Health promotion and the common good: Towards a politics of practice

One of the ethical dilemmas facing health promotion and disease prevention (HP/DP) practitioners is ensuring that programmes undertaken in the name of health as a ‘common good’ do not unnecessarily restrict individual liberties. This dilemma is compounded by theories of the common good being essentially normative and broadly categorized as libertarian (individual rights) or social justice (collective responsibilities). Both of these common good theories are described and critiqued. While the libertarian theory offers an important caution against the tendency of state institutions to undermine individual autonomy, a social justice theory is more consistent with research on health determinants and the historical practice of public health. The problem of individual liberties becomes most acute when HP/DP is restricted to efforts to curb or proscribe individual health behaviours. A social justice approach to HP, however, must be complemented by a ‘deliberative democratic’ practice. Such a practice recognizes the contingency involved in most HP/DP decision making, and the need for inequalities in opportunity for poor or socially disadvantaged (oppressed) groups in order to achieve greater equality in health outcomes. The argument presented draws primarily from debates within the public health, health promotion and disease prevention literature, and is illustrated by reference to two recent attempts in Canada to formulate ethical principles for health promotion practice.     

Shifting the Moral Burden: Expanding Moral Status and Moral Agency

Two problems are considered here. One relates to who has moral status, and the other relates to who has moral responsibility. The criteria for mattering morally have long been disputed, and many humans and nonhuman animals have been considered “marginal cases,” on the contested edges of moral considerability and concern. The marginalization of humans and other species is frequently the pretext for denying their rights, including the rights to health care, to reproductive freedom, and to bodily autonomy. There is broad agreement across cultural and philosophical traditions about the capacities and responsibilities of moral agents. I propose an inclusive and expansive way of thinking about moral status, situating it not in the characteristics or capacities of individuals, but in the responsibilities and obligations of moral agents. Moral agents, under this view, are not privileged or entitled to special treatment but rather have responsibilities. I approach this by considering some African communitarian conceptions of moral status and moral agency. I propose that moral agency can also be more expansive and include not just individual moral agents but collective entities that have some of the traits of moral agents: power, freedom, and the capacity to recognize and act on the demands of morality and acknowledge and respect the rights of others. Expanding who and what is a moral agent correspondingly extends moral responsibility for respecting rights and fostering the conditions for the health and wellbeing of humans and animals onto the collective entities who uniquely have the capacity to attend to global-scale health threats such as pandemics and human-caused climate change.     

Investigating global mental health: Contributions from political science

ABSTRACT

This article outlines an agenda for political science engagement with global mental health. Other social sciences have tackled the topic, investigating such questions as the link between poverty and mental health disorders. Political science is noticeably absent from these explorations. This is striking because mental health disorders affect one billion people globally, governments spend only about 2% of their health budgets on these disorders, and most people lack access to treatment. With its focus on power, political science could deepen knowledge on vulnerabilities to mental illness and explain weak policy responses. By illustrating how various forms of power pertaining to governance, knowledge, and moral authority work through the concepts of issue framing, collective action, and institutions, the article shows that political science can deepen knowledge on this global health issue. Political science can analyse how incomplete knowledge leads to contentious framing, thus hobbling advocacy. It can explain why states shirk their obligations in mental health, and it can question how incentives drive mental health mobilisation. The discipline can uncover how power undergirds institutional responses to global mental health at the international, national, and community levels. Political science should collaborate with other social sciences in research networks to improve policy outcomes.     

