An International Review of Health Technology Assessment Approaches to Prescription Drugs and Their Ethical Principles

In many countries, health technology assessment (HTA) organizations determine the economic value of new drugs and make recommendations regarding appropriate pricing and coverage in national health systems. In the US, recent policy proposals aimed at reducing drug costs would link drug prices to six countries: Australia, Canada, France, Germany, Japan, and the UK. We reviewed these countries' methods of HTA and guidance on price and coverage recommendations, analyzing methods and guidance documents for differences in (1) the methodologies HTA organizations use to conduct their evaluations and (2) considerations they use when making recommendations. We found important differences in the methods, interpretations of HTA findings, and condition-specific carve-outs that HTA organizations use to conduct evaluations and make recommendations. These variations have ethical implications because they influence the recommendations of HTA organizations, which affect access to the drug through national insurance and price negotiations with manufacturers. The differences in HTA approaches result from the distinct political, social, and cultural contexts of each organization and its value judgments. New cost-containment policies in the US should consider the ethical implications of the HTA reviews that they are considering relying on to negotiate drug prices and what values should be included in US pricing policy.

Progress bias versus status quo bias in the ethics of emerging science and technology

How should we handle ethical issues related to emerging science and technology in a rational way? This is a crucial issue in our time. On the one hand, there is great optimism with respect to technology. On the other, there is pessimism. As both perspectives are based on scarce evidence, they may appear speculative and irrational. Against the pessimistic perspective to emerging technology, it has been forcefully argued that there is a status quo bias (SQB) fuelling irrational attitudes to emergent science and technology and greatly hampering useful development and implementation. Therefore, this article starts by analysing the SQB using human enhancement as a case study. It reveals that SQB may not be as prominent in restricting the implementation of emergent technologies as claimed in the ethics literature, because SQB (a) is fuelled by other and weaker drivers than those addressed in the literature, (b) is at best one amongst many drivers of attitudes towards emergent science and technology, and (c) may not be a particularly prominent driver of irrational decision-making. While recognizing that SQB can be one driver behind pessimism, this article investigates other and counteracting forces that may be as strong as SQB. Progress bias is suggested as a generic term for the various drivers of unwarranted science and technology optimism. Based on this analysis, a test for avoiding or reducing this progress bias is proposed. Accordingly, we should recognize and avoid a broad range of biases in the assessment of emerging and existing science and technology in order to promote an open and transparent deliberation.

Does Consumer Engagement in Health Technology Assessment Enhance or Undermine Equity?

Consumer engagement in decisions about the funding of medicines is often framed as a good in and of itself and as an activity that should be universally encouraged. A common justification for calls for consumer engagement is that it enhances equity. In this paper we systematically critique this assumption. We show that consumer engagement may undermine equity as well as enhance it and show that a simple relationship cannot be assumed but must be justified and demonstrated. In concluding, we present a number of challenges that need to be overcome in order for consumer engagement to contribute to health technology assessment in a morally and politically sound manner.

Mobile health ethics and the expanding role of autonomy

Mhealth technology is mushrooming world-wide and, in a variety of forms, reaches increasing numbers of users in ever-widening contexts and virtually independent from standard medical evidence assessment. Yet, debate on the broader societal impact including in particular mapping and classification of ethical issues raised has been limited. This article, as part of an ongoing empirically informed ethical research project, provides an overview of ethical issues of mhealth applications with a specific focus on implications on autonomy as a key notion in the debate. A multi-stage model of references to the potential of mhealth use for strengthening some or other form of self-determination will be proposed as a descriptive tool. It illustrates an assumed continuum of enhanced autonomy via mhealth broadly conceived: from patient to user autonomy, to improved health literacy, and finally to the vision of supra-individual empowerment and democratised, participatory health and medicine as a whole. On closer examination, however, these references are frequently ambivalent or vague, perpetuating the at times uncritical use of established autonomy concepts in medical ethics. The article suggests zooming in on the range of autonomy-related aspects against the backdrop of digital innovation and datafied health more generally, and on this basis add to existing frameworks for the ethical evaluation of mhealth more specifically.

Mapping the rise of digital mental health technologies: Emerging issues for law and society

The use of digital technologies in mental health initiatives is expanding, leading to calls for clearer legal and regulatory frameworks. However, gaps in knowledge about the scale and nature of change impede efforts to develop responsible public governance in the early stages of what may be the mass uptake of 'digital mental health technologies'. This article maps established and emerging technologies in the mental health context with an eye to locating major socio-legal issues. The paper discusses various types of technology, including those designed for information sharing, communication, clinical decision support, 'digital therapies', patient and/or population monitoring and control, bio-informatics and personalised medicine, and service user health informatics. The discussion is organised around domains of use based on the actors who use the technologies, and those on whom they are used. These actors go beyond mental health service users and practitioners/service providers, and include health and social system or resource managers, data management services, private companies that collect personal data (such as major technology corporations and data brokers), and multiple government agencies and private sector actors across diverse fields of criminal justice, education, and so on. The mapping exercise offers a starting point to better identify cross-cutting legal, ethical and social issues at the convergence of digital technology and contemporary mental health practice.

