Mahmoud F. Fathalla
There is an ethical imperative to take public health action to eliminate the global problem of unsafe abortion. The moral obligation is dictated by the magnitude of the problem, the health inequities and social injustices that result from lack of access to safe abortion, the voices of women calling for action, and an international consensus recognizing unsafe abortion as a global health problem. The availability of public health interventions and the cost savings associated with fewer abortion complications reinforce the obligation to address unsafe abortion. Public health actions include reducing the need for abortion through family planning, providing safe abortion to the full extent of the law, managing abortion complications, and providing post-abortion care. These actions intersect with morality, religion, law, justice, and human rights. The public health community has a collective social and ethical responsibility to stand beside and behind women as they claim their human right to health.
Anne Drapkin Lyerly, Elana Jaffe, and Margaret Olivia Little
Advancing fair access to evidence-based pregnancy-related services is a critical public health priority. It is widely recognized that there are inequalities in lifesaving interventions. This chapter however addresses issues raised by services whose value or utility are contested. Using illustrative examples of prenatal genetic testing and modes of childbirth, the chapter highlights the ways in which issues of access are complicated by social and cultural ideas about what is valued; discusses contested questions about what is ethically responsible or required of patients, providers, and public health systems in these reproductive health contexts; and addresses areas of needed research and further ethical analysis. It concludes that issues of access in pregnancy-related care must attend both to broad issues of justice and access and to particular ways that pregnancy services are valued, debated, and made available to women who might—or might not—benefit from them.
This chapter examines three primary public health goals relating to elderly populations: promoting healthy aging (including aging in place), reducing health inequities, and extending life spans. It then considers the ways in which programs or policies to advance population-wide goals are challenged to meet ethical responsibilities to protect older adults from harm, respect their autonomy and dignity, and treat them fairly or justly when resources are limited. Lastly, by looking at a difficult situation commonly faced in hospitals—the discharge of an elderly patient who may not be able to safely return home—the chapter introduces questions about the relationship between public health ethics, clinical ethics, and social justice, and about the future role of public health as a field of inquiry and action.
This chapter examines ethical principles that guide public health intervention to reduce the harms of alcohol and other drugs, including justice-based concerns regarding intervention. While many egalitarian moral theories support public health measures to reduce these harms, and thereby protect individual capability and opportunity, there are opposing arguments to limit public health intervention based on either individual liberty or personal responsibility. The chapter also reviews ethical issues related to prevention, treatment, harm reduction, and decriminalization/legalization. Prevention through education is politically appealing, but is not always evidence-based and can be stigmatizing. Treatment can be highly cost-effective, but some approaches are controversial, such as legally coerced treatment. Harm reduction approaches, such as needle exchange, can reduce many of the negative health consequences of alcohol and drug use, but they require a more direct government role in illicit behaviors. Marijuana legalization is a growing movement in the United States, but it poses complex regulatory challenges.
This chapter explores disability-based criticism against what is here called selective reproductive technology (SRT) such as prenatal screening programs in light of recent calls for disability theory, as well as political activism based on that, to accommodate for an intersectional turn across all types of critical social identity studies (class, disability, gender, LGBT, queer, race, etc.). Applying intersectionality to the disability SRT critique generates complex and provoking implications, not invalidating it but radically transforming its shape and direction. Most notably, it inserts a wedge between the identity-based experience that SRT unjustly discriminates and oppresses disabled people and the identity political call for SRT programs to be shut down or at least not publicly supported. Intersectionality steers the justification toward politically addressing structural factors explaining injustice independently of identity-based experience, and SRT programs may have to be allowed for such action to be sustainable also from a disability identity standpoint.