Exploring the relevance of social justice within a relational nursing ethic

In the last few decades, a growing number of commentators have questioned the appropriateness of the 'justice view' of ethics as a suitable approach in health care ethics, and most certainly in nursing. Essentially, in their ethical deliberations, it is argued that nurses do not readily adopt the high degree of impartiality and objectivity that is associated with a justice view; instead their moral practices are more accurately reflected through the use of alternative approaches such as relational or care-based ethics. Yet, it has also been argued that this viewpoint does not necessarily 'do justice' to the broader moral responsibilities of nurses towards humanity in general, i.e. to the wider socio-cultural and socio-political issues in society, and to the concept of social justice in particular. This criticism has triggered a much closer examination of relational and care-based ethics in nursing at levels beyond individual responsiveness within relationships and brought into the spotlight the need for a more ethically refined nursing response to an increasingly complex set of socio-cultural inequalities. This article explores a relational ethic within nursing practices with contemporary ideas regarding social justice. In particular, it is argued that the synergy between the two actually produces an ethic that is capable of not only challenging the continuing predominance of justice-based ethics within health care, but of replacing it. Subsequently, in the discussion that follows, it is suggested that a combined social justice and relational care-based approach, as a social ethic, should guide the moral deliberations and actions of nurses. It is maintained that such an approach is not only possible, but crucial if nurses are to realize their full potential as ethical agents for individual and social good.     

Teaching health care ethics: the importance of moral sensitivity for moral reasoning

Abstract My discussion reflects on the nature of moral sensitivity. The inquiry is guided by a pedagogical concern: if the goal of teaching practical‐minded nurses about health care ethics is to develop the capacity to be aware of ethical implications of certain acts, events and treatments in the health care setting as well as the skills to resolve ethical dilemmas, it seems important to have a clear sense of what it means to be morally sensitive. How, for example, does a health care worker come to recognize in a particular and institutionally defined situation his or her moral responsibilities towards the other? What exactly is moral sensitivity? Is it something that academic philosophers can teach? I argue that moral sensitivity is a capacity for relatedness indispensable to moral theorizing that can be either cultivated or undermined and therefore ought not to be ignored by educators nor those responsible for ethically weighted decision‐making situations.     

Justice and Proximity: Problems for an Ethics of Care

This paper aims at addressing some questions considering the conflicting normative claims of partiality, i.e. to provide for the caring needs of the particular patient, and impartial claims of treating all patients with a relevant need equally. This ethical conflict between different conceptions of moral responsibilities within professional ethics relates to debates between an ethics of care and an ethics of justice. An ethics of care is a particularistic position that endorses some form of partiality, i.e. favouring persons to whom one stands in particular relationships. This paper argues that also a professional ethics must endorse some kind of partiality at the clinical level of health care. In fact, consideration of care for particular patients is a prerequisite for giving proper and attentive care towards the individual patient. This paper will discuss how partial concerns might be balanced against claims of distributive justice within the frame of the formal principle of justice. It is concluded that there is an urgent need for the recognition of the consequences of macro-level decisions for the possibility of the discharge of moral responsibility on a clinical level of health care. This would mean that health care institutions should adapt for the possibility of a basic standard of proper care and attention for the individual patient.     

A framework for applying ethical theory to public health practice.

Like most other public health agencies, the Georgia Department of Human Resources, Division of Public Health (DPH) has encountered a growing number of questions and conflicts with ethical implications. To address these and other questions, DPH started to develop a framework, in January 1985, specifically related to solving problems, setting priorities, and developing policy that adds an ethical perspective. DPH must deal with issues and conflicts that transcend the traditional model of medical care: with the new economic reality, programs must continue with less resources; medical technology is now raising questions, but not necesarily answers, related to life and death; and the rights and responsibilities of individuals and institutions are not clearly defined. In this context, DPH has started to examine ethical considerations with respect to the individual and the community. An interface exists between ethical theory and health care. Over the years, however, this relationship has assumed different manifestations, ranging from the formation of precise conduct codes for health care professionals to the establishment of review boards that examine specific morally questionable procedures. DPH's purpose in applying ethical theory to its health care practices is not to develop an inflexible code nor a committee to review isolated cases of moral conflict. The purpose is to use ethical theory as a form of vision for the remainder of the 1980s and beyond.     