Maqasid al-Shariah Based Islamic Bioethics: A Comprehensive Approach

Maqasid al-Shariah based Islamic bioethics is an Islamic bioethics concept which uses the objectives of the Shariah (maqasid al-Shariah) as its approach in analysing and assessing bioethical issues. Analysis based on maqasid al-Shariah based Islamic bioethics will examine any bioethical issues from three main aspects namely intention, method, and output or final goal of the studied issues. Then, the evaluation will be analysed from human interest hierarchy, inclusivity, and degree of certainty. The Islamic bioethics concept is a manifestation of dynamic Islamic jurisprudence which can overcome new complex and complicated bioethical issues such as tri-parent baby technology issues. Therefore, this article will introduce and explain the concept of maqasid al-Shariah based Islamic bioethics and outline a general guidance of maqasid al-Shariah based Islamic bioethics to determine a maqṣad (objective) based on standards of human good or well-being (maslahah) and harm (mafsadah).

An Ethical Analysis of Coverage With Evidence Development

Sometimes a government or other payer is called on to fund a new health technology even when the evidence leaves a lot of uncertainty. One option is for the payer to provisionally fund the technology and reduce uncertainty by developing evidence. This is called coverage with evidence development (CED). Only-in-research CED, when the payer funds the technology only for patients who participate in the evidence development, raises the sharpest ethical questions. Is the patient coerced or induced into participating? If so, under what circumstances, if any, is this ethically justified? Building on work by Miller and Pearson, we argue that patients have a right to funding for a technology only when the payer can be confident that the technology provides reasonable value for money. Technologies are candidates for CED precisely because serious questions remain about value for money, and therefore patients have no right to technologies under a CED arrangement. This is why CED induces rather than coerces. The separate question of whether the inducement is ethically justified remains. We argue that CED does pose risks to patients, and the worse these risks are, the harder it is to justify the inducement. Finally, we propose conditions under which the inducement could be ethically justified and means of avoiding inducement altogether. We draw on the Australian context, and so our conclusions apply most directly to comparable contexts, where the payer is a government that provides universal coverage with a regard for cost-effectiveness that is prominent and fairly clearly defined.

Evaluating and Valuing Drugs for Rare Conditions: No Easy Answers

We find ourselves in an era of unprecedented growth in the development and use of so-called "orphan" drugs to treat rare diseases, which are poised to represent more than one-fifth of pharmaceutical expenditures by 2022. This widespread use has been facilitated by legislative and regulatory incentives in both the United States and abroad, yet US payers and health systems have not yet made a concerted effort to understand whether and how rare diseases require special considerations on their part and how to adapt traditional methods of health technology assessment and economic evaluation to accommodate these situations. In this article, we explore the general ethical dilemmas that rare diseases present, steps taken by health technology assessment bodies worldwide to define the level of rarity that would necessitate special measures and the modifications to their assessment and valuation processes needed, and the contextual components for rare-disease evaluation that lie outside of the assessment framework as a guide to US decision makers on constructing a formal and relevant process stateside.

Appropriate ethics review is required

Health leaders manage many types of risk. One type of risk that may be underrecognized is the ethical risk in the many projects and activities that are done regularly besides research (eg, program evaluation, quality improvement, and health innovation). Applying clinical, personal, professional, and organizational ethics can help address the risks but are insufficient by themselves or in combination. Each different type of project or activity requires an ethics review that is appropriate for that activity. Health leaders must first acknowledge that ethical risks exist in many of the activities occurring in their organization and then support the different types of ethics review required to adequately protect and respect people and their information.

Une analyse éthique appropriée s'impose

Les leaders en santé gèrent de nombreux types de risques. Le risque éthique associé aux multiples projets et activités, réalisés régulièrement hors du secteur de la recherche, est probablement négligé (p. ex., évaluation de programmes, amélioration de la qualité et innovation en santé). La mise en application de l'éthique clinique, personnelle, professionnelle et organisationnelle peut contribuer à atténuer les risques, mais ensemble ou séparément, ces divers types d'éthique ne suffisent pas. Chaque type de projet ou d'activité doit être assorti d'une analyse éthique qui lui est adaptée. Les leaders en santé doivent d'abord prendre conscience du fait que de nombreuses activités réalisées au sein de leur organisation comportent un risque éthique, puis soutenir les divers types d'analyse éthique nécessaires pour bien protéger et respecter les individus et leurs renseignements personnels.

