Bioengineers, health-care technology and bioethics

Technology has created moral dilemmas in recent years creating an increased interest in the field of bioethics, which affects engineers in biomedicine, physicians, other health-care professionals, and society in general. For example devices like the kidney dialysis machine or Nuclear Magnetic Resonance (NMR) diagnostic scanner demonstrate state-of-the-art capabilities, yet they are very expensive. Therefore, standards of the past involving health care and allocation of resources are changing, and professionals must be aware of this change, as well as the responsibility for complete testing and review during the research and development process of medical devices. In this paper, we illustrate technological impact and stress the necessity of an understanding of ethics in order to deal effectively with product liability, conflicts of interests, and allocation of scarce resources. Hopefully, this will result in awareness and education in ethics and professional responsibilities.     

The diffusion of virtual communities in health care: concepts and challenges

OBJECTIVE: This paper providers an overview and discussion of virtual communities in health care. Furthermore, we aim to discuss in this context ethical, legal and technical considerations and the current status of research in this domain. METHODS: We searched medical and social science literature including survey studies, randomized and non-randomized controlled interventions and reviews. RESULTS: The literature indicates that a virtual community in health care as a group of people using telecommunication with the purposes of delivering health care and education, and/or providing support, covers a wide range of clinical specialties, technologies and stakeholders. Examples include peer-to-peer networks, virtual health care delivery and research teams. Ethical challenges including the concepts of identity and deception, privacy and confidentiality and technical issues, such as sociability and usability are discussed. CONCLUSION: Virtual communities may empower patients and enhance coordination of care services; however, there is not sufficient systematic evidence of the effectiveness of virtual communities on clinical outcomes or patient empowerment. Researchers need to address issues, such as sample sizes and experimental design to further the research field in this domain. PRACTICE IMPLICATIONS: When practitioners utilize virtual community tools to communicate with patients or colleagues they have to maximize sociability and usability of this mode of communication, while addressing concerns for privacy and the fear of de-humanizing practice, and the lack of clarity or relevance of current legislative frameworks.     

Viewpoint discrimination and contestation of ideas on its merits,leadership and organizational ethics: expanding the African bioethics agenda

The 3^rd Pan-African Ethics Human Rights and Medical Law (3^rd EHRML) conference was held in Johannesburg on July 7, 2013, as part of the Africa Health Congress. The conference brought together bioethicists, researchers and scholars from South Africa, Zimbabwe, Kenya and Nigeria working in the field of bioethics as well as students and healthcare workers interested in learning about ethical issues confronting the African continent. The conference which ran with a theme of "Bioethical and legal perspectives in biomedical research and medical practice in Africa with a focus on: Informed consent, HIV-AIDS & Tuberculosis, leadership & organizational ethics, patients and healthcare workers rights," was designed to expand the dialogue on African bioethics beyond the traditional focus on research ethics and the ethical dilemmas surrounding the conduct of biomedical research in developing countries. This introductory article highlights some of areas of focus at the conference including issues of leadership, organizational ethics and patients and healthcare workers rights in Africa. We analyze the importance of free speech, public debate of issues, argumentation and the need to introduce the teaching and learning of ethics to students in Africa in accordance with UNESCO guidelines. This article also focuses on other challenges confronting Africa today from an ethical standpoint, including the issues of poor leadership and organizational ethics which are main contributors to the problems prevalent in African countries, such as poverty, poor education and healthcare delivery systems, terrorism, social inequities, infrastructural deficits and other forms of 'structural violence' confronting vulnerable African communities. We believe that each of the eight articles included in this supplement, which have been rigorously peer-reviewed are a good example of current research on bioethics in Africa, and explore some new directions towards broadening the African bioethics agenda as we move forward to a new dawn for Africa in the 21^st century.     

Addressing conflicts of interest in the research paper: a societal demand in contemporary science?

