Plugging the “Phishing” Hole: Legislation Versus Technology

This iBrief analyzes the Anti-Phishing Act of 2005, legislation aimed at curbing the problem of phishing. Phishing is the sending of fraudulent emails which appear to be from legitimate businesses and thereby fooling the recipients into divulging personal information such as credit card numbers. While this legislation may provide some assistance in the fight against phishing, it is limited by the global nature of the Internet and the ease with which phishers can hide and avoid judgments. This iBrief therefore concludes that although the Anti-Phishing Act can play a supporting role in the battle, technological solutions are the most effective means of reducing or eliminating phishing attacks

Prioritising, Ranking and Resource Implementation - A Normative Analysis

Abstract Background: Priority setting in publicly financed healthcare systems should be guided by ethical norms and other considerations viewed as socially valuable, and we find several different approaches for how such norms and considerations guide priorities in healthcare decision-making. Common to many of these approaches is that interventions are ranked in relation to each other, following the application of these norms and considerations, and that this ranking list is then translated into a coverage scheme. In the literature we find at least two different views on how a ranking list should be translated into coverage schemes: (1) rationing from the bottom where everything below a certain ranking order is rationed; or (2) a relative degree of coverage, where higher ranked interventions are given a relatively larger share of resources than lower ranked interventions according to some “curve of coverage.” Methods: The aim of this article is to provide a normative analysis of how the background set of ethical norms and other considerations support these two views. Results: The result of the analysis shows that rationing from the bottom generally gets stronger support if taking background ethical norms seriously, and with regard to the extent the ranking succeeds in realising these norms. However, in non-ideal rankings and to handle variations at individual patient level, there is support for relative coverage at the borderline of what could be covered. A more general relative coverage curve could also be supported if there is a need to generate resources for the healthcare system, by getting patients back into production and getting acceptance for priority setting decisions. Conclusion: Hence, different types of reasons support different deviations from rationing from the bottom. And it should be noted that the two latter reasons will imply a cost in terms of not living up to the background set of ethical norm

Severity as a Priority Setting Criterion: Setting a Challenging Research Agenda

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s severity criteria in Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda

Beyond the Black Box Approach to Ethics! Comment on “Expanded HTA: Enhancing Fairness and Legitimacy”

In the editorial published in this journal, Daniels and colleagues argue that his and Sabin’s accountability for reasonableness (A4R) framework should be used to handle ethical issues in the health technology assessment (HTA)-process, especially concerning fairness. In contrast to this suggestion, it is argued that such an approach risks suffering from the irrrelevance or insufficiency they warn against. This is for a number of reasons: lack of comprehensiveness, lack of guidance for how to assess ethical issues within the “black box” of A4R as to issues covered, competence and legitimate arguments and finally seemingly accepting consensus as the final verdict on ethical issues. We argue that the HTA community is already in a position to move beyond this black box approac

Ethical deliberations about involuntary treatment: interviews with Swedish psychiatrists

Background: Involuntary treatment is a key issue in healthcare ethics. In this study, ethical issues relating to involuntary psychiatric treatment are investigated through interviews with Swedish psychiatrists. Methods: In-depth interviews were conducted with eight Swedish psychiatrists, focusing on their experiences of and views on compulsory treatment. In relation to this, issues about patient autonomy were also discussed. The interviews were analysed using a descriptive qualitative approach. Results: The answers focus on two main aspects of compulsory treatment. Firstly, deliberations about when and why it was justifiable to make a decision on involuntary treatment in a specific case. Here the cons and pros of ordering compulsory treatment were discussed, with particular emphasis on the consequences of providing treatment vs. refraining from ordering treatment. Secondly, a number of issues relating to background factors affecting decisions for or against involuntary treatment were also discussed. These included issues about the Swedish Mental Care Act, healthcare organisation and the care environment. Conclusions: Involuntary treatment was generally seen as an unwanted exception to standard care. The respondents’ judgments about involuntary treatment were typically in line with Swedish law on the subject. However, it was also argued that the law leaves room for individual judgments when making decisions about involuntary treatment. Much of the reasoning focused on the consequences of ordering involuntary treatment, where risk of harm to the therapeutic alliance was weighed against the assumed good consequences of ensuring that patients received needed treatment. Cases concerning suicidal patients and psychotic patients who did not realise their need for care were typically held as paradigmatic examples of justified involuntary care. However, there was an ambivalence regarding the issue of suicide as it was also argued that risk of suicide in itself might not be sufficient for justified involuntary care. It was moreover argued that organisational factors sometimes led to decisions about compulsory treatment that could have been avoided, given a more patient-oriented healthcare organisation. Electronic supplementary material The online version of this article (doi:10.1186/s12910-015-0029-5) contains supplementary material, which is available to authorized users