Innovation Promises and Evidence Realities

Over the past year media outlets and scientific and bioethics journals have reported about several medical and scientific innovations touted as having the potential to fundamentally change not only how diseases and disorders are diagnosed and treated but even how to alter the genomes of future generations. The purported "miracle" blood-testing technology of Theranos and the potential use of the genome editing technology CRISPR-Cas9 to modify human and nonhuman organisms reflect dramatic advances in scientific understanding about the biological mechanisms of humans and other living organisms. Yet evidence about whether these and other innovative biomedical technologies are safe and effective and lead to improved health outcomes for patients young and old is often in dispute. How to assess the safety and effectiveness of innovative biomedical technologies, who should be involved in that effort, and how to define risks and benefits of those technologies are questions at the intersection of values, interests, and politics.

ETHICS, EMBRYOS, AND EVIDENCE: A LOOK BACK AT WARNOCK

The Report of the Committee of Inquiry into Human Fertilisation and Embryology, the Warnock Report, forms the basis of the UK legislation on embryo research, and its influence continues to be felt, even though over 30 years have passed since its publication. The Warnock Committee was the first of its kind to consider how advancements in human fertilisation and embryology should be regulated. This article examines the evidence submitted to the Warnock Committee, upon which its members ultimately reached their conclusions. With ongoing debate as to the status of the human embryo, it is important to recognise that the legislative position is one that was reached after extensive consultation and consideration of submitted evidence by the Warnock Committee. This article considers the differing ethical viewpoints that were expressed by organisations both prior and post-publication of the Warnock Report, and how the Committee used that evidence to reach their conclusions, and ultimately calls for a new Warnock-style committee.

A matter of accuracy. Nanobiochips in diagnostics and in research: ethical issues as value trade-offs

The paper deals with the introduction of nanotechnology in biochips. Based on interviews and theoretical reflections, it explores blind spots left by technology assessment and ethical investigations. These have focused on possible consequences of increased diffusability of a diagnostic device, neglecting both the context of research as well as increased accuracy, despite it being a more essential feature of nanobiochip projects. Also, rather than one of many parallel aspects (technical, legal and social) in innovation processes, ethics is considered here as a ubiquitous system of choices between sometimes antagonistic values. Thus, the paper investigates what is at stake when accuracy is balanced with other practical values in different contexts. Dramatic nanotechnological increase of accuracy in biochips can raise ethical issues, since it is at odds with other values such as diffusability and reliability. But those issues will not be as revolutionary as is often claimed: neither in diagnostics, because accuracy of measurements is not accuracy of diagnostics; nor in research, because a boost in measurement accuracy is not sufficient to overcome significance-chasing malpractices. The conclusion extends to methodological recommendations.

Social and ethical analysis in health technology assessment

This paper presents a review of the domestic and international literature on the assessment of the social and ethical implications of health technologies. It gives an overview of the key concepts, principles, and approaches that should be taken into account when conducting a social and ethical analysis within health technology assessment (HTA). Although there is growing consensus among healthcare experts that the social and ethical ramifications of a given technology should be examined before its adoption, the demand for this kind of analysis among policy-makers around the world, including in Thailand, has so far been lacking. Currently decision-makers mainly base technology adoption decisions using evidence on clinical effectiveness, value for money, and budget impact, while social and ethical aspects have been neglected. Despite the recognized importance of considering equity, justice, and social issues when making decisions regarding health resource allocation, the absence of internationally-accepted principles and methodologies, among other factors, hinders research in these areas. Given that developing internationally agreed standards takes time, it has been recommended that priority be given to defining processes that are justifiable, transparent, and contestable. A discussion of the current situation in Thailand concerning social and ethical analysis of health technologies is also presented.

The application of economics concepts to stratified medicine--use of health economics data to support market access for stratified medicine interventions

Stratified medicine (SM), as opposed to empirical medicine, is the practice of using biomarkers or diagnostic tests to guide the choice of therapeutic treatments. The link between the diagnostic test and the therapy provides new opportunities for value creation and may strengthen the value proposition to pricing and reimbursement authorities. However, SM provides new challenges for the value assessment process, in particular health technology assessment (HTA) and pricing and reimbursement (P&R) decisions. Although health economics (HE) should be relevant for all stakeholders, not all stakeholders are comfortable with analysis/interpretation of economic data relevant to SM interventions as this approach is still in an early/emergent stage in most markets. This article addresses how different stakeholders are using health economic data in the overall value of information analysis to inform prioritization and reimbursement of SM interventions. Findings of an expert discussion outlines key challenges affecting various stakeholders when applying health economic data in the healthcare decision-making process for SM interventions.

The prevention of postmenopausal osteoporotic fractures: results of the Health Technology Assessment of a new antiosteoporotic drug

OBJECTIVE

The Health Technology Assessment (HTA) approach was applied to denosumab in the prevention of osteoporotic fractures in postmenopausal women.

METHOD

Epidemiological, clinical, technical, economic, organizational, and ethical aspects were considered. Medical electronic databases were accessed to evaluate osteoporosis epidemiology and therapeutical approaches. A budget impact and a cost-effectiveness analyses were performed to assess economic implications. Clinical benefits and patient needs were considered with respect to organizational and ethical evaluation.

