work of the interviewed scientists; they do not address directly but instead smooth over concerns by a ritualised way of using ethics. This may foreclose substantive reflection and function as a stabiliser for 'business as usual'. Overall, the current way of responding to concerns as described by the interviewees may contribute to a depoliticisation of important issues. The paper contributes to sociological work on ethics by linking it to recent discussions on Responsible Research and Innovation (RRI) and by the empirical research presented. The insights can also help improve science policies such as RRI.

Serious Crisis in the Practice of International Health by the World Health Organization: The Commission on Social Determinants of Health

The Commission on Social Determinants of Health (CSDH) is the latest effort by the World Health Organization to improve health and narrow health inequalities through action on social determinants. The CSDH does not note that much work has already been done in this direction, does not make a sufficient attempt to analyze why earlier efforts failed to yield the desired results, and does not seem to have devised approaches to ensure that it will be more successful this time. The CSDH intends to complement the work of the earlier WHO Commission on Macroeconomics and Health, which has not had the desired impact, and it is unclear how the CSDH can complement work that suffers from such serious infirmities. Inadequacies of both commissions reflect a crisis in the practice of international health at the WHO, stemming from a combination of unsatisfactory administrative practices and lack of technical competence to provide insights into the problems afflicting the most needy countries. Often the WHO has ended up distorting the rudimentary health systems of the poor countries, by pressuring them into accepting health policies, plans, and programs that lack sound scientific bases. The WHO no longer seems to take into account historical and political factors when it sets out to improve the health situation in low-income countries—which is supposed to be the focus of the CSDH. An alternative approach is suggested.

Medical sociology as a vocation

This article extends Weber's discussion of science as a vocation by applying it to medical sociology. Having used qualitative methods for nearly 40 years to interpret problems of meaning as they arise in the context of health care, I describe how ethnography, in particular, and qualitative inquiry, more generally, may be used as a tool for understanding fundamental questions close to the heart but far from the mind of medical sociology. Such questions overlap with major policy questions such as how do we achieve a higher standard for quality of care and assure the safety of patients. Using my own research, I show how this engagement takes the form of showing how simple narratives of policy change fail to address the complexities of the problems that they are designed to remedy. I also attempt to explain how I balance objectivity with a commitment to creating a more equitable framework for health care.

Bushido and medical professionalism in Japan

Medical professionalism has become a core topic in medical education. As it has been considered mostly from a Western perspective, there is a need to examine how the same or similar concepts are reflected in a wider range of cultural contexts. To gain insights into medical professionalism concepts in Japanese culture, the authors compare the tenets of a frequently referenced Western guide to professionalism (the physician charter proposed by the American Board of Internal Medicine Foundation, American College of Physicians Foundation, and the European Federation of Internal Medicine) with the concepts of Bushido, a Japanese code of personal conduct originating from the ancient samurai warriors. The authors also present survey evidence about how a group of present-day Japanese doctors view the values of Bushido.Cultural scholars have demonstrated Bushido's continuing influence on Japanese people today. The authors explain the seven main virtues of Bushido (e.g., rectitude), describe the similarities and differences between Bushido and the physician charter, and speculate on factors that may account for the differences, including the influence of religion, how much the group versus the individual is emphasized in a culture, and what emphasis is given to virtue-based versus duty-based ethics.The authors suggest that for those who are teaching and practicing in Japan today, Bushido's virtues are applicable when considering medical professionalism and merit further study. They urge that there be a richer discussion, from the viewpoints of different cultures, on the meaning of professionalism in today's health care practice.

Six paths for the future of social epidemiology

Social epidemiology is now an accepted part of the academic intellectual landscape. However, in many ways, social epidemiology also runs the risk of losing the identity that distinguished it as a field during its emergence. In the present article, we scan the strengths of social epidemiology to imagine paths forward that will make the field distinct and useful to the understanding of population health in future. We suggest 6 paths to such a future, each emerging from promising research trends in the field in which social epidemiologists can, and should, lead in coming years. Each of these paths contributes to the formation of distinct capacities that social epidemiologists can claim and use to elaborate or fill in gaps in the already strong history of social epidemiology. They present an opportunity for the field to build on its strengths and move forward while leading in new and critical areas in population health.

Invited commentary: Off-roading with social epidemiology--exploration, causation, translation

Population health improvements are the most relevant yardstick against which to evaluate the success of social epidemiology. In coming years, social epidemiology must increasingly emphasize research that facilitates translation into health improvements, with continued focus on macro-level social determinants of health. Given the evidence that the effects of social interventions often differ across population subgroups, systematic and transparent exploration of the heterogeneity of health determinants across populations will help inform effective interventions. This research should consider both biological and social risk factors and effect modifiers. We also recommend that social epidemiologists take advantage of recent revolutionary improvements in data availability and computing power to examine new hypotheses and expand our repertoire of study designs. Better data and computing power should facilitate underused analytic approaches, such as instrumental variables, simulation studies and models of complex systems, and sensitivity analyses of model biases. Many data-driven machine-learning approaches are also now computationally feasible and likely to improve both prediction models and causal inference in social epidemiology. Finally, we emphasize the importance of specifying exposures corresponding with realistic interventions and policy options. Effect estimates for directly modifiable, clearly defined health determinants are most relevant for building translational social epidemiology to reduce disparities and improve population health.

Invited commentary: Paths and pathologies of social epidemiology

The article by professors Galea and Link in this issue of the Journal (Am J Epidemiol. 2013;178(6):843-849) is an important contribution to the field of social epidemiology. Their 6 paths provide ample fodder for reflection, debate, and advancement. Although I agree with the thrust and spirit of their recommendations, I argue that if social epidemiology is to advance and become not just more popular but also more useful, we social epidemiologists need to first address our disciplinary pathologies. Among other things, we must embrace macro-to-micro transitions, understand and act on the principles of effect identification, conduct many more experiments, and train students to be not researchers but scientists.

