Looking Ahead: Addressing Ethical Challenges in Public Health Practice

Ethical challenges in public health can have a significant impact on the health of communities if they impede efficiencies and best practices. Competing needs for resources and a plurality of values can challenge public health policymakers and practitioners to make fair and effective decisions for their communities. In this paper, the authors offer an analytic framework designed to assist policymakers and practitioners in managing the ethical tensions they face in daily practice. Their framework is built upon the following set of six considerations: determining population-level utility of the proposed action; demonstrating evidence of need and effectiveness of actions; establishing fairness of goals and proposed implementation strategies; ensuring accountability; and, assessing expected efficiencies and costs associated with the proposed action. Together, these considerations create a structured guide to assist decision-makers in identifying potential ethical challenges and in assessing the moral considerations that underlie public health practice - and possibly even, if the conditions are met, reduce the creation of ethical tension. Although the authors'empirical experiences provide the basis for the framework advanced here, their approach remains to be tested and evaluated by public health practitioners.     

Responding to the immunoglobulin shortage: a case study

In fall 1997, a shortage of intravenous immunoglobulin (IVIG) developed in the United States because of increased demand for the product, reduced supply, and product recalls. This shortage is a useful model for understanding how our health care system responds to scarcity. Although the U.S. government took steps to inform the medical community of the shortage, with few exceptions, the government did not respond to the shortage in a timely or effective manner. Instead, it took a relatively passive role, leaving IVIG manufacturers and distributors, health care institutions, and clinicians to fend for themselves. The shortage likely had an uneven impact on patients, based on the relative market strength of the health care institutions in which they received care and the individual patient's ability to absorb the increasing out-of-pocket costs of scarce IVIG. Market mechanisms have now largely alleviated the shortage and significantly reduced its detrimental impact on patients. However, future shortages of IVIG or other scarce medical products, such as vaccines and antibiotics, would benefit from more immediate and coordinated efforts not only to make sure that scarce health care resources are distributed in a just manner but also to identify and remedy the sources of health product supply problems.     

Re-Evaluating ‘Best Interests’ in the Wake of Raqeeb v Barts NHS Foundation Trust & Anors

In Raqeeb v Barts NHS Foundation Trust, the latest of a number of cases concerning whether a child can travel abroad for treatment that doctors in the UK do not consider to be in their best interests, the High Court held that the hospital had acted unlawfully by failing to consider the child's rights under EU law when refusing to allow her to travel. Although this derogation could be justified on public policy grounds, as such treatment was, on the facts, in her best interests, no further interference with her rights was justified. In making this finding, the court recognised the ‘stress’ that such a case placed on the best interests test, lending weight to the argument for moving instead to a risk of significant harm threshold for judicial intervention in parental decisions, which better accounts for legitimate differences of value and strikes a better balance under Article 8 ECHR.     

Choosing Healthplans All Together: a deliberative exercise for allocating limited health care resources

CHAT (Choosing Healthplans All Together) is an exercise in participatory decision making designed to engage the public in health care priority setting. Participants work individually and then in groups to distribute a limited number of pegs on a board as they select from a wide range of insurance options. Randomly distributed health events illustrate the consequences of insurance choices. In 1999-2000, the authors conducted fifty sessions of CHAT involving 592 residents of North Carolina. The exercise was rated highly regarding ease of use, informativeness, and enjoyment. Participants found the information believable and complete, thought the group decision-making process was fair, and were willing to abide by group decisions. CHAT holds promise as a tool to foster group deliberation, generate collective choices, and incorporate the preferences and values of consumers into allocation decisions. It can serve to inform and stimulate public dialogue about limited health care resources.     

Surrogacy: is there a case for legal prohibition?

Surrogacy arrangements are a complex and challenging issue for legal regulation. On the one hand, if we wish to promote personal autonomy and enable the infertile to experience parenthood, there is a case for allowing these arrangements to proceed. However, objections to legal sanctioning of surrogacy include concerns for the surrogate and the child born through the surrogacy arrangement. Legally sanctioning surrogacy may also adversely affect social conceptions of women's roles or may be considered a form of commodifying women's reproductive capacities. This article examines these challenges to allowing surrogacy, but concludes that surrogacy should not be legally prohibited.     

Culture,Obesity Stereotypes,Self-Esteem,and the “Thin Ideal”: A Social Identity Perspective

Recent concerns with the increasing prevalence of overweight and obesity among children and adults indicate the need to better understand the psychosocial correlates of weight. We examined the relationships among negative stereotypes of obesity, thin ideal beliefs, perceptions of the causes of obesity and of control over weight, body esteem, and global self-esteem. A negative correlation between beliefs in control over one's weight and self-esteem was mediated by both negative attitudes toward obesity and thin idealization. Additionally, body esteem and gender were related but this relationship was mediated by beliefs in control over weight and valuation of the thin ideal. Central to the theoretical foundation of this research, however, was the observed negative correlation between negative attitudes toward obesity and self-esteem. This relationship was mediated primarily by the belief that obesity is caused by personality shortcomings. This last finding is explained from a social identity perspective.     

Tissue donation: ethical guidance and legal enforceability

The legal and ethical framework regulating the use of tissue donated for medical research in Australia provides clear direction on the appropriate use of donated tissue in many instances. However, this article argues that the current framework may be inadequate to address some of the problems that may arise from misuse of such tissue. It argues that the Human Tissue Acts do not provide a sufficiently broad system of regulation and require updating. It also notes that as much of Australian research practice is regulated through ethics guidelines, which do not have the status of law, in some cases this approach may fail to provide remedies for those whose tissue is used inappropriately.