In the last decade, dialogue between science and society has found a forum in an increasing number of publications on topics such as public engagement with science and public trust in science. Concerning the latter, issues that include cases of research misconduct, accountability in research, and conflicts of interest (COIs) have shaped global discussions on the communication of science. In the publication setting, the perception that hiding COIs and/or not managing them well may affect public trust in the research record has grown among editors. We conducted a search for editorials addressing COIs between 1989 and 2011, using four major databases: Medline/PubMed, Embase, Scopus, and Web of Knowledge. We explored the content of these editorials and the relationship they established between COIs and the public trust in science. Our results demonstrate that the relationship between disclosure of COIs and public trust in science has become a major concern among editors. We, thus, argue that COIs should be discussed more openly and frequently in graduate courses in the sciences, around the globe, not only in biomedical but also in non-biomedical areas. This is a critical issue in contemporary science, as graduate students are the future voices and decision-makers of the research community. Therefore, COIs, especially in the broader context of science and society, merit closer attention from policymakers, researchers, and educators. At times of great expectations for public engagement with science, mishandling of COIs may have undesirable consequences for public engagement with science and confidence in the scientific endeavor.     

Environmental factors influencing public health and medicine: policy implications

Environmental health threats are increasing throughout the United States, particularly in low-income populations and in communities of color. Environmental science researchers are investigating plausible associations between the environment and human health. As a result, the role and responsibility of the primary care physicians and other health care providers are changing. This paper highlights selected lines of evidence suggesting that clinicians should now consider interactions between humans and their environment as central to providing effective primary care. Subject areas include: exposure to environmental agents, reproductive toxicity, pulmonary disease, neurobehavioral toxicity, endocrine disruptors, mechanisms of environmental disease, and cultural competence. Concerns about these and other environmentally related issues influence the manner in which primary care is practiced now, and will be practiced in the future. Biomedical technology and community awareness demand that physicians pay more attention to advances in environmental medicine. Ironically, one of the least taught subjects in medical school is environmental medicine. To effectively respond to growing concerns about the role of the environment in human health, clinicians, researchers, educators, public policy officials, and the general public must join together to reduce the risk of environmental health threats and improve quality of life.     

Promoting patient involvement: educational, organizational, and environmental strategies

The chronic nature of disease in the late 20th century, the issues of health resource constraint, and substantial ethical concerns associated with high technology medical care require the identification of efficient and effective ways to involve patients and families in ongoing health decision making and self-management. While only a limited number of comprehensive approaches have been identified, a wide range of more limited interventions by hospitals and other health care providers suggest the practicality of these strategies. Although the research base is weak with regard to the combination of the interventions, more evidence suggests the value of such strategies as changes in the physical environments of health care institutions, interventions to promote a healthier organizational culture, changes in the care delivery process, increasing patient/family responsibility for care delivery, and helping patients adapt regimens to their own lifestyles.     

The ethics of cultural competence.

Cultural competence curricula have proliferated throughout medical education. Awareness of the moral underpinnings of this movement can clarify the purpose of such curricula for educators and trainees and serve as a way to evaluate the relationship between the ethics of cultural competence and normative Western medical ethics. Though rarely stated explicitly, the essential principles of cultural competence are (1) acknowledgement of the importance of culture in people's lives, (2) respect for cultural differences, and (3) minimization of any negative consequences of cultural differences. Culturally competent clinicians promote these principles by learning about culture, embracing pluralism, and proactive accommodation. Generally, culturally competent care will advance patient autonomy and justice. In this sense, cultural competence and Western medical ethics are mutually supportive movements. However, Western bioethics and the personal ethical commitments of many medical trainees will place limits on the extent to which they will endorse pluralism and accommodation. Specifically, if the values of cultural competence are thought to embrace ethical relativity, inexorable conflicts will be created. The author presents his view of the ethics of cultural competence and places the concepts of cultural competence in the context of Western moral theory. Clarity about the ethics of cultural competence can help educators promote and evaluate trainees' integration of their own moral intuitions, Western medical ethics, and the ethics of cultural competence.     