Understanding the futility of countries’ obligations for health rights: realising justice for the global poor

Background

Although health is a right of all individuals without any distinction, the realisation of this right has remained very difficult for the marginalised populations of poor countries. Inequitable distribution of health opportunities globally is a major factor in explaining why this is the case. Whereas the Protection, Promotion and Fulfilment of the health rights of poor country citizens are a joint responsibility of both domestic and external governments, most governments flout their obligations. So far disproportionate effort has been dedicated to reaffirming and interpreting these obligations as opposed to investigating the fundamental question regarding why these obligations have nevertheless remained largely unfulfilled. Further the normative question regarding what ought to be done about the shortcomings of current obligations has been largely ignored.

Methods

We conduct a critical content analysis of existing literature on efforts towards the realisation of the health rights of marginalised populations in our attempt to ascertain their capacity to guarantee basic health opportunities to marginalised populations. In our analysis we treat issues of ‘health rights’ and ‘justice in global health’ as having unity of purpose – guaranteeing basic health opportunities to the marginalised populations.

Results

We identify two sets of reasons for the failure of present obligations for global distributive justice in general: a set of ‘superficial reasons’ and a set of ‘fundamental reasons’ which account for the superficial reasons.

Discussion

In order to overcome these reasons we propose a strategy which consists in specifying a number of minimum and less-demanding obligations for both external and domestic governments to guarantee to all individuals a certain threshold of health goods and services. We argue that these minimum obligations can be freely accepted and fully complied with or enforced with “a thin system of enforcement” without significant threat to national sovereignty and autonomy.

Conclusion

The futility of countries’ obligations for the health rights of the global poor as is the case with global distributive injustice is because of lack of political will to specify and enforce such obligations. Minimum obligations should be specified and enforced with a “thin system” which is consistent with principles of national sovereignty and autonomy.

     

How can health systems research reach the worst-off? A conceptual exploration

Background

Health systems research is increasingly being conducted in low and middle-income countries (LMICs). Such research should aim to reduce health disparities between and within countries as a matter of global justice. For such research to do so, ethical guidance that is consistent with egalitarian theories of social justice proposes it ought to (amongst other things) focus on worst-off countries and research populations. Yet who constitutes the worst-off is not well-defined.

Methods and Results

By applying existing work on disadvantage from political philosophy, the paper demonstrates that (at least) two options exist for how to define the worst-off upon whom equity-oriented health systems research should focus: those who are worst-off in terms of health or those who are systematically disadvantaged. The paper describes in detail how both concepts can be understood and what metrics can be relied upon to identify worst-off countries and research populations at the sub-national level (groups, communities). To demonstrate how each can be used, the paper considers two real-world cases of health systems research and whether their choice of country (Uganda, India) and research population in 2011 would have been classified as amongst the worst-off according to the proposed concepts.

Conclusions

The two proposed concepts can classify different countries and sub-national populations as worst-off. It is recommended that health researchers (or other actors) should use the concept that best reflects their moral commitments—namely, to perform research focused on reducing health inequalities or systematic disadvantage more broadly. If addressing the latter, it is recommended that they rely on the multidimensional poverty approach rather than the income approach to identify worst-off populations.

     

Global Equity Gauge Alliance: reflections on early experiences

The paper traces the evolution and working of the Global Equity Gauge Alliance (GEGA) and its efforts to promote health equity. GEGA places health equity squarely within a larger framework of social justice, linking findings on socioeconomic and health inequalities with differentials in power, wealth, and prestige in society. The Alliance's 11 country-level partners, called Equity Gauges, share a common action-based vision and framework called the Equity Gauge Strategy. An Equity Gauge seeks to reduce health inequities through three broad spheres of action, referred to as the 'pillars' of the Equity Gauge Strategy, which define a set of interconnected and overlapping actions. Measuring and tracking the inequalities and interpreting their ethical import are pursued through the Assessment and Monitoring pillar. This information provides an evidence base that can be used in strategic ways for influencing policy-makers through actions in the Advocacy pillar and for supporting grassroots groups and civil society through actions in the Community Empowerment pillar. The paper provides examples of strategies for promoting pro-equity policy and social change and reviews experiences and lessons, both in terms of technical success of interventions and in relation to the conceptual development and refinement of the Equity Gauge Strategy and overall direction of the Alliance. To become most effective in furthering health equity at both national and global levels, the Alliance must now reach out to and involve a wider range of organizations, groups, and actors at both national and international levels. Sustainability of this promising experiment depends, in part, on adequate resources but also on the ability to attract and develop talented leadership.     