Invited commentary: On the future of social epidemiology--a case for scientific realism

In their article in this issue of the Journal (Am J Epidemiol. 2013;178(6):843-849), Galea and Link identify important heuristics for our discipline. In this commentary, I build upon their ideas by arguing that (1) social epidemiology has become an Asian, European, Latin American, and African rather than just North American endeavor, (2) realism is better suited to social epidemiology than positivism, (3) more work on social mechanisms (social class relations, racial discrimination) is needed to increase the explanatory power of social epidemiology, (4) increased attention on (social) causal models will generate more innovative social interventions, and (5) social interventions should be conducted in full partnerships with affected populations.

Developing a reporting guideline for social and psychological intervention trials

Social and psychological interventions are often complex. Understanding randomised controlled trials (RCTs) of these complex interventions requires a detailed description of the interventions tested and the methods used to evaluate them; however, RCT reports often omit, or inadequately report, this information. Incomplete and inaccurate reporting hinders the optimal use of research, wastes resources, and fails to meet ethical obligations to research participants and consumers. In this paper, we explain how reporting guidelines have improved the quality of reports in medicine, and describe the ongoing development of a new reporting guideline for RCTs: CONSORT-SPI (an Extension for social and psychological interventions). We invite readers to participate in the project by visiting our website, in order to help us reach the best-informed consensus on these guidelines (http://tinyurl.com/CONSORT-study).

[General medicine in the 21st century]

General medicine is the main pivot of our healthcare system. General practitioners' tasks are numerous: front line responsibility, networking coordination, long-term patient care, community medicine and also primary care research. In the framework of general medicine that has been undergoing profound change for many years, we have chosen to develop three of these facets: general practitioners' knowledge of family, psychological, social or environmental factors and their capacity to coordinate with other health workers will help them in their primary and secondary prevention and also quaternary work by sparing patients unnecessary treatment and examinations. General medicine will increasingly become a discipline, one of which specific expertise will be to manage bio-psycho-societal complexity. Multidisciplinary action will be the rule: general practitioners will no longer be able to claim they can deal with all the curative, preventive and health education tasks. And the research in general medicine is essential because general practitioners can deal with over 80% of the health problems identified by patients and because the symptoms leading to the treatment cannot only be studied by laboratory or hospital research.

Beyond EBM: new directions for evidence-based public health

Public health researchers, policy makers, and practitioners agree that health is the outcome of interactions between biological, behavioral, and social determinants. Nonetheless, institutional patterns of research funding and practice remain obstacles to generating research at and between each of these levels. These practices are embedded in historic assumptions about the nature of reality and how it can best be understood. Current debates over the criteria for evaluating public health research have centered on the applicability of the clinical evidence-based medicine (EBM) model to the field of public health. The EBM hierarchy, which is based on traditional scientific assumptions about causality, is insufficient and potentially harmful as the basis for evaluating research on the determinants of health. Yet those who have put forward a critique of EBM have failed to develop a plausible alternative. Critical realism, based on the philosophy of Roy Bhaskar, may provide a way out of the current stalemate, enabling public health researchers from various disciplines and research paradigms to work together, bringing the full weight of scientific knowledge to bear on increasingly complex and global public health problems.

The tempering of medical anthropology: troubling natural categories

This article reviews an approach in medical anthropology that commenced in the early 1980s and that continues to the present day in which biomedical knowledge and practices are systematically incorporated into anthropological analyses. Discussion then focuses on contributions made by feminists and medical anthropologists to the literature on medicalization and resistance, illustrating how the ethnographic approach has been crucial in critically reconceptualizing and situating these concepts historically and cross-culturally. The concept of local biologies is introduced in the third section of the article in creating the argument that the coproduction of biologies and cultures contributes to embodied experience, which, in turn, shapes discourse about the body. Subjective reporting at menopause provides an illustrative case study of local biologies in action. The final part of the article takes up the question of the moral economy of scientific knowledge. Comparative ethnographic work in intensive care units in Japan and North America reveals how a moral economy is put into practice in connection with brain-dead bodies and the procurement of organs from them. Medical anthropological contributions to policy making about biomedical technologies is briefly considered in closing.

[Methodology for the comprehensive evaluation of the quality of performance of activities of medical and social experts]

The paper scientifically substantiates methodology, approaches, criteria, and control indices for assessment of activities of establishments of medical-and-social performance. Most indices for efficiency and certain indices for week points in the work of establishments of the service depend on interaction thereof with curative- and prophylactic institutions; the best results with the problem of prevention of disability and rehabilitation of invalids are supposed to be achieved through collaborative efforts. Other criteria and intermediate indices having an effect on the quality of activities reflect the resource- and trained personnel supplies of establishments of the service, amount of work, organizational measures designed to raise the quality of medical-and-social expert performance.

Social ecology and behavioral medicine: implications for training, practice, and policy

Social ecology offers a conceptual framework for understanding the etiology of multiple health problems and a basis for designing broad-gauge educational, therapeutic, and policy interventions to enhance personal and community well-being. Implications of social ecology for behavioral medicine are considered in relation to the development of diagnostic and therapeutic practices, professional training programs, and health policies implemented at municipal, state, and national levels. By influencing the training and practices of healthcare professionals and the decisions of corporate and community leaders, behavioral medicine can expand the scope and impact of future interventions beyond the health gains achievable through provision of direct services to patient populations. Potential barriers to establishing ecologically based health programs and policies and directions for research at the interface of behavioral medicine, social ecology, and public health are discussed.