RESULTS

In Italy around four millions women are affected by osteoporosis and have a higher risk for fractures with 70,000 women being hospitalized every year. Bisphosphonates and strontium ranelate are recommended as first line treatment for the prevention of osteoporotic fractures. Denosumab is effective in reducing vertebral, nonvertebral, and hip/femoral fractures with an advantage of being administered subcutaneously every six months. The budget impact analysis estimated a reduction in costs for the National Health Service with the introduction of denosumab. Furthermore, the economic analysis demonstrated that denosumab is cost-effective in comparison to oral bisphosphonates and strontium ranelate. Denosumab can be administered in outpatients by involving General Practitioners in the management. Ethical evaluation is positive because of its efficacy and compliance.

CONCLUSION

Denosumab could add value in the prevention of osteoporotic fractures.

Can the NICE "end-of-life premium" be given a coherent ethical justification?

In 2009 the UK National Institute for Health and Clinical Excellence (NICE) announced that its health technology appraisal committees would henceforth give special additional weight to health gains from life-extending end-of-life treatments. This was a response to mounting concern from NICE's stakeholders that effective new drugs for end-stage cancer often fail NICE's standard test of cost effectiveness. This change of policy may be justifiable on procedural grounds as the result of a democratic political process responding to stakeholder concerns. However, according to the "accountability for reasonableness" framework proposed by the philosopher Norman Daniels and endorsed by NICE, there also needs to be transparency about the substantive ethical grounds for public health care resource allocation decisions. In that spirit, I analyze eleven potentially relevant justifications for the NICE "end-of-life premium," drawn from the economics and philosophy literature: (1) rule of rescue, (2) fair chances, (3) ex post willingness to pay, (4) caring externality, (5) financial protection, (6) symbolic value, (7) diminishing marginal value of future life years, (8) concentration of benefits, (9) dread, (10) time to set your affairs in order, and (11) severity of illness. I conclude that none of them yields a coherent ethical justification for the NICE end-of-life premium.

Ethical evaluation model for technologies. the role of medical technology in the development of autonomy in diabetes patient

Romanian Government Decision (GD) No. 8/2012 amending and supplementing GD No. 144/2010 regarding the function and organization structures of the Ministry of Health defines health technology assessment (HTA) as "a systematic and multidisciplinary analysis of the existing and new medical technologies, through which medical, economic, social, ethical and organizational information are synthesized so that medical technologies to be used in a transparent and unbiased manner". We propose an ethical assessment model of technologies used in the care of diabetic patients. The nature of this research was exploratory, giving the novelty of this approach to the clinical and social context of Romania.

MATERIAL AND METHODS

The assessment of health technologies used in the care of diabetic patients was based on the following research question: What is the role of health technology in developing autonomy and responsibility in patients suffering from chronic diseases? Individual interviews and focus groups were held from June, 2011 to November, 2012 in Iasi. The criterion for selecting the participants was belonging to the target groups: family doctors or diabetes specialist, patients with type 1 (TID) and type 2 diabetes (T2D), caregivers and other professionals involved in diabetes patient care.

KEYWORDS

The diabetic patient benefits from a specific treatment and has the privilege of self-administering it, his life expectancy and quality of life depending upon the compliance and responsibility he demonstrates.

NICE technology appraisals: working with multiple levels of uncertainty and the potential for bias

One of the key roles of the English National Institute for Health and Clinical Excellence (NICE) is technology appraisal. This essentially involves evaluating the cost effectiveness of pharmaceutical products and other technologies for use within the National Health Service. Based on a content analysis of key documents which shed light on the nature of appraisals, this paper draws attention to the multiple layers of uncertainty and complexity which are latent within the appraisal process, and the often socially constructed mechanisms for tackling these. Epistemic assumptions, bounded rationality and more explicitly relational forms of managing knowledge are applied to this end. These findings are discussed in the context of the literature highlighting the inherently social process of regulation. A framework is developed which posits the various forms of uncertainty, and responses to these, as potential conduits of regulatory bias-in need of further research. That NICE's authority is itself regulated by other actors within the regulatory regime, particularly the pharmaceutical industry, exposes it to the threat of regulatory capture. Following Lehoux, it is concluded that a more transparent and reflexive format for technological appraisals is necessary. This would enable a more robust, defensible form of decision-making and moreover enable NICE to preserve its legitimacy in the midst of pressures which threaten this.

