Defying the will of the people: The US Supreme Court overturns right to abortion

On June 24, 2022, the US Supreme Court issued its ruling in the landmark case Dobbs v Jackson Women's Health Organization that overturned the constitutional right to abortion with a decision that opposes the will of the majority of Americans. Two earlier Supreme Court decisions had established and upheld that constitutional right for almost 50 years. Now, however, a "super majority" of the Court (6 of its 9 members) has voted to leave laws regarding abortion to the individual states. As soon as the Court's final decision was announced, demonstrations began in front of the Supreme Court in Washington, DC and throughout many states and cities. At the same time, anti-abortion crowds celebrated their victory in the streets, an indication of how polarised the United States has become.

Abortion laws in the United States: Turning the calendar back 50 years?

Just as nations around the world have begun to revise their laws that restrict women's access to safe, legal abortions, the United States is moving rapidly in the opposite direction. The past few years have seen several countries in Latin America enact new legislation; these include Argentina, Mexico, and Colombia as well as Chile [1], which formerly had an absolute ban that prohibited abortion even to save the life of the pregnant woman. In Africa, Tunisia, Zambia, South Africa, and other countries have loosened their restrictions on abortion [2]. In the US, despite nearly 50 years of having a constitutionally protected right to abortion, women now face an array of current and pending restrictions in about half of the fifty states. A case before the Supreme Court promises to upend that constitutional right. Recent developments leading up to the Court's decision promise to reverse a half century of women's right to abortion in the United States. When hard-won rights such as this are overturned, it not only requires an explanation; it also calls for a look at what other well-established structures are at risk in a liberal democracy.

A new definition for global bioethics: COVID-19, a case study

A truly global bioethics involves cooperation and collaboration among countries. Most of the articles published in bioethics journals address a problem that exists in one or more countries, but the articles typically do not discuss solutions that require collaboration or cooperation. COVAX is one example of proposed international cooperation related to the current COVID-19. pandemic. Yet it is evident that nations have been proceeding on their own with little, if any collaboration. Despite international research ethics guidance from the World Health Organization (WHO), an article published under WHO auspices violates an ethical principle rejecting “double standards” in the conduct of global research. The COVID pandemic provides an opportunity for countries to learn from the recent lack of international cooperation and employ a multi-national strategy in future global health crises.

Operation of research ethics committees in Colombia, Costa Rica, Guatemala, and Mexico: Mesoamerican Project

Objective. To attain a better understanding of the structure and processes of Research Ethics Committees (REC) in the low-and middle-income countries of the Mesoamerican region. The objectives are knowing the operational practices of the RECs regarding project evaluation, training needs, and infrastructure. Materials and methods. The REC training and needs assessment involved an online survey of all the RECs (n=55) identified in Colombia (n=11), Costa Rica (n=5), Guatemala (n=5), and Mexico (n=34). Results. Participants reported inadequate infrastructure for its proper operation (only 49.1 %, or 27/55, have an exclusive office to safeguard files); insufficient administrative staff (47.3%, 26/55), or financial resources to conduct active site monitoring (85.6%, 47/55) toensure the protection of rights and welfare of study participants. Conclusions. Investments in REC member training and infrastructure are needed to ensure compliance of REC evaluations with the standards for ethical conduct of research.

Double standards redux

It is fair to say that nothing is more pressing in today's world than bringing an end to the Covid-19 pandemic. Or to be more precise, if not an end, then the quickest and most effective reduction of mortality and morbidity from the disease in every country where infections exist. The forthcoming theme issue of IJME explores a long-standing ethical concern in research with human beings, focused mainly on a question posed about vaccine research for prevention of Covid-19. Contributors from six continents address the question: In what circumstances - if any ‒ is it ethically acceptable to use a research design in which the control group in a randomised, controlled trial (RCT) receives a placebo instead of a vaccine already approved for emergency use by regulatory bodies? That ethical question is not new.

Integrating public health programs and research after the malaria vaccine implementation program (MVIP): Recommendations for next steps

BACKGROUND

In February 2020, international controversy arose about the ethical acceptability of the WHO Malaria Vaccine Implementation Program (MVIP). Whereas some have argued that this program must be seen as research that is not in line with international ethical standards, notably regarding informed consent and local ethical review, some WHO representatives consider the MVIP as a public health implementation program that need not adhere to these standards.