Rights-based approaches to addressing food poverty and food insecurity in Ireland and UK

Food poverty is an important contributing factor to health inequalities in industrialised countries; it refers to the inability to acquire or eat an adequate quality or sufficient quantity of food in socially acceptable ways (or the uncertainty of being able to do so). Synonymous with household food insecurity, the issue needs to be located within a social justice framework. Recognising the clear interdependence between the right to food and the right to health, this paper explores how international human rights obligations could inform approaches to addressing food poverty and insecurity with specific reference to Ireland and the UK. Little attention has been paid to how countries should meet their obligations to respect, protect and fulfil the right to food in developed countries. The paper contributes by examining the social and policy circumstances which inhibit poor households from obtaining sufficient food to eat healthily, along with strategies and interventions from State and civil society actors in the two countries. In practice, problems and potential solutions have largely been directed towards the individual rather than at social determinants, particularly as research on environmental factors such as distance to shops has produced equivocal results. Other key structural aspects such as income sufficiency for food are broadly ignored by the State, and anti-poverty strategies are often implemented without monitoring for effects on food outcomes. Thus scant evidence exists for either Ireland or the UK meeting its rights to food obligations to date, in terms of roles and responsibilities in ensuring access to affordable, available and appropriate food for all.     

Place-focused physical activity research, human agency, and social justice in public health: taking agency seriously in studies of the built environment

Built environment characteristics have been linked to health outcomes and health disparities. However, the effects of an environment on behavior may depend on human perception, interpretation, motivation, and other forms of human agency. We draw on epidemiological and ethical concepts to articulate a critique of research on the built environment and physical activity. We identify problematic assumptions and enumerate both scientific and ethical reasons to incorporate subjective perspectives and public engagement strategies into built environment research and interventions. We maintain that taking agency seriously is essential to the pursuit of health equity and the broader demands of social justice in public health, an important consideration as studies of the built environment and physical activity increasingly focus on socially disadvantaged communities. Attention to how people understand their environment and navigate competing demands can improve the scientific value of ongoing efforts to promote active living and health, while also better fulfilling our ethical obligations to the individuals and communities whose health we strive to protect.     

Framing health and foreign policy: lessons for global health diplomacy

Global health financing has increased dramatically in recent years, indicative of a rise in health as a foreign policy issue. Several governments have issued specific foreign policy statements on global health and a new term, global health diplomacy, has been coined to describe the processes by which state and non-state actors engage to position health issues more prominently in foreign policy decision-making. Their ability to do so is important to advancing international cooperation in health. In this paper we review the arguments for health in foreign policy that inform global health diplomacy. These are organized into six policy frames: security, development, global public goods, trade, human rights and ethical/moral reasoning. Each of these frames has implications for how global health as a foreign policy issue is conceptualized. Differing arguments within and between these policy frames, while overlapping, can also be contradictory. This raises an important question about which arguments prevail in actual state decision-making. This question is addressed through an analysis of policy or policy-related documents and academic literature pertinent to each policy framing with some assessment of policy practice. The reference point for this analysis is the explicit goal of improving global health equity. This goal has increasing national traction within national public health discourse and decision-making and, through the Millennium Development Goals and other multilateral reports and declarations, is entering global health policy discussion. Initial findings support conventional international relations theory that most states, even when committed to health as a foreign policy goal, still make decisions primarily on the basis of the 'high politics' of national security and economic material interests. Development, human rights and ethical/moral arguments for global health assistance, the traditional 'low politics' of foreign policy, are present in discourse but do not appear to dominate practice. While political momentum for health as a foreign policy goal persists, the framing of this goal remains a contested issue. The analysis offered in this article may prove helpful to those engaged in global health diplomacy or in efforts to have global governance across a range of sectoral interests pay more attention to health equity impacts.     