The ethics of attaching research conditions to access to new health technologies

Decisions on which new health technologies to provide are controversial because of the scarcity of healthcare resources, the competing demands of payers, providers and patients and the uncertainty of the evidence base. Given this, additional information about new health technologies is often considered valuable. One response is to make access to a new health technology conditional on further research. Access can be restricted to patients who participate in a research study, such as a randomised controlled trial; alternatively, a new treatment can be made generally available, but only on condition that further evidence is collected (eg, on long-term outcomes and adverse events, in patient registries). The National Institute for Health and Clinical Excellence (NICE), which provides guidance on which new health technologies to make available under the UK's NHS, for example, has made some research conditional recommendations, and the current interest in such options suggests that they are likely to become more prevalent in the future. This paper identifies and discusses the main ethical issues created by this distinctive range of recommendations. We argue that decisions to put research conditions on access to new technologies are compatible with widely accepted values, principles and practices relevant to resource allocation. However, there are important features of these distinctive judgements that must be taken into account by resource allocation decision-making bodies and research ethics committees, and that require new sorts of empirical data.

Corporate social responsibility for nanotechnology oversight

Growing public concern and uncertainties surrounding emerging technologies suggest the need for socially-responsible behavior of companies in the development and implementation of oversight systems for them. In this paper, we argue that corporate social responsibility (CSR) is an important aspect of nanotechnology oversight given the role of trust in shaping public attitudes about nanotechnology and the lack of data about the health and environmental risks of nanoproducts. We argue that CSR is strengthened by the adoption of stakeholder-driven models and attention to moral principles in policies and programs. In this context, we examine drivers of CSR, contextual and leadership factors that influence CSR, and strategies for CSR. To illustrate these concepts, we discuss existing cases of CSR-like behavior in nanotechnology companies, and then provide examples of how companies producing nanomedicines can exhibit morally-driven CSR behavior.

Health technology assessment in oral health

Health-care costs are rising at an alarmingly fast rate worldwide, particularly in developed countries such as the United States. This is predominantly a result of the development of new, high-cost health technologies intended for improved diagnosis and treatment. The purpose of health technology assessment is to systematically determine the true benefits of new technologies, taking into account clinical efficacy/effectiveness and cost as well as societal preference and ethical issues. In this report, the purpose of health technology assessment is explained in light of new developments in oral health technology, particularly intraoral implants. This information is intended to educate and to challenge oral health opinion leaders to consider all of the issues involved in the development and diffusion of new oral health technologies.

A Rawlsian approach to distribute responsibilities in networks

Due to their non-hierarchical structure, socio-technical networks are prone to the occurrence of the problem of many hands. In the present paper an approach is introduced in which people's opinions on responsibility are empirically traced. The approach is based on the Rawlsian concept of Wide Reflective Equilibrium (WRE) in which people's considered judgments on a case are reflectively weighed against moral principles and background theories, ideally leading to a state of equilibrium. Application of the method to a hypothetical case with an artificially constructed network showed that it is possible to uncover the relevant data to assess a consensus amongst people in terms of their individual WRE. It appeared that the moral background theories people endorse are not predictive for their actual distribution of responsibilities but that they indicate ways of reasoning and justifying outcomes. Two ways of ascribing responsibilities were discerned, corresponding to two requirements of a desirable responsibility distribution: fairness and completeness. Applying the method triggered learning effects, both with regard to conceptual clarification and moral considerations, and in the sense that it led to some convergence of opinions. It is recommended to apply the method to a real engineering case in order to see whether this approach leads to an overlapping consensus on a responsibility distribution which is justifiable to all and in which no responsibilities are left unfulfilled, therewith trying to contribute to the solution of the problem of many hands.

Mobile-centric ambient intelligence in health- and homecare-anticipating ethical and legal challenges

Ambient Intelligence provides the potential for vast and varied applications, bringing with it both promise and peril. The development of Ambient Intelligence applications poses a number of ethical and legal concerns. Mobile devices are increasingly evolving into tools to orientate in and interact with the environment, thus introducing a user-centric approach to Ambient Intelligence. The MINAmI (Micro-Nano integrated platform for transverse Ambient Intelligence applications) FP6 research project aims at creating core technologies for mobile device based Ambient Intelligence services. In this paper we assess five scenarios that demonstrate forthcoming MINAmI-based applications focusing on healthcare, assistive technology, homecare, and everyday life in general. A legal and ethical analysis of the scenarios is conducted, which reveals various conflicting interests. The paper concludes with some thoughts on drafting ethical guidelines for Ambient Intelligence applications.

The social nature of engineering and its implications for risk taking

Making decisions with an, often significant, element of risk seems to be an integral part of many of the projects of the diverse profession of engineering. Whether it be decisions about the design of products, manufacturing processes, public works, or developing technological solutions to environmental, social and global problems, risk taking seems inherent to the profession. Despite this, little attention has been paid to the topic and specifically to how our understanding of engineering as a distinctive profession might affect how we should make decisions under risk. This paper seeks to remedy this, firstly by offering a nuanced account of risk and then by considering how specific claims about our understanding of engineering as a social profession, with corresponding social values and obligations, should inform how we make decisions about risk in this context.

