Ethics of early detection of disease risk factors: A scoping review

BACKGROUND

Scientific and technological advancements in mapping and understanding the interrelated pathways through which biological and environmental exposures affect disease development create new possibilities for detecting disease risk factors. Early detection of such risk factors may help prevent disease onset or moderate the disease course, thereby decreasing associated disease burden, morbidity, and mortality. However, the ethical implications of screening for disease risk factors are unclear and the current literature provides a fragmented and case-by-case picture.

METHODS

To identify key ethical considerations arising from the early detection of disease risk factors, we performed a systematic scoping review. The Scopus, Embase, and Philosopher's Index databases were searched for peer-reviewed, academic records, which were included if they were written in English or Dutch and concerned the ethics of (1) early detection of (2) disease risk factors for (3) disease caused by environmental factors or gene-environment interactions. All records were reviewed independently by at least two researchers.

RESULTS

After screening 2034 titles and abstracts, and 112 full papers, 55 articles were included in the thematic synthesis of the results. We identified eight common ethical themes: (1) Reliability and uncertainty in early detection, (2) autonomy, (3) privacy, (4) beneficence and non-maleficence, (5) downstream burdens on others, (6) responsibility, (7) justice, and (8) medicalization and conceptual disruption. We identified several gaps in the literature, including a relative scarcity of research on ethical considerations associated with environmental preventive health interventions, a dearth of practical suggestions on how to address expressed concerns about overestimating health capacities, and a lack of insights into preventing undue attribution of health responsibility to individuals.

CONCLUSIONS

The ethical concerns arising with the early detection of risk factors are often interrelated and complex. Comprehensive ethical analyses are needed that are better embedded in normative frameworks and also assess and weigh the expected benefits of early risk factor detection. Such research is necessary for developing and implementing responsible and fair preventive health policies.

Water governance diversity across Europe: Does legacy generate sticking points in implementing multi-level governance?

The Water Framework Directive (WFD) aims to protect and improve water quality across Europe through an integrative and multi-level water governance approach. The goal is to ensure that water quality in Europe meets good ecological status by 2027. Whilst the WFD has been hailed as a cornerstone for governance innovation in water management, most EU member states (MS) still struggle to achieve good ecological status of their waters. The realignment to a multi-level governance structure under the WFD is discretionary, and has generated diversity in WFD multi-level governance implementation approaches and final governance arrangements across MS. This diversity may contribute to low goal achievement and weak compliance. This paper investigates how visual impressions of legislative structure across nine MS can illustrate and contribute to understanding the differences in multi-level implementation of WFD and associated water protection directives. We explore, in-depth, the drivers of visual differences in Portugal, Germany (Lower Saxony) and France. We hypothesise that many of the challenges of WFD implementation, and resulting governance arrangements can be explained in terms of the legacy effects of previous water governance choices. With this conceptual framework of investigating the history and legacy, we found the three in depth studies have had different starting points, paths, and end points in their water governance, with sticking points influencing the decision-making processes and compliance required by the WFD. Sticking points include the complexity of existing water governance structures, lobbying by different sectors, and the mandatory WFD timeline for implementation. Portugal had to resolve its focus on water infrastructure and engineering to enable a re-focus on water quality. France and Portugal experienced 'top down' governance at different points in time, slowing the shift to a multi-level governance system. Lower Saxony, representing just one of 16 federal state systems in Germany, highlighted the complex historic governance structures which cannot easily be restructured, generating a layering effect where new governance systems are fitted to old governance systems. We conclude that there is a need to implement a hybrid approach to water governance and WFD implementation including decentralisation (discretionary) to ensure collaboration and engagement of stakeholders at the local level. This hybrid governance system should run in parallel with a centralised (mandatory) governance and regulatory system to enable national environmental standards to be set and enforced. Such systems may provide the best of both worlds (bottom-up involvement of stakeholders meeting top-down goal achievements) and is worthy of further research.

Protection of drinking water resources from agricultural pressures: Effectiveness of EU regulations in the context of local realities

Over the last decades, nutrients and pesticides have proved to be a major source of the pollution of drinking water resources in Europe. Extensive legislation has been developed by the EU to protect drinking water resources from agricultural pollution, but the achievement of water quality objectives is still an ongoing challenge throughout Europe. The study aims to identify lessons that can be learnt about the coherence and consistency of the application of EU regulations, and their effects at the local level, using qualitative expert data for 13 local to regional governance arrangements in 11 different European countries. The results show that the complexities and inconsistencies of European legislation drawn up to protect drinking water resources from agricultural pollution come forward most explicitly at local level where cross-sectoral measures have to be taken and effects monitored. At this local level, rather than facilitate, they hamper efforts to achieve water quality objectives. The upcoming revision of the Water Framework Directive (WFD) should strengthen the links between the different directives and how they could be applied at local level. In addition, a more facilitated cross-sectoral approach should be adopted to improve stakeholder networks, between institutional levels and hydrological scales, to attain policy objectives at local level.

The COVID-19 pandemic and global environmental change: Emerging research needs

The outbreak of COVID-19 raised numerous questions on the interactions between the occurrence of new infections, the environment, climate and health. The European Union requested the H2020 HERA project which aims at setting priorities in research on environment, climate and health, to identify relevant research needs regarding Covid-19. The emergence and spread of SARS-CoV-2 appears to be related to urbanization, habitat destruction, live animal trade, intensive livestock farming and global travel. The contribution of climate and air pollution requires additional studies. Importantly, the severity of COVID-19 depends on the interactions between the viral infection, ageing and chronic diseases such as metabolic, respiratory and cardiovascular diseases and obesity which are themselves influenced by environmental stressors. The mechanisms of these interactions deserve additional scrutiny. Both the pandemic and the social response to the disease have elicited an array of behavioural and societal changes that may remain long after the pandemic and that may have long term health effects including on mental health. Recovery plans are currently being discussed or implemented and the environmental and health impacts of those plans are not clearly foreseen. Clearly, COVID-19 will have a long-lasting impact on the environmental health field and will open new research perspectives and policy needs.