METHODS

We performed a case analysis in light of the 2016 CIOMS International Ethical Guidelines for Health-related Research involving Humans.

FINDINGS

We argue that the MVIP has a substantial research component, and that it is prudent to therefore apply ethical norms for research involving humans, such as the CIOMS guidelines. Accordingly, we agree that the ethical requirements of informed consent and independent ethical review have not been met. In addition, we are concerned that the study might not meet CIOMS's social value requirement.

RECOMMENDATIONS

We urge WHO to release more details about the process that led to the MVIP program and make the MVIP protocol publicly available. The full protocol should be assessed by the relevant ethics committees, new and already enrolled parents should be informed about the uncertainties under investigation and given a real opportunity to consent or refuse (continued) participation, communities should be engaged, and aspects of MVIP that require alteration in light of ethical review should be altered, if possible. Furthermore, in order to improve good ethical practices, it is necessary to engage in international debate regarding the integration of research and public health programs. Procedurally, vaccine implementation programs that combine both prevention and research should involve the wider international ethics community and ensure participation of the target populations in setting the proper conditions for launching such programs.

Allocating medical resources fairly:the CSG bioethics guide

On April 12, 2020, a bioethics guide for allocating scarce hospital resources during the current Covid-19 pandemic was posted on the website of the Consejo de Salubridad General(CSG) of the Government of Mexico. The guide, entitled Guía bioética para asignación de recursos limitados de medicina crítica en situación de emergencia, was intended as a preliminary document, but the website posting did not describe it as a first step in the process. The publicity resulted in a wide array of comments and criticisms. That first version posted on the CSG website contained an age-based criterion for breaking a tie between two or more medically eligible patients who needed of a ventilator: younger patients would have prefer-ence over older ones. The final version of the guide eliminated that criterion and instead, relied on the leading public health principle, "save the most lives", without regard to personal characteristics other than the possibility of benefitting from the scarce medical resources.

Covid-19: A view from New York

I live in New York City, identified as the epicenter of the Covid-19 pandemic. My view differs from that of many of the millions living in this large metropolitan area who are poor. I am not rich, but I am privileged: I have a retirement income for which I have saved all my working life and I have no debts. I am isolated in my apartment having food delivered. But what if I require hospitalization, from Covid-19 or another medical condition? New York State has guidelines for allocation of scarce ventilators in times of scarcity. The guidelines reject advanced age as a criterion for triage because it discriminates against the elderly. Other proposals contend that priority should be given to those who have not yet ;lived a full life. Allocation guidelines set a priority on saving the most lives, but hard choices remain within that broadly defined goal. Key words: Covid-19 pandemic, New York epicenter, resource allocation, age-based selection, shortage of ventilators, triage committee.

Misrepresenting "Usual Care" in Research: An Ethical and Scientific Error

Comparative effectiveness studies, referred to here as "usual-care" trials, seek to compare current medical practices for the same medical condition. Such studies are presumed to be safe and involve only minimal risks. However, that presumption may be flawed if the trial design contains "unusual" care, resulting in potential risks to subjects and inaccurately informed consent. Three case studies described here did not rely on clinical evidence to ascertain contemporaneous practice. As a result, the investigators drew inaccurate conclusions, misinformed research participants, and subjects' safety was compromised. Before approving usual-care protocols, IRBs and scientific review committees should evaluate the quality and completeness of information documenting usual-care practices. Guidance from governmental oversight agencies regarding evidence-based documentation of current clinical practice could prevent similar occurrences in future usual-care trials. Accurate information is necessary to ensure that trials comply with government regulations that require minimizing research risks to subjects and accurate informed consent documents.

The "Global gag rule": Curtailing women's reproductive rights

The Global gag rule (GGR), originally known as the Mexico City Policy, is a United States policy that limits the reproductive rights of women in many resource-poor countries. In 2018, the US administration of President Donald Trump reinstated this policy, which was first issued by President Ronald Reagan in 1984, and later annulled by two US presidents in the intervening years. The policy prohibits any non-governmental organisation (NGO) outside the US from providing women or couples with family planning information that includes access to abortion, as a condition of receiving US funding. Although the policy is designed to reduce the rate of abortion in countries where NGOs have adopted it, studies have shown the opposite effect. The policy violates fundamental ethical principles, as well as United Nations human rights treaties and action programmes.