Why science cannot be value-free: understanding the rationality and responsibility of science

Against the ideal of value-free science I argue that science is not--and cannot be--value-free and that relevant values are both cognitive and moral. I develop an argument by indicating various aspects of the value-ladenness of science. The recognition of the value-ladenness of science requires rethinking our understanding of the rationality and responsibility of science. Its rationality cannot be seen as merely instrumental--as it was seen by the ideal of value-free science--for this would result in limiting the autonomy of science and reducing scientists to "minds to hire". The scientific rationality must be seen as practical rationality which takes into account the full horizon of values. The scientific responsibility must also be broaden in scope and type. On this basis I draw three practical conclusions concerning the organization of research and training of young scientists, appealing to Plato's claim that those most capable of healing are also those most capable of harming.

The bioterrorism threat and dual-use biotechnological research: an Israeli perspective

Israel has a long history of concern with chemical and biological threats, since several hostile states in the Middle East are likely to possess such weapons. The Twin-Tower terrorist attacks and Anthrax envelope scares of 2001 were a watershed for public perceptions of the threat of unconventional terror in general and of biological terror in particular. New advances in biotechnology will only increase the ability of terrorists to exploit the burgeoning availability of related information to develop ever-more destructive bioweapons. Many areas of modern biological research are unavoidably dual-use by nature. They thus have a great potential for both help and harm; and facilitating the former while preventing the latter remains a serious challenge to researchers and governments alike. This article addresses how Israel might best (1) prevent hostile elements from obtaining, from Israel's biological research system, materials, information and technologies that might facilitate their carrying out a biological attack, while (2) continuing to promote academic openness, excellence and other hallmarks of that system. This important and sensitive issue was assessed by a special national committee, and their recommendations are presented and discussed. One particularly innovative element is the restructuring and use of Israel's extensive biosafety system to also address biosecurity goals, with minimal disruption or delay.

Philosophical aspects of dual use technologies

The term dual use technologies refers to research and technology with the potential both to yield valuable scientific knowledge and to be used for nefarious purposes with serious consequences for public health or the environment. There are two main approaches to assessing dual use technologies: pragmatic and metaphysical. A pragmatic approach relies on ethical principles and norms to generate specific guidance and policy for dual use technologies. A metaphysical approach exhorts us to the deeper study of human nature, our intentions, goals, values ideals and social relations when considering dual use technology. Use of science and technology (S and T) is determined by two components of human nature: human intentions and choices. We have drawn a distinction between specific measures, goals and intentions with respect to technologies in order to show that moral judgment about technologies must precede their use. Understanding of our intentionality and values, and our moral ideals, as a measurable, tangible part of the real world is important for the prevention of any possible harm from S and T. In the context of dual use technologies, we stress the importance of three main understandings of human nature: vulnerability, responsibility and narrative identity. These can become a strong ontological "antidote" to technology's poisoning of modern man. Each new technology can be measured and compared with man's values, traditions and societal norms. This can be done bearing in mind the concept that human nature is not dualistic, but pluralistic. A system of ethical principles that includes the principles of good intentions, the correspondence of goals and means, the balancing of risks and benefits, simplicity, and contextuality, will help ensure that technologies are more humanistic and friendly to human beings.

A note on the definition of "dual use"

While there has been much interest in this topic, no generally accepted definition of dual use has been forthcoming. As a contribution to this issue, it is maintained that three related kinds of things comprise the category of dual use: research, technologies and artefacts. In regard to all three kinds, difficulties are identified in making clear distinctions between those that are and are not dual use. It is suggested that our classification should take account of actual capacities and willingness to make use of these objects for 'bad ends' and not the mere possibility that this could be done, and here three 'contextual factors' are identified. A (provisional) definition is proposed that takes account of threats and risks.

Molecular medicine and concepts of disease: the ethical value of a conceptual analysis of emerging biomedical technologies

Although it is now generally acknowledged that new biomedical technologies often produce new definitions and sometimes even new concepts of disease, this observation is rarely used in research that anticipates potential ethical issues in emerging technologies. This article argues that it is useful to start with an analysis of implied concepts of disease when anticipating ethical issues of biomedical technologies. It shows, moreover, that it is possible to do so at an early stage, i.e. when a technology is only just emerging. The specific case analysed here is that of 'molecular medicine'. This group of emerging technologies combines a 'cascade model' of disease processes with a 'personal pattern' model of bodily functioning. Whereas the ethical implications of the first are partly familiar from earlier--albeit controversial--forms of preventive and predictive medicine, those of the second are quite novel and potentially far-reaching.

Why scientific details are important when novel technologies encounter law, politics, and ethics

This paper focuses on the issue of what to do if a couple who generates embryos chooses to lawfully, and in their (and my) view, ethnically discard those embryos. Specifically, is it appropriate to use the cells that come from "excess" embryos in medical research instead of discarding them when a couple has ceased trying to have any additional children?