How did European countries set health priorities in response to the COVID-19 threat?:A comparative document analysis of 24 pandemic preparedness plans across the EURO region

The COVID-19 pandemic has forced governments across the world to consider how to prioritise the allocation of scarce resources. There are many tools and frameworks that have been designed to assist with the challenges of priority setting in health care. The purpose of this study was to examine the extent to which formal priority setting was evident in the pandemic plans produced by countries in the World Health Organisation's EURO region, during the first wave of the COVID-19 pandemic. This compliments analysis of similar plans produced in other regions of the world. Twenty four pandemic preparedness plans were obtained that had been published between March and September 2020. For data extraction, we applied a framework for identifying and assessing the elements of good priority setting to each plan, before conducting comparative analysis across the sample. Our findings suggest that while some pre-requisites for effective priority setting were present in many cases - including political commitment and a recognition of the need for allocation decisions - many other hallmarks were less evident, such as explicit ethical criteria, decision making frameworks, and engagement processes. This study provides a unique insight into the role of priority setting in the European response to the onset of the COVID-19 pandemic.</p

An ethical analysis of a lower age threshold for gender confirmation surgery of the genitalia

Den etiska analys som presenteras i rapporten rör sänkt åldersgräns för underlivskirurgi vid könsbekräftande vård från 18 till 15 år och har skett på uppdrag av Socialstyrelsen. I analysen berörs denna fråga från följande perspektiv: risk/nytta, autonomi och rättvisa/jämlikhet. Analysen landar i en försiktighetsprincip med att erbjuda patienter från 15 år underlivskirurgi baserat på följande huvudargument. Det rör sig om irreversibla ingrepp med stora konsekvenser för den person som genomgår dessa, där ett svagt evidensläge för en äldre population ska överföras till en yngre population. Utfallets är starkt beroende av personens upplevda könsidentitet vilket skapar större osäkerhet för en population som är under kognitiv och emotionell utveckling. Vårdbehovets karaktär, där ett nödvändigt (men inte tillräckligt) villkor är att de fysiologiska ingreppen görs i den mån personen önskar sig dessa och inte ges på rekommendation av vårdpersonalen – skapar en större osäkerhet. Det lidande och de problem som uppkommer på grund av fördröjd behandling förefaller i många fall vara reversibelt (förutom när det gäller suicid), och det finns osäkerheter kring om suicid på grund av fördröjd behandling (som förefaller vara ett av huvudargumenten för tidigarelagd behandling) förekommer och i så fall i vilken utsträckning. Skulle det visa sig att det finns en sådan koppling bör det övervägas om försiktighetsprincipen snarare talar för att erbjuda behandling. Det saknas studier kring om risken för ånger efter underlivskirurgi skulle skilja sig för en yngre åldersgrupp, men det kan finnas faktorer som skulle kunna tala för det. Detta utesluter inte att det i individuella fall kan anses berättigat att erbjuda underlivskirurgi i undantagsfall, särskilt om personerna fysiologiskt och mognadsmässigt närmar sig vad som generellt gäller för personer som är 18 år. Eftersom det är ett oavvisligt krav för underlivskirurgi i detta fall att personen kan ge sitt informerade samtycke, finns det skäl att ha en lägsta åldersgräns från vilket personer generellt kan anses har tillräcklig förmåga att kunna ge ett sådant samtycke. Trots att det är svårt att sätta upp generella åldersgränser för autonom förmåga, så förefaller 15 år vara en rimlig gräns givet att det är den ålder i vilken personer tillåts självständigt ge sitt informerade samtycke till att delta i forskningsprojekt. Restriktivitet med att erbjuda personer under 18 år tillgång till underlivskirurgi utifrån ovanstående risk/nytta-bedömning, implicerar