Public-Health-Ethik ist Partnerschaftsethik

Securing and safeguarding the health of citizens are preeminent governmental obligations and cultural as well as ethical responsibilities. Public health needs to be developed, implemented and reviewed in partnership with existing private and public market forces and with health-literate citizens; mission, strategy, tactics and ethics of public health depend on partnership ethics. Traditional sets of principles in bioethics, research ethics, or clinical ethics are not useful to delineate the framework, the mandate, and the specific conflicts and risks in public health. The SEMPER model exemplifies the role of the principles of safety, education, minimax, partnership, efficiency, review and their interactions for public health in securing and promoting health and quality of life.     

Equity and resource allocation in health care: Dialogue between Islam and Christianity

Inequities in health and health care are one of the greatest challenges facing the international community today. This problem raises serious questions for health care planners, politicians and ethicists alike. The major world religions can play an important role in this discussion. Therefore, interreligious dialogue on this topic between ethicists and health care professionals is of increasing relevance and urgency. This article gives an overview on the positions of Islam and Christianity on equity and the distribution of resources in health care. It has been written in close collaboration and constant dialogue between the two authors coming from the two religions. Although there is no specific concept for the modern term equity in either of the two religions, several areas of agreement have been identified: All human beings share the same values and status, which constitutes the basis for an equitable distribution of rights and benefits. Special provisions need to be made for the most needy and disadvantaged. The obligation to provide equitable health services extends beyond national and religious boundaries. Several areas require intensified research and further dialogue: the relationship between the individual and the community interms of rights and responsibilities, how to operationalize the moral duty to decrease global inequalities in health, and the understanding and interpretation of human rights in regard to social services. This revised version was published online in July 2006 with corrections to the Cover Date.     

Why do health inequalities matter?]

OBJECTIVES: The aim of this study was to introduce the concept of health inequalities, and to discuss the underlying assumptions and ethical backgrounds associated with the issue, as well as the theoretical and practical implications of health inequalities. METHODS: Based on a review of the literature, we summarize the concepts of health inequalities and inequities and discuss the underlying assumptions and ethical backgrounds associated with these issues from the view of social justice theory. We then discuss the theoretical and practical implications of health inequalities. RESULTS: Health inequality involves ethical considerations, such as judgments on fairness, and it could provide a sensitive barometer to reflect the fairness of social arrangements. Discussion on health inequalities could deepen our understanding of the social etiology of health and provide a basis for the development of comprehensive and integrative social policies. CONCLUSIONS: Health equity is not a social goal in and of itself, but should be considered as a part of a broader effort to seek social justice.     

AIDS and the human community

This paper examines ethical behavior in the face of the threat posed by the AIDS epidemic from the vantage point of: (1) different ways of looking at communal structure; (2) notions of justice and of 'rights' which develop from different ways of looking at community; and (3) views of the 'natural lottery' and of self-causation linked to attitudes towards community, justice and 'rights'. Possibilities of resolution are then examined briefly addressing problems of: (1) nonvoluntary testing of persons, and of reporting and restricting those believed to be infected; (2) professional responsibility towards the infected; and (3) communal responsibilities to those infected with AIDS. Communities which hold freedom (and its corollary autonomy) to be an absolute and which see beneficence as a 'nice' but nonmoral quality, will refrain from nonvoluntary testing, reporting and restricting. Professionals in such communities will view themselves as bureaucrats of health, their obligations restricted by explicit contract. Such communities will hold the 'natural lottery' (strengthened by notions of self-causation) to be at fault for all illness. It, therefore, would perceive no obligation to aid patients afflicted by AIDS or other misfortune. Communities of this sort, it is argued, when they feel sufficiently threatened by epidemics may (when they finally abrogate their principles or redefine the problem by excluding patients as members of the community) resort to extreme and no longer limited measures. The paper concludes that most look at community as constituted by more than the minimal obligations of refraining from harm to one another and include beneficence among the moral obligations.(ABSTRACT TRUNCATED AT 250 WORDS)     