Health technology assessment (HTA): ethical aspects

"HTA is a multidisciplinary process that summarizes information about the medical, social, economic and ethical issues related to the use of a health technology in a systematic, transparent, unbiased, robust manner. Its aim is to inform the formulation of safe, effective, health policies that are patient focused, and seek to achieve best value" (EUnetHTA 2007). Even though the assessment of ethical aspects of a health technology is listed as one of the objectives of a HTA process, in practice, the integration of these dimensions into reports remains limited. The article is focused on four points: 1. the HTA concept; 2. the difficult HTA-ethics relationship; 3. the ethical issues in HTA; 4. the methods for integrating ethical analysis into HTA.

Bioconservatism, bioliberalism, and the wisdom of reflecting on repugnance

We consider the current debate between bioconservatives and their chief opponents--whom we dub bioliberals--about the moral acceptability of human enhancement and the policy implications of moral debates about enhancement. We argue that this debate has reached an impasse, largely because bioconservatives hold that we should honour intuitions about the special value of being human, even if we cannot identify reasons to ground those intuitions. We argue that although intuitions are often a reliable guide to belief and action, there are circumstances in which they are not reliable. Intuitions--including intuitions about enhancement--are subject to various cognitive biases rendering them unreliable in some circumstances. We argue that many bioconservative intuitions about enhancement are examples of such unreliable intuitions. Given this, it is unrealistic of bioconservatives to expect others to rely on their unexamined intuitions. Furthermore, refusing to engage in debates about the reasons and values that underpin their intuitions about enhancement will have the effect of making bioconservative voices less relevant in policy debates about enhancement than they would otherwise be.

The ethics of expectations: biobanks and the promise of personalised medicine

Expectations play a major role in 'driving' biotechnology research and development. However, their ethical significance has been largely overlooked. This article examines the dynamics and ethics of expectations surrounding biotechnologies, focusing on biobanks and the promise of personalised medicines. It explores the personal and social implications of expectations, especially where technologies fail to eventuate. The article identifies the claims and practices that support the expectations pertaining to biotechnologies and some of the factors that work against the fulfilment of predicted innovations. It is argued that the role of expectations in shaping thinking and action needs to be taken seriously by those who are concerned about the ethical implications of biotechnologies.

Ethical, legal, and social issues in health technology assessment for prenatal/preconceptional and newborn screening: a workshop report

Prenatal/preconceptional and newborn screening programs have been a focus of recent policy debates that have included attention to ethical, legal, and social issues (ELSIs). In parallel, there has been an ongoing discussion about whether and how ELSIs may be addressed in health technology assessment (HTA). We conducted a knowledge synthesis study to explore both guidance and current practice regarding the consideration of ELSIs in HTA for prenatal/preconceptional and newborn screening. As the concluding activity for this project, we held a Canadian workshop to discuss the issues with a diverse group of stakeholders. Based on key workshop themes integrated with our study results, we suggest that population-based genetic screening programs may present particular types of ELSIs and that a public health ethics perspective is potentially highly relevant when considering them. We also suggest that approaches to addressing ELSIs in HTA for prenatal/preconceptional and newborn screening may need to be flexible enough to respond to diversity in HTA organizations, cultural values, stakeholder communities, and contextual factors. Finally, we highlight a need for transparency in the way that HTA producers move from evidence to conclusions and the ways in which screening policy decisions are made.

Public healthcare resource allocation and the Rule of Rescue

In healthcare, a tension sometimes arises between the injunction to do as much good as possible with scarce resources and the injunction to rescue identifiable individuals in immediate peril, regardless of cost (the "Rule of Rescue"). This tension can generate serious ethical and political difficulties for public policy makers faced with making explicit decisions about the public funding of controversial health technologies, such as costly new cancer drugs. In this paper we explore the appropriate role of the Rule of Rescue in public resource allocation decisions by health technology funding advisory bodies such as the National Institute for Health and Clinical Excellence. We consider practical approaches to operationalising the Rule of Rescue from Australia and the UK before examining the relevance of individual moral imperatives to public policy making. We conclude that that whilst public policy makers in a humane society should facilitate exceptional departures from a cost effectiveness norm in clinical decisions about identified individuals, it is not so obvious that they should, as a matter of national public policy, exempt any one group of unidentified individuals within society from the rules of opportunity cost at the expense of all others.

Engineering with uncertainty: monitoring air bag performance

Modern engineering is complicated by an enormous number of uncertainties. Engineers know a great deal about the material world and how it works. But due to the inherent limits of testing and the complexities of the world outside the lab, engineers will never be able to fully predict how their creations will behave. One way the uncertainties of engineering can be dealt with is by actively monitoring technologies once they have left the development and production stage. This article uses an episode in the history of automobile air bags as an example of engineers who had the foresight and initiative to carefully track the technology on the road to discover problems as early as possible. Not only can monitoring help engineers identify problems that surface in the field, it can also assist them in their efforts to mobilize resources to resolve problem.