att det bör ställas höga krav på autonom förmåga för att tillåta det i individuella fall för personer under 18 år. Utifrån behovet att stärka evidensen för behandling av den yngre populationen och som en kontrollfunktion finns det skäl att sådan behandling endast ges inom ramen för kliniska studier som genomgått etikprövning vid Etikprövningsmyndigheten. Generellt gäller att försiktighetsprincipen implicerar en större försiktighet ju yngre personerna är för att gradvis kunna minska ju mer personerna närmar sig 18-årsgränsen.The ethical analysis in this report concerns a lower age threshold for gender confirmation surgery of the genitalia and is commissioned by the Swedish National Board of Health and Welfare. In the analysis the following aspects are discussed: risk/benefit, autonomy, fairness/equality. Generally, a precautionary principle for offering gender confirmation surgery to patients from 15 years of age is suggested with the following arguments. Surgery have irreversible and far-ranging consequences, and where fairly weak evidence from an older population are just to treat a younger population. The outcome of the surgery is strongly dependent upon the gender identity of the person, causing insecurity for a population undergoing strong cognitive and emotional development. The specific character of the patient need, where a necessary (though not sufficient) criterion is the person’s own preferences for which interventions are necessary to reduce gender dysphoria, and not recommendations from the healthcare staff. The suffering caused by delaying treatment seems reversible, except when it comes to possible suicide. At the same time, there is lack of evidence to what extent suicide as a result of delayed treatment occurs. If such a causal correlation would be established, a precautionary principle could support offering treatment. There is lack of knowledge on regret after treatment for the younger group, but being in a situation of strong cognitive and emotional development could give us reason to believe there will be a higher frequency of regret. This does not preclude that in the individual case, gender confirmation surgery of the genitalia could be motivated – especially if the person is considered to be physiologically and emotionally in line with an 18-year-old. Given that a person should be able to give an informed consent to the treatment, we have reason to have a lowest possible age threshold where persons generally have autonomous ability to give such consent. Despite it being difficult to define such a threshold, 15 could be a suitable threshold given Swedish legislation on when individuals are allowed to give informed consent to participate in research projects. Given the restrictive stance based on the above risk/ benefit assessment, individual exception should have high standards for autonomous ability. The need to strengthen the evidence base for treatment of the younger population, and as an extra control function, we have reason only allowing such treatment within clinical studies with ethical review from the Ethical Review Authority. Generally, the precautionary principle recommends greater precaution the younger a person is, gradually be relaxed as the person approaches the age of 18

Ett gott liv på äldre dar

När människor blir äldre och drabbas av sjukdom så ökar deras beroende av andra människors hjälp, iförlängningen innebär det att deras beroende av professionell hjälp ökar och att de därmed blir beroendeav äldreomsorg i olika former. Att de blir beroende sker ju inte över en natt utan det sker gradvis och detinnebär då att det sker en gradvis förändring av deras normala liv. I detta normala liv försöker de flestamänniskor skapa ett så gott liv som möjligt för sig själv och sina närmaste och följaktligen bör då ävenäldreomsorgen ha som mål att skapa möjlighet för den äldre och dennes närmaste att leva ett så gott livsom möjligt, trots sjukdom och ökat beroende (Brülde 2001). Äldreomsorgens mål kan alltså inte i förstahand vara att bota utan framförallt att ge möjlighet till ett fortsatt gott liv