Ethical principles for physician rating sites

During the last 5 years, an ethical debate has emerged, often in public media, about the potential positive and negative effects of physician rating sites and whether physician rating sites created by insurance companies or government agencies are ethical in their current states. Due to the lack of direct evidence of physician rating sites’ effects on physicians’ performance, patient outcomes, or the public’s trust in health care, most contributions refer to normative arguments, hypothetical effects, or indirect evidence. This paper aims, first, to structure the ethical debate about the basic concept of physician rating sites: allowing patients to rate, comment, and discuss physicians’ performance, online and visible to everyone. Thus, it provides a more thorough and transparent starting point for further discussion and decision making on physician rating sites: what should physicians and health policy decision makers take into account when discussing the basic concept of physician rating sites and its possible implications on the physician–patient relationship? Second, it discusses where and how the preexisting evidence from the partly related field of public reporting of physician performance can serve as an indicator for specific needs of evaluative research in the field of physician rating sites. This paper defines the ethical principles of patient welfare, patient autonomy, physician welfare, and social justice in the context of physician rating sites. It also outlines basic conditions for a fair decision-making process concerning the implementation and regulation of physician rating sites, namely, transparency, justification, participation, minimization of conflicts of interest, and openness for revision. Besides other issues described in this paper, one trade-off presents a special challenge and will play an important role when deciding about more- or less-restrictive physician rating sites regulations: the potential psychological and financial harms for physicians that can result from physician rating sites need to be contained without limiting the potential benefits for patients with respect to health, health literacy, and equity.     

不同民族城市公职人员精神疾病知晓率及态度

目的:调查了解新疆克拉玛依区不同民族城市公职人员对精神卫生与心理保健知识的知晓情况及对精神疾病的态度差异。方法:整群抽取新疆克拉玛依区城市公职人员2046人,采用精神卫生与心理保健知识问卷(MK)、精神疾病有关态度问卷(MA)进行调查。应用SPSS 17.0软件对数据进行方差分析、独立样本t检验以及描述性统计。结果:城市公职人员对精神疾病的认识不够全面,对精神疾病仍存在一定的偏见和误解;不同民族的城市公职人员在精神卫生与心理保健知识上的得分差异具有显著统计学意义(F=23.65,P0.001);不同民族的公职人员在精神卫生态度上的得分差异显著,具有统计学意义(F=2.766,P0.01)。结论:城市公职人员对精神疾病缺乏正确认识;城市公职人员的精神卫生知晓率、对精神疾病有关态度具有民族差异。     