A commentary on "Securing Access to Health Care." Ethics Commission access report urges adequate care for all

Society has a moral obligation to provide adequate access to health care for all, concludes the President's Commission for te Study of Ethical Problems in Medicine and Biomedical and Behavorial Research in its report Securing Access to Health Care. Though the federal government's involvement is not necessary if private forces are able to achieve equity in health care delivery, the government bears the ultimate responsibility for ensuring that society fulfills its obligations. Meeting these objectives will require changes in the country's political and economic systems, which traditionally have not emphasized subordinating the individual good to the common good. The needs of the poor must take priority even at risk of burdening the advantaged. The commission recognizes that it is irresponsible to advocate equity without acknowledging the need to control costs. Greater equity can be attained only if changes in health care management practices are adopted and if decisions regarding resource use are based on social goals. Thus placing the needs of the poor first may mean a commitment to use less high-cost treatment. The report presents an opportunity to promote a more just health care policy. Catholic health care facilities, for example, can be made models of institutions that have met the needs of the poor, and they can become social justice advocates for government policies that benefit the poor and the disadvantaged.     

In Search of the 'New Informal Legitimacy' of Médecins Sans Frontières

FOR MEDICAL HUMANITARIAN ORGANIZATIONS, MAKING THEIR SOURCES OF LEGITIMACY EXPLICIT IS A USEFUL EXERCISE, IN RESPONSE TO: misperceptions, concerns over the 'humanitarian space', controversies about specific humanitarian actions, challenges about resources allocation and moral suffering among humanitarian workers. This is also a difficult exercise, where normative criteria such as international law or humanitarian principles are often misrepresented as primary sources of legitimacy. This essay first argues for a morally principled definition of humanitarian medicine, based on the selfless intention of individual humanitarian actors. Taking Médecins Sans Frontières (MSF) as a case in point, a common source of moral legitimacy for medical humanitarian organizations is their cosmopolitan appeal to distributive justice and collective responsibility. More informally, their legitimacy is grounded in the rightfulness of specific actions and choices. This implies a constant commitment to publicity and accountability. Legitimacy is also generated by tangible support from the public to individual organizations, by commitments to professional integrity, and by academic alliances to support evidence-based practice and operational research.     

The Suleman Octuplet Case: An Analysis of Multiple Ethical Issues

The Suleman octuplet case is the first reported case in which surviving octuplets were born as a result of in vitro fertilization and embryo transfer. In this case, the octuplets were born to an American single mother of six children, who was on public assistance, and who used a sperm donor. This has raised multiple ethical questions, which include the ethical obligations of the health care providers involved, the informed consent process, as well as moral obligations of the mother to her existing children and unborn children. This case analysis provides a clinical ethics and prenatal ethics framework, based on relevant American media and public documents available from January 26, 2009, to January 26, 2010, the period of time in which media scrutiny of this case was most relevant. Although this analysis introduces broader ethical implications, it is not intended as a philosophical discourse regarding the rights of patients to reproduce or the rights of society to place limits on who can and who cannot reproduce; neither is it intended as an in-depth policy review of reproductive technologies. Rather, this analysis focuses on clinical ethics breaches in this particular case, which led to an unintended outcome. The relevant clinical ethical principles, duties, and obligations are identified, with recommendations for a preventative ethics approach in the absence of clear policies that regulate embryo transfer.