Nicholas Evans and Thomas Inglesby
This chapter introduces ethical issues that arise in the context of biosecurity: policies and actions intended to prevent the development or emergence, or mitigate the consequences, of serious biological threats. These threats could include deliberate biological weapon attacks (bioterrorism), pandemics, emerging infectious diseases, or major laboratory accidents. The basic values that underpin these public health concerns are first introduced. Ethical issues that arise before, during, and following a biosecurity crisis are then examined, including issues of resource allocation, dual-use research, and the possibility of quarantine. Their resolution requires trade-offs among different ethical values, including utility, fairness, and liberty.
This article argues in defence of the application of an empathy-based approach to moral education. It describes the nature of care ethics as it has developed in recent years in the work of many authors and shows the relevance of empathy to care ethics and to moral education based on such ethics. It discusses Carol Gilligan's In a Different Voice: Psychological Theory and Women's Development and Nel Noddings recent work to highlight some ways in which the relevance of caring to moral education may be relatively independent of questions of empathy.
The population of children and adolescents encompasses a remarkable range of physiological, developmental, and experiential phenomena. Considered from a global perspective, differences may seem to overwhelm similarities. This chapter proposes and explains three distinct but interrelated characteristics that should frame ethical considerations of public health approaches to children and adolescents: (1) lack of political, economic, and social power; (2) status as subject to stewardship by adults; and (3) presumed lack of capacity for decision-making.The impact of these shared characteristics is examined using public health approaches to health information, health promotion and access to confidential services. Public health policies that anticipate the risks related to powerlessness and failures of stewardship, and seek to promote respect for developing capacity can help to create conditions in which children can thrive.
This chapter develops a civic republican approach to disability justice. It begins by articulating a republican account of liberty as nondomination before showing how such domination can shape the relationships of people with disabilities. This leads to a consideration of whether disability justice can be defined in terms of maximizing or sufficient nondomination. Instead, the chapter provides a civic framework within which republican disability justice can be understood, encompassing both the absence of oppressive relationships and the presence of capabilities of special egalitarian concern. It also considers some specific normative implications of a republican account of disability justice—doubting the suitability of contestatory democracy but pointing toward the merits of self-education and universal basic income. Finally, the objection that this republican approach to disability justice unreasonably denigrates dependence is rebutted.
This chapter explores the ethical dimensions of diplomatic efforts to form a global agreement on climate change. It offers a brief historical background on the core multilateral climate negotiation body, the United Nations Framework Convention on Climate Change, and highlights some contentious moral elements of these negotiations. In particular, it explores the complex ways in which the principle of “common but differentiated responsibilities” (CBDR) has driven debates on how burdens for mitigation, adaptation, and finance should be distributed between developed and developing countries. It then considers the transformation in these climate negotiations since 2009, including the move toward a bottom-up architecture as part from the Copenhagen Accord to the Paris Agreement. Finally, it assesses the current state of climate diplomacy in relation to broader diplomatic priorities, arguing that climate diplomacy must be elevated alongside other top-tier foreign policy issues today in order to eventually achieve some level of climate stability.
Zoe Drayson and Andy Clark
Many models of cognitive ability and disability rely on the idea of cognition as abstract reasoning processes implemented in the brain. Research in cognitive science, however, emphasizes the way that our cognitive skills are embodied in our more basic capacities for sensing and moving, and the way that tools in the external environment can extend the cognitive abilities of our brains. It is important to address the implications of research in embodied cognition and extended cognition for how we think about cognitive impairment and rehabilitation, how cognitive reserve mitigates neural impairment, and the distinction between medical and social models of disability.
This chapter provides a roadmap of ongoing conversations about cognitive disability and moral status. Its aim is to highlight the political stakes of these conversations for advocates for the cognitively disabled while at the same time bringing out how a fundamental point of divergence within the conversations has to do with what count as appropriate methods of ethics. The main divide is between thinkers who take ethical neutrality to be a regulative ideal for doing empirical justice to the lives of people with cognitive disabilities and those who reject this methodological precept as unduly restrictive. What results is a debate between, on the one hand, fans of various familiar forms of moral individualism and Kantian approaches in ethics and, on the other, a range of disability scholars and activists who implicitly or explicitly make use of philosophically more radical methods.