Global challenges and globalization of bioethics

This article analyzes problems and implications for man and nature connected with the formation of a new architecture of science, based on the convergence of nanotechnology, biotechnology, information technology, and cognitive science (NBIC). It also describes evolution and genesis of bioethics, a scientific discipline and social practice with a special role of ethical management of potential risks of scientific research. The aim was to demonstrate the necessity of bioethical social control in the development of a global bioeconomy driven by NBIC technologies.As humankind is entering the 21st century, it is bringing along all the achievements and changes that were realized in the previous centuries, as well as its unfulfilled potentials. In the technological era, the speed of change is so high that humankind does not have enough time to comprehend and learn (1-3). This is, in my opinion, one of the main reasons for the so called civilization crisis. Motive forces of this process are the following global trends:1. Need for energy and raw materials2. Need to solve the problem of hunger3. Incessant fight against diseases and protection of health of humans, animals, and plants4. Aspiration of the population to achieve a new quality of life5. Search for new technological platforms of innovative development in the conditions of the global competitionThe global problems that we speak about arose in the 20th century. What do these problems signify today, in the 21st century?Primarily, the concept of “global” has changed. Practically all global problems reflect on regional and local levels. Therefore the term “glocal” is emerging to represent the natural process of projection of global problems on the local level considering the geographical, cultural, political, national, and religious features of the region. In consequence, it is important to analyze possible positive and negative impacts of global problems on local communities.Second, with the emergence of nanotechnology, biotechnology, information technology, and cognitive science (NBIC) technologies (4,5), humankind has started to change the way it approaches communications, social interactions, and its own biogenetic nature. Although we, by creation of uncontrollable new technological possibilities, assume the role of God, we unfortunately do not take up the responsibility for the consequences of such aspirations. Revolutionary breakthroughs in NBIC technologies give access not only to “nuclear,” but also to the “biogenetic” threats to humanity (3,6,7).There is a search for a unified human platform to solve the global problems, face the consequences of the artificial/biological blend, and preserve fundamental bases of humanity and nature (2,8). As the possibility for the extension of life arises, the most existential questions of humankind come into focus, and the vital need for solutions is becoming clear.The increased risks to human life as it is now understood put forward some imperative questions:Why does changing of the fundamental bases of a person’s life turns his or her environment to a “globalized society of risks”?Where can we find a uniform system for all moral coordinates and what is the role of global bioethics in its achievement?Is the question of fundamental bases of human life really central for the world intellectual thought of the 21st century?Are there positive scenarios for the future of human civilization?We will briefly consider the main “disturbing” signals broadcast by the “glocal” problems.Post-industrial consumer society of the 21st century offers vast possibilities for the use of transgenic organisms. The use of genetic bioengineering could transform global flora and fauna to a planetary network of biofactories, biofarms, and bioreactors for production of goods and services. At the same time, the question of biological safety arises, understood as preservation of biological essence of live organisms, biological qualities, backbone communications and characteristics, and prevention of a large-scale loss of biological integrity (9). Achievements of technical progress are shown today by wide application of artificial organs as replacing elements for the human body. Medical preparations are capable of correcting the characteristics of personality, alter thoughts and emotions, and even change the person’s gender (10). Many successes of genetic engineering, stem cell technology, and in vitro fertilization are ethically tolerated by the international organizations and the states. What can the consequences be?1. Changing the meaning of life itself. The traditional views on the relationship between a person and its material surroundings, the clear difference between life and death, the distinction between the simulated object and the biological being, are being challenged with the coming of new technologies. The total reorganization of the human body with the incorporation of artificial elements changes our interrelations with physical space and time.2. Changes in evolution. A revolution in biology, generating biomedical technologies (genetic engineering, implantology, stem cell engineering, cloning, etc) has brought into question the natural selection of individuals. The evolutionary potential put forward by this trend results in modern persons’ relinquishing some inherent biological properties, acquiring “non-human” qualities, and changing the anthropomorphous shape of civilization.Some researchers declared the beginning of a new phase in the development of technological civilization – “risk society” or “society of globalizing risks” (1,2,11,12). What choice will humankind make? The great potential and real danger of modern biotechnological achievements makes the social and regulatory role of bioethics very important (13-20).Why did bioethics become global?• it is an interdisciplinary platform of dialogue• it is a form of social regulation of risks brought about by changes in all branches of society and NBIC technologies• it is a constructive means of communications between power, business, scientists, and civil society• it supports and promotes scientific research and the social projects directed at preservation of health and well-being of people and nature• it is a humanitarian expertise, “internal optics” of moral relation to life and to categorical imperative of bio economyProceeding from my definition of “bioethics as pursuit, assessment, and a choice of criterion of the moral relation to live” (9,21) it is possible to define three levels:1. Theoretical level – the interdisciplinary and complex analysis of ethical and axiological aspects of different life activities. There are numerous concepts and theories of moral relation of a person to life (eg, humanitarian, utilitarian, deontological, etc). There are also historical, cultural, and social implications that need to be taken into account when assessing these problems. The features of recoverability and irrevocability of moral decision-making as an axial principle depend on the available technological possibilities of transformation of life systems.2. The bioethical aspects can be applied to activity types such as medicine, science, politics, sports, agriculture, etc. These systems are operated and regulated by professional codes and moral principles, laws, and regulations through a prism of a public discourse (22). On this level, it is possible to speak about different types of bioethics which we observe today: biomedical ethics, agro bioethics, cyber bioethics, sports bioethics, ecological bioethics, global bioethics, scientific bioethics, etc (21).3. Practical or clinical bioethics – concrete bioethical examination and assessment of the problem, demanding a moral choice here and now, in a situation (as a rule) not previously experienced. This application is summarized in the term bioethical know-how. Examples of such decisions create a bank of bioethical casuistry (23,24), which becomes a practical and methodological basis of “advancing knowledge,” providing comprehension and reformative impact on “small standard and valuable systems.”     