Erosion of informed consent in U.S. research

This paper evaluates four recent randomized clinical trials in which the informed consent of participants was either not sought at all, or else was conducted with critical information missing from the consent documents. As these studies have been taking place, various proposals to conduct randomized clinical trials without consent have been appearing in the medical literature. Some of the explanations offered for why it is appropriate to bypass consent or disclosure requirements appear to represent a fundamental misunderstanding of applicable government regulations and even the research enterprise. Others are the result of conceptual disagreements about the importance and application of traditional research ethics norms to 'comparative effectiveness research' and modern research environments. Common among these explanations, however, is a failure to appreciate when a research intervention, rather than merely an observation or review of data, is taking place. Review committees and investigators are failing to see, or choosing to ignore, interventions in the lives of research subjects. When these studies have come to light, government agencies with oversight authority have done little or backed down. Prestigious medical journals have published research results knowing that the required consent was not obtained, or they have stood by the published studies even after the inadequacy of consent is discovered. This article critically examines this erosion of consent in theory and practice and calls for restoring the requirement of informed consent to its proper place as a priority in human subjects research.

Challenges Working with Presidential Bioethics Commissions

Presidential commissions come and go by design, and it is reasonable to wonder about the impact of their recommendations. I have been involved in the work of two presidential commissions: as a member of the Advisory Committee on Human Radiation Experiments (from 1994 to 1995) and as senior consultant to the National Bioethics Advisory Commission (from 1999 to 2000) for its report on multinational research. I continue to reflect on and look for the impact of both these commissions. ACHRE's charter included the review of experiments with ionizing radiation sponsored or conducted by the United States government since the 1940s. The committee was also charged with investigating specific intentional releases of radiation into the environment. ACHRE had a somewhat unique difficulty built into its work: the need to make retrospective ethical judgments. With the National Bioethics Advisory Commission, my main role as senior consultant consisted of writing chapters of the report on multinational research for the commissioners' approval. A more important concern for me as a hired consultant was how to maintain intellectual and moral integrity. Unlike when writing scholarly papers, where I can express my own views, when I was drafting text for a presidential commission, the commissioners' views took precedence over my own when we disagreed. I wondered, how much could I comply with the commissioners' positions without compromising my own integrity?

Conflict of interest and bias in publication

In his excellent article about commercial conflict of interest, Mark Wilson quotes Dennis Thompson, a political scientist who provided a searching analysis of the concept of conflict of interest (Col). Using Thompson's analysis, Wilson writes: "Determining whether factors such as ambition, the pursuit of fame and financial gain had biased a judgment was challenging. Motives are not always clear to either the conflicted party or to an outside observer." In this commentary, I aim to broaden the discussion beyond the narrowly commercial aspects of Col. I argue that bias can be introduced in major scientific journals by the editors' choices and policies. The context is a controversy that erupted in 2013 over the adequacy of informed consent in a clinical trial involving extremely premature infants. In this, as in Wilson's example, the players included the New England Journal of Medicine (NEJM), as well as the highest officials of the US National Institutes of Health (NIH).

Translating PrEP effectiveness into public health impact: key considerations for decision-makers on cost-effectiveness, price, regulatory issues, distributive justice and advocacy for access

INTRODUCTION

The extraordinary feat of proving the effectiveness of oral pre-exposure prophylaxis (PrEP) in clinical trials in different populations in a variety of settings may prove to have been easier than ensuring it is used well. Decision-makers must make difficult choices to realize the promise of antiretroviral prophylaxis for their countries. This paper outlines key economic, regulatory and distributive justice issues that must be addressed for effective and acceptable PrEP implementation.

