Why we shouldn’t always compensate people for historical wrongs

Human research ethics has often been formulated in response to scandals. However, the majority of research ethics cases are actually quite mundane. They involve committees making decisions about the likely balance between risks and benefits of the proposed research. Most researchers are well-intentioned and much research is conducted for public benefit. But what should we do when things go wrong? What about when evidence of wrongdoing is uncovered long after the event? Are survivors entitled to compensation? A current example of just such a case provides an opportunity to examine the issues involved

Trust, trustworthiness and health

Trust is an essential component of good healthcare. If patients trust their physicians, then the relationship between them can be a richer and more meaningful one. The patient is more likely to feel confident and able to disclose symptoms, helping diagnosis and future care. If public health and community workers are trusted, not only is it likely that their work will be easier, in that their actions will be respected and accepted, but their advice will also be sought spontaneously. Trust, can, therefore, be thought of as something that is of benefit to all: healthcare workers, individuals and communities. Trust is, generally, something to be prized and we need to do anything we can to strengthen it. However, trust can also be misplaced (1) Individuals may be trusted because of their social position and role, rather than because they necessarily deserve it

Snakes and ladders: state interventions and the place of liberty in public health policy

In this paper I outline and explore some problems in the way that the Nuffield Council of Bioethics’ report Public Health: Ethical Issues presents its ‘Intervention Ladder’. They see the metaphor of a ladder both as capturing key normative priorities and as making a real and important contribution to ethical policymaking in public health. In this paper I argue that the intervention ladder is not a useful model for thinking about policy decisions, that it is likely to produce poor decisions, and that it is incompatible with the report’s stated approach to relevant public health policy values

The nature and ethics of natural experiments

Natural experiments are an important methodology often used to answer research questions that would, otherwise, be impossible to address, or employed because of ethical concerns about the use of randomisation to interventions that carry known risks. The UK Medical Research Council (MRC) recently produced an extremely useful document discussing the nature and significance of natural experiments within medical and public health research. In this paper, however, we suggest that the MRC document's definition of the term ‘natural experiment’ is insufficiently precise. In response, we offer a taxonomy of different types of natural experiments and related methods, and explore the ethical implications of these different types. We argue that while the ethical issues that may arise within natural experiments in relation to risks of harm or informed consent may differ from those within the randomised controlled trial, they are not thereby less pressing. The implications of the argument are explored and recommendations made for those involved in research governance

Ethical Frameworks in Public Health Decision-Making: Defending a Value-Based and Pluralist Approach

A number of ethical frameworks have been proposed to support decision-making in public health and the evaluation of public health policy and practice. This is encouraging, since ethical considerations are of paramount importance in health policy. However, these frameworks have various deficiencies, in part because they incorporate substantial ethical positions. In this article, we discuss and criticise a framework developed by James Childress and Ruth Bernheim, which we consider to be the state of the art in the field. Their framework distinguishes aims, such as the promotion of public health, from constraints on the pursuit of those aims, such as the requirement to avoid limitations to liberty, or the requirement to be impartial. We show how this structure creates both theoretical and practical problems. We then go on to present and defend a more practical framework, one that is neutral in avoiding precommitment to particular values and how they ought to be weighted. We believe ethics is at the very heart of such weightings and our framework is developed to reflect this belief. It is therefore both pluralist and value-based. We compare our new framework to Childress and Bernheim’s and outline its advantages. It is justified by its impetus to consider a wide range of alternatives and its tendency to direct decisions towards the best alternatives, as well as by the information provided by the ranking of alternatives and transparent explication of the judgements that motivate this ranking. The new framework presented should be useful to decision-makers in public health, as well as being a means to stimulate further reflection on the role of ethics in public health. Keywords Decision-making Ethical frameworks Justification Public health Value pluralis

Academic freedom and the professional responsibilities of applied ethicists: a comment on Minerva

Academic freedom is an important good, but it comes with several responsibilities. In this commentary we seek to do two things. First, we argue against Francesca Minerva's view of academic freedom as presented in her article ‘New threats to academic freedom’ on a number of grounds. We reject the nature of the absolutist moral claim to free speech for academics implicit in the article; we reject the elitist role for academics as truth-seekers explicit in her view; and we reject a possible more moderate re-construction of her view based on the harm/offence distinction. Second, we identify some of the responsibilities of applied ethicists, and illustrate how they recommend against allowing for anonymous publication of research. Such a proposal points to the wider perils of a public discourse which eschews the calm and careful discussion of ideas

Global Health and National Borders

ABSTRACT: BACKGROUND: The governments and citizens of the developed nations are increasingly called upon to contribute financially to health initiatives outside their borders. Although international development assistance for health has grown rapidly over the last two decades, austerity measures related to the 2008 and 2011 global financial crises may impact negatively on aid expenditures. The competition between national priorities and foreign aid commitments raises important ethical questions for donor nations. This paper aims to foster individual reflection and public debate on donor responsibilities for global health. METHODS: We undertook a critical review of contemporary accounts of justice. We selected theories that: (i) articulate important and widely held moral intuitions; (ii) have had extensive impact on debates about global justice; (iii) represent diverse approaches to moral reasoning; and (iv) present distinct stances on the normative importance of national borders. Due to space limitations we limit the discussion to four frameworks. RESULTS: Consequentialist, relational, human rights, and social contract approaches were considered. Responsibilities to provide international assistance were seen as significant by all four theories and place limits on the scope of acceptable national autonomy. Among the range of potential aid foci, interventions for health enjoyed consistent prominence. The four theories concur that there are important ethical responsibilities to support initiatives to improve the health of the worst off worldwide, but offer different rationales for intervention and suggest different implicit limits on responsibilities. CONCLUSIONS: Despite significant theoretical disagreements, four influential accounts of justice offer important reasons to support many current initiatives to promote global health. Ethical argumentation can complement pragmatic reasons to support global health interventions and provide an important foundation to strengthen collective action

Global health and national borders : the ethics of foreign aid in a time of financial crisis

Background: The governments and citizens of the developed nations are increasingly called upon to contribute financially to health initiatives outside their borders. Although international development assistance for health has grown rapidly over the last two decades, austerity measures related to the 2008 and 2011 global financial crises may impact negatively on aid expenditures. The competition between national priorities and foreign aid commitments raises important ethical questions for donor nations. This paper aims to foster individual reflection and public debate on donor responsibilities for global health. Methods: We undertook a critical review of contemporary accounts of justice. We selected theories that: (i) articulate important and widely held moral intuitions; (ii) have had extensive impact on debates about global justice; (iii) represent diverse approaches to moral reasoning; and (iv) present distinct stances on the normative importance of national borders. Due to space limitations we limit the discussion to four frameworks. Results: Consequentialist, relational, human rights, and social contract approaches were considered. Responsibilities to provide international assistance were seen as significant by all four theories and place limits on the scope of acceptable national autonomy. Among the range of potential aid foci, interventions for health enjoyed consistent prominence. The four theories concur that there are important ethical responsibilities to support initiatives to improve the health of the worst off worldwide, but offer different rationales for intervention and suggest different implicit limits on responsibilities. Conclusions: Despite significant theoretical disagreements, four influential accounts of justice offer important reasons to support many current initiatives to promote global health. Ethical argumentation can complement pragmatic reasons to support global health interventions and provide an important foundation to strengthen collective action