African bioethics: methodological doubts and insights

Background

A trend called ‘African bioethics’ is growing on the continent due to perceptions of existing bioethics, especially guidelines for international collaborative research, as ‘ethical imperialism’. As a potential alternative to ‘Western Principlism,’ ‘African bioethics’ is supposed to be indigenous to Africa and reflective of African identity. However, despite many positive insights in the on-going discussions, it is feared that the growth of bioethics in Africa lacks a clear direction. Some of the views threaten to distort the essence of bioethics and its development on the continent.

Main text

This paper presents some of the dominant views on ‘African bioethics’, an examination of which reveals some valuable insights into the direction bioethics in Africa ought to take, but at the same time confirms some methodological challenges in some contributions to the discussion. On top of acknowledging critical insights in the discussion, the paper reveals that some views are characterized by arbitrariness and rhetorical discussions based on a strong negative and yet hard-to-accept assumption; doubtful designation; lack of a clearer problem being addressed and consequently obscure question(s) and aim(s) of the discourse. Finally, some methodological insights are proposed to guide bioethics research and scholarship in Africa. Specifically, the paper proposes that in search for the legitimacy of bioethics in Africa, we ought to protect the essence of bioethics by giving considerable attention to the utility of subsequent bioethics. To achieve this we need to specify the problem and proper designation for the discourse; focus on principles qua principles with impartiality and how to ensure their strict implementation; and encourage critical thinking as part of bioethics.

Conclusion

In cultivating bioethics in Africa, the pursuit of identity is legitimate but must be conditional in light of other competing considerations. We should focus on an objective search for bioethical principles that can be effective in responding to African and global health challenges of moral significance, irrespective of the origin of the principles and at the same time focus more on strategies for ensuring compliance with resulting principles.

     

The role of U.S. public hospitals in urban health.

Public hospitals in the United States play a key role in urban health. In many metropolitan communities, public hospitals maintain the health care safety net. Most urban public hospitals have evolved to not only provide care for the indigent but also to serve their communities in other ways, including serving as major providers for tertiary services such as trauma and those that support homeland security; serving as the foundation for primary care services; continuing to train a significant number of physician, nurses, and other medical personnel; and providing laboratories for clinical medical research. Federal budget cuts such as those in the Balanced Budget Act of 1997, recent state budget deficits, competition for Medicaid Managed Care, and the growth in the number of uninsured have led to a decline in revenues among urban public hospitals. To be better stewards of scarce resources, public hospitals have moved to reduce inpatient demand by adopting prevention strategies that are aimed at addressing the determinants of health, the complex interactions among social and economic factors, the physical environment, and individual behavior. These factors contribute to health status and offer opportunities to intervene and improve community health. Urban public hospitals, to be successful in the next stage of their evolution, need to learn to manage the "in-betweens"--partnering with governmental and nongovernmental entities to identify and work together on common health and safety issues. If public hospitals engage the community successfully, building trust and establishing new capability and capacity, urban public hospitals will survive, evolve, and continue their tradition of service.     