DISCUSSION

In considering the role that PrEP can play in combination prevention programmes, decision-makers must determine who can benefit most from PrEP, how PrEP can be provided safely and efficiently, and what kind of health system support will ensure successful implementation. To do this, they need contextualized information on disease burden by population, analyses of how PrEP services might best be delivered, and projections of the human resource and infrastructure requirements for each potential delivery model. There are cost considerations, varying cost-effectiveness results and regulatory challenges. The principles of ethics can inform thorny discussions about who should be prioritized for oral PrEP and how best to introduce it fairly. We describe the cost-effectiveness of PrEP in different populations at higher risk of HIV exposure, its price in low- and middle-income countries, and the current regulatory situation. We explore the principles of ethics that can inform resource allocation decision-making about PrEP anchored in distributive justice, at a time when universal access to antiretroviral treatment remains to be assured. We then highlight the role of advocacy in moving the PrEP agenda forward.

CONCLUSIONS

The time is ripe now for decisions about whether, how and for whom PrEP should be introduced into a country's HIV response. It has the potential to contribute significantly to high impact HIV prevention if it is tailored to those who can most benefit from it and if current regulatory and pricing barriers can be overcome. Advocacy at all levels can help inform decision-making and push the access agenda to avert HIV infections among those at highest risk of HIV exposure. The benefits will accrue beyond the individual level to slow HIV transmission at the population level.

More on SUPPORT: the controversy continues

The article by Sunita VS Bandewar in the January-March issue does an excellent job of describing the controversy over informed consent in the SUPPORT clinical trial. As one of the authors of the duelling articles Bandewar cites, I commend the author's conclusions calling for disclosure not only of randomisation in so-called "standard of care" clinical trials, but also the comprehensive disclosure of risks in this type of research (also known as "comparative effectiveness research [CER]"). Bandewar surmises that the disclosure of randomisation could result in a "much higher chance of patients declining to participate in a randomised trial"; and that this may be one of the motives of those who argue for non-disclosure of randomisation. In fact, at least some supporters of limited disclosure of the risks in CER trials have expressly acknowledged their concerns about the recruitment of participants if all the risks of "standard of care" treatments are mentioned in the consent forms.

Can one do good medical ethics without principles?

The criteria for determining what it is to do good medical ethics are the quality of ethical analysis and ethical justifications for decisions and actions. Justifications for decisions and actions rely on ethical principles, be they the 'famous four' or subsidiary ethical principles relevant to specific contexts. Examples from clinical ethics, research ethics and public health ethics reveal that even when not stated explicitly, principles are involved in ethical justifications. Principles may come into conflict, however, and the resolution of an ethical dilemma requires providing good reasons for preferring one principle over another.

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.

Ethical issues for late-stage trials of multipurpose prevention technologies for HIV and pregnancy

Multipurpose prevention technologies (MPTs) designed to simultaneously prevent pregnancy and HIV could provide urgently needed tools to address unmet sexual and reproductive health needs of women worldwide. Late-stage clinical trials will be complex given the need to demonstrate efficacy for HIV and contraceptive indications simultaneously from a single product. Currently, HIV and pregnancy prevention trials have distinctive design features that will need to be reconciled in MPT trials. This article identifies several ethical issues uniquely associated with this research that will benefit from future deliberation and guidance to ensure that this globally important research can proceed efficiently and expeditiously.

Conducting Health Disparities Research with Criminal Justice Populations: Examining Research, Ethics, and Participation

This study explored the challenges of informed consent and understanding of the research process among Black and Latino men under community supervision (e.g., parole and/or probation). Between February and October 2012, we conducted cognitive face-to-face interviews using open-ended questions on the significant areas of research participation (i.e., the informed consent process, confidentiality, compensation, what is meant by human subject and clinical trials) among 259 men aged 35 to 67 under community supervision in Bronx, New York. Content analysis of the open-ended questions revealed limited knowledge concerning the understanding of research participation. The study participants appeared to generally understand concepts such as compensation after research participation and confidentiality. Participants demonstrated a lack of understanding of certain aspects of the research process-informed consent, human subject, Institutional Review Board, and clinical trials. These findings are informative to researchers conducting studies with criminal justice populations and Institutional Review Boards reviewing research studies.