The good engineer: giving virtue its due in engineering ethics

During the past few decades, engineering ethics has been oriented towards protecting the public from professional misconduct by engineers and from the harmful effects of technology. This "preventive ethics" project has been accomplished primarily by means of the promulgation of negative rules. However, some aspects of engineering professionalism, such as (1) sensitivity to risk (2) awareness of the social context of technology, (3) respect for nature, and (4) commitment to the public good, cannot be adequately accounted for in terms of rules, certainly not negative rules. Virtue ethics is a more appropriate vehicle for expressing these aspects of engineering professionalism. Some of the unique features of virtue ethics are the greater place it gives for discretion and judgment and also for inner motivation and commitment. Four of the many professional virtues that are important for engineers correspond to the four aspects of engineering professionalism listed above. Finally, the importance of the humanities and social sciences in promoting these virtues suggests that these disciplines are crucial in the professional education of engineers.

Payment to healthcare professionals for patient recruitment to trials: systematic review and qualitative study

OBJECTIVES

To review UK guidelines regarding the use of financial incentives for healthcare professionals to become involved in clinical trials, and to survey perceptions and current practice.

DATA SOURCES

Electronic databases were searched from inception to June 2006. Interviews were held with NHS healthcare professionals, research managers from the pharmaceutical industry and members of the public.

REVIEW METHODS

From the searches, 634 identified studies were assessed for inclusion in the systematic review, but only three met the criteria for data extraction. Fifty-eight individuals were interviewed: 38 chief investigators, six non-research active clinicians, eight public and six pharmaceutical managers. Investigators were selected from those funded by the HTA Programme, the other by 'snowballing' and personal contact.

RESULTS

The evidence from the literature was limited and inconclusive. In UK guidelines, the issues around payments to clinicians or patients were implied rather than stated, usually linked to discussion of conflict of interest and disclosure of any such conflicts. Developments in NHS research governance had led to increased transparency in all payments for research participation and for payments to be made to NHS Trusts rather than individual clinicians. While reimbursement of costs incurred by research was strongly supported by the interviewees, payments to incentivise recruitment were not. A code of practice was suggested for payments in publicly funded trials, which was closely linked to the principles of Good Clinical Practice in research. Factors such as interest in the topic, scope for patient benefit and good communication were considered more important than payment. Interviews with the general public indicated low levels of awareness of the existence of payments to clinicians linked to patient recruitment in trials, and unanimous support for full disclosure. Interviews with managers in the pharmaceutical industry showed greater familiarity with payments for research involvement. GPs were seen as the only group for whom scope existed for individual payments. Concerns were expressed by the pharmaceutical company interviewees at the rising cost of research and unnecessary bureaucracy.

CONCLUSIONS

The ethical stances outlined in Good Clinical Practice in research were widely endorsed by the three groups interviewed. These allow reasonable payments to clinicians, subject to disclosure of any possible conflicts of interest. The potential for incentivising clinicians to recruit was limited as any payments should be based on the cost of inputs and should not be made to individuals but to their host organisation. NHS professionals were concerned that payments could damage the quality of research and also considered full disclosure to patients as challenging. Patients and members of the public favoured full disclosure and payment of expenses to patients involved in research. Pharmaceutical company interviewees viewed payment to the NHS for all research activities as normal and highly regulated. They complained that the prices charged were high and so variable that they required benchmarking. Considerable scope exists for compiling data on the factors that help and hinder the progress of clinical trials and also for experimenting with different incentives to encourage involvement in clinical research. Further research should focus on improved reporting of those organisational aspects of trials that are known to affect recruitment; retrospective analysis of the factors associated with different levels of recruitment to RCTs; prospective comparative research on trial recruitment; qualitative research on participants' experiences of being involved in different kinds of trials, and proposals to include within trials experiments with payments methods.

Public dialogue and xenotransplantation

Toi te Taiao: the Bioethics Council was established in 2002 to enhance New Zealand's understanding of the cultural, ethical and spiritual aspects of biotechnology and ensure that the use of biotechnology has regard for the values held by New Zealanders. In 2005, the Bioethics Council focused on xenotransplantation. A series of dialogue events were held, the public had the opportunity to participate in an online discussion forum and were able to make written submissions. There is worldwide interest in the potential of this biotechnology to cure or alleviate a number of serious health conditions. However, there are concerns about the risks, especially the potential for cross species infection. Such risks have not yet been reliably quantified, but any decision about safety and effectiveness is also about cultural, ethical and spiritual factors. This paper considers some of the outcomes from the dialogue process and the reflections of the Bioethics Council on these. It contrasts the process with that of classic consultation and concludes that, although the process may be more costly and time consuming than the traditional consultative approach, it enables the role of science to be appreciated in its full context, including appreciation of the uncertainties of natural systems and the relevance of cultural, ethical and spiritual human values. It will be suggested that the public are able to interweave ethical concerns with scientific knowledge to engage in meaningful dialogue, resulting in useful recommendations.