Ethical issues raised by incorporation of genetics into the National Birth Defects Prevention Study

Investigators involved in public health research must conduct high-quality studies that advance scientific knowledge for the collective benefit of the public's health, while at the same time ensuring that the individual rights of human subjects are protected. Successful completion of the Human Genome Project provides greater opportunity to incorporate the study of genetic factors into public health research. Integration of DNA specimen collection into epidemiological studies of complex disorders, such as birth defects, is necessary to identify genetic risk factors that affect susceptibility to potentially modifiable environmental risk factors, but collection of DNA samples often heightens concerns about ethical issues. Some of these issues include ensuring informed consent in an ongoing study as new genetic risk factors and novel genetic technologies for study continue to be identified, achieving a balance between improving participation using incentives and avoiding coercion, ensuring confidentiality of individual genetic data, and considering when and how to report research results to study participants. We present a discussion of ethical issues addressed by investigators of the National Birth Defects Prevention Study, a multisite, population-based, case-control study of risk factors for birth defects, which has incorporated the study of genetic risk factors. Study participants include infants and young children whose parents consent on their behalf, increasing the complexity of the ethical issues. Discussion of these issues and the methods employed to ensure protection of human subjects might be helpful to other investigators working to integrate genetics into large epidemiological studies.     

Urban health: a look out our windows.

Approximately 80% of Americans live in cities or immediately adjacent communities. Such urban environments are complex amalgams of people of disparate backgrounds, economic status, and expectations, with extraordinary disparities in health status and outcomes between groups just blocks apart. Urban health as a framing paradigm is of recent vintage and offers a perspective on health and disease that integrates clinical medicine and public health and draws on the social and political sciences to seek understanding of the impact of cities on the health of populations and individuals. Ironically, disparate outcomes and increased mortality among poor minority populations in cities are not primarily related to the consequences of the urban epidemics of drugs and violence but rather are due to the increased prevalence and severity of common diseases such as asthma, cardiovascular disease, diabetes, and kidney disease. Several factors may be responsible for such disparities, including stress, racism, perceptions of deprivation, economic inequalities, and lack of access to quality health care. It is time for leaders in medical education and health care delivery to focus on the populations that surround their institutions in order to study urban health and meet the challenge of caring for all the residents of our cities.     

Deception, discrimination, and fear of reprisal: lessons in ethics from third-year medical students.

PURPOSE: To systematically examine ethical conflicts reported by all State University of New York Upstate Medical University third-year students, compare them with conflicts reported in the literature, and identify content areas that compel new or renewed emphasis in national educational objectives, standard curricula, and texts. METHOD: From 1999 to 2002, all third-year students submitted papers for a required bioethics course. These papers depicted ethical issues arising during clinical clerkships. The authors devised a checklist of ethical issues; after analyzing the students' papers, the authors applied the checklist to the papers to create a taxonomy. RESULTS: Three hundred twenty-seven students submitted 688 cases involving 40 ethical issues. The most common issues were deliberate lies or deceptions (n = 68), patients' right to refuse recommended treatment (n = 48), and insistence on futile treatment (n = 46). Students perceived overt and subtle discrimination toward patients, reflected in substandard or excessive treatment. In 81 cases (12%), students expressed reluctance to speak up about moral conflict for fear of reprisal. This fear was expressed in 18 (45%) of the 40 issues-particularly student-specific (36 [52% of 69]) and quality of care (7 [24% of 29])-and most frequently in cases involving surgery (p < .025) and obstetrics-gynecology patients (p < .01). CONCLUSIONS: Students discerned ethical dilemmas in both "usual and customary" and seemingly incidental situations. Students who described fear of speaking up perceived a tradeoff between academic survival and patients' interests. The cases demonstrated that students still lacked the tools to navigate ethical dilemmas effectively. The authors propose that moral courage is within the realm of professional expectations for medical students; its cultivation is an appropriate formal objective for medical education.     