Informed consent and standard of care: what must be disclosed

The Office for Human Research Protections (OHRP) was correct in determining that the consent forms for the National Institutes of Health (NIH)-sponsored SUPPORT study were seriously flawed. Several articles defended the consent forms and criticized the OHRP's actions. Disagreement focuses on three central issues: (1) how risks and benefits should be described in informed consent documents; (2) the meaning and application of the concept of "standard of care" in the context of research; and (3) the proper role of OHRP. Examination of the consent forms reveals that they failed to disclose the reasonably foreseeable risks of the experimental interventions in the study, as well as the potential for differences in the degree of risk between these interventions. Although the concept of "standard of care" may be helpful in determining the ethical acceptability of other aspects of research, such as clinical equipoise, it is not helpful in discussing consent requirements.

Given financial constraints, it would be unethical to divert antiretroviral drugs from treatment to prevention

Striking advances in HIV prevention have set the stage for renewed debate on setting priorities in the fight against HIV/AIDS. Two new prevention strategies--preexposure prophylaxis and treatment as prevention--use antiretroviral drugs for prevention of HIV/AIDS in addition to treating patients. The potential for success of these new prevention strategies sets up an ethical dilemma: where resources are limited and supplies of lifesaving antiretroviral medications are insufficient to treat those currently living with HIV, how should these resources be divided between treatment and prevention? This article explores several ethical principles used in formulating public health policy. Assuming that limited resources are available for spending on drugs, we conclude that it would be unethical to watch patients with treatable AIDS worsen and die, even with supportive care, so that medications for treatment can be diverted for prevention.

Unconsented HIV testing in cases of occupational exposure: ethics, law, and policy

Postexposure prophylaxis (PEP) has substantially reduced the risk of acquiring human immunodeficiency virus (HIV) after an occupational exposure; nevertheless, exposure to HIV remains a concern for emergency department providers. According to published guidelines, PEP should be taken only when source patients are HIV-positive or have risk factors for HIV. Initiating PEP when source patients are uninfected puts exposed persons at risk from taking toxic drugs with no compensating benefit. Forgoing PEP if the source is infected results in increased risk of acquiring HIV. What should be done if source patients refuse HIV testing? Is it justifiable to test the blood of these patients over their autonomous objection? The authors review current law and policy and perform an ethical analysis to determine if laws permitting unconsented testing in cases of occupational exposure can be ethically justified.

The ethics of sex selection and family balancing

Ethical concerns about the ethics of selecting the sex of a child predate current techniques of prenatal genetic diagnosis (PGD) and sperm sorting. The only methods previously available were highly problematic, as they involved infanticide or abortion of an unwanted sex. PGD is less problematic than the earlier methods, yet still troubling to some because it involves destruction of a healthy embryo and risks to women. The technique of sperm sorting, still in an experimental phase, is the least ethically problematic method, yet opponents argue that sex selection by any means involves sex discrimination and can have undesirable consequences. One such consequence is an imbalance in the sex ratio. This imbalance already exists in some Asian countries that favor male children, but is less likely in Western Europe and North America. There is increasing acceptance of family balancing as a reason for sex selection, but some people remain opposed to broadening the indications for sex selection of offspring beyond family balancing. Nevertheless, parents may have good reasons other than family balancing for choosing the sex of a future child. Such reasons may be justified by the principle of reproductive liberty.

The death of bioethics (as we once knew it)

Fast forward 50 years into the future. A look back at what occurred in the field of bioethics since 2010 reveals that a conference in 2050 commemorated the death of bioethics. In a steady progression over the years, the field became increasingly fragmented and bureaucratized. Disagreement and dissension were rife, and this once flourishing, multidisciplinary field began to splinter in multiple ways. Prominent journals folded, one by one, and were replaced with specialized publications dealing with genethics, reproethics, nanoethics, and necroethics. Mainstream bioethics organizations also collapsed, giving way to new associations along disciplinary and sub-disciplinary lines. Physicians established their own journals, and specialty groups broke away from more general associations of medical ethics. Lawyers also split into three separate factions, and philosophers rejected all but the most rigorous, analytic articles into their newly established journal. Matters finally came to a head with global warming, the world-wide spread of malaria and dengue, and the cost of medical treatments out of reach for almost everyone. The result was the need to develop plans for strict rationing of medical care. At the same time, recognition emerged of the importance of the right to health and the need for global justice in health. By 2060, a spark of hope was ignited, opening the door to the resuscitation of bioethics and involvement of the global community.