Psychologists in Long-Term Care: Overview of Practice and Public Policy: Introduction to the Special Series

With the overall aging of the population and the concomitant need for the provision of mental health care for older adults, professional psychology in long-term care has come of age. Psychologists are now increasingly practicing in such traditional long-term care settings as nursing homes and in less traditional ones such as rehabilitation units, day centers, partial hospitaliza-tion programs, and hospices. The practice of psychology in long-term care is strongly influenced by public policy issues relating to Medicare, such as conditions of reimbursement, the rise of managed Medicare, and the continued disparity between payment for mental health and medical diagnoses. Ceropsychologists must be flexible in the form of their healthcare delivery to continue to provide quality services. The following articles in this special section on long-term care summarize the research on assessment and interventions for long-term care patients, outline the training opportunities available, and provide a decision-making framework for the common professional ethical/legal issues encountered in long-term care settings.     

Right to health and social justice in Bangladesh: ethical dilemmas and obligations of state and non-state actors to ensure health for urban poor

Background

The world is urbanizing rapidly; more than half the world’s population now lives in urban areas, leading to significant transition in lifestyles and social behaviours globally. While offering many advantages, urban environments also concentrate health risks and introduce health hazards for the poor. In Bangladesh, although many public policies are directed towards equity and protecting people’s rights, these are not comprehensively and inclusively applied in ways that prioritize the health rights of citizens. The country is thus facing many issues that raise moral and ethical concerns.

Methods

A narrative literature review was conducted between October 2016 and November 2017 on issues related to social justice, health, and human rights in urban Bangladesh. The key questions discussed here are: i) ethical dilemmas and inclusion of the urban poor to pursue social justice; and ii) the ethical obligations and moral responsibilities of the state and non-state sectors in serving Bangladesh’s urban poor. Using a Rawlsian theory of equality of opportunity to ensure social justice, we identified key health-related ethical issues in the country’s rapidly changing urban landscape, especially among the poor.

Results

We examined ethical dilemmas in Bangladesh’s health system through the rural–urban divide and the lack of coordination among implementing agencies. The unregulated profusion of the private sector and immoral practices of service providers result in high out-of-pocket expenditures for urban poor, leading to debt and further impoverishment. We also highlight policy and programmatic gaps, as well as entry points for safeguarding the right to health for Bangladeshi citizens.

Conclusions

The urban health system in Bangladesh needs a reform in which state and non-state actors should work together, understanding and acknowledging their moral responsibilities for improving the health of the urban poor by engaging multiple sectors. The social determinants of health should be taken into account when formulating policies and programs to achieve universal health coverage and ensure social justice for the urban poor in Bangladesh.

     

Acknowledging and addressing the many ethical aspects of disease

Diseases change the life of individuals, the social status of groups, the obligations of professionals, and the welfare of nations. Disease classifications function as a demarcation of access to care, rights, and duties. Disease also fosters social stigmatization and discrimination, and is a personal, professional, and political matter. It raises a wide range of ethical issues that are of utmost importance in patient communication and education. Accordingly, the objective of this article is to present and discuss a range of basic ethical aspects of this core concept of medicine and health care. First and foremost, disease evokes compassion for the person suffering and induces a moral impetus to health professionals and health policy makers to avoid, eliminate or ameliorate disease. The concept of disease has many moral functions, especially with respect to attributing rights and obligations. Classifying something as disease also has implications for the status and prestige of the condition as well as for the attitudes and behavior towards people with the condition. Acknowledging such effects is crucial for avoiding discrimination and good communication. Moreover, different perspectives on disease can create conflicts between patients, professionals and policy makers. While expanding the concept of disease makes it possible to treat many more people for more conditions - earlier, it also poses ethical challenges of doing more harm than good, e.g., in overdiagnosis, overtreatment, and medicalization. Understanding these ethical issues can be difficult even for health professionals, and communicating them to patients is challenging, but crucial for making informed consent. Accordingly, acknowledging and addressing the many specific ethical aspects of disease is crucial for patient communication and education.