David R. Buchanan
The conduct of community-based participatory research (CBPR) is a recent innovation in research designs aimed at identifying effective public health interventions. CBPR aims to maximize participation of affected populations in all phases of the research to fulfill three purposes: it is (1) a method for developing innovative interventions, (2) an intervention itself intended to change the respective partners positively as a result of their participation, and (3) a means to fulfill an ethical obligation. CBPR is most ethically significant for respecting community autonomy and providing protections from community-level harms, such as stigmatization of identifiable social groups, lost opportunity costs, and overcoming mistrust, which may lead to reluctance to participate in research and, hence, a lack of empirical data on potential adverse effects or benefits for certain social groups. Key unresolved issues include procedures for enlisting legitimate community representatives and the scope of their authority over the conduct of the research.
Armand H. Matheny Antommaria
Conscientious objection in health care generally involves conflicts between health care providers asserting authority not to provide certain goods and services such as emergency contraception or abortion and patients seeking them. The conflict is may be exacerbated by objectors’ refusal to cooperate with others performing these actions. Equitable resolution of this conflict depends on the role responsibilities of health care providers and the availability of alternatives for patients. Protection of the integrity of providers should not substabtially limit patients’ access to needed goods and services, especially because of the power and knowledge differential between health care professionals and patients and the restrictions on patients obtaining goods and services through other means. Although professional obligations entail clear duties such as notification, informed consent, and emergency treatment, there is contining debate about obligations to refer and what constitutes discrimination. Organizations may make analogous claims regarding their integrity and similar systems should be developed to assure patient access.
Consciousness, understood as an awareness of what is going on that helps shape one’s experiences, is one of the ways that scholars have distinguished animal life from the rest of the natural world. Beings that have interests in having good experiences and avoiding bad ones deserve our moral attention, and this quality is an important feature of ethical engagement with other sentient beings, both human and nonhuman. What interests matter and why they matter is a subject of disagreement that has affected what we judge to be permissible or impermissible treatment of other animals. Empathy toward and respect for other animals takes us beyond attention to their suffering and has us focus on what counts as well-being for others, by their own lights.
Saumya RamaRao and John Townsend
This chapter discusses how potential conflicts between individual rights and public health goals can be managed in the context of contraceptive service delivery and research. It applies three ethical principles—respect for persons, beneficence, and justice—to illustrate how those tensions play out in a variety of challenging situations prevalent in the fields of family planning and reproductive health. That analysis is followed by a discussion of the consequences of those conflicts for health systems, family planning providers, and users of health systems. The chapter focuses on developing countries and makes relevant parallels for global policymaking and service delivery.
This chapter considers why social contract accounts may seem particularly ill-suited to address justice for all persons with impairments or illnesses. Two variants of social contract theory are discussed: contractarianism and contractualism. It is argued that while contractarian theories may be able to address certain basic needs and interests of persons with impairments or illnesses, such theories are, nonetheless, unacceptable if one holds that (nearly all) human beings are owed justice because of their own value or intrinsic worth. Although Rawls did not address justice for those with impairments in his theory in any detail, it is argued that contractualists can develop quite inclusive theories. Two strategies for developing an inclusive contractualism are discussed, both of which focus on a capacity for cooperative contribution possessed by nearly all human beings and in which we can understand the intrinsic value of persons as inhering.
Laura Greisman, Barbara Koenig, and Michele Barry
This chapter delves into the ethical issues surrounding the implementation of public health interventions for control of mosquito-borne illnesses. Emerging and reemerging mosquito-borne infections remain a public health threat worldwide, prompting public health agencies to strengthen individual and population-wide measures for mosquito control. Ethical issues surrounding surveillance activities and key public health interventions for mosquito control are discussed, including provision of insecticide-treated nets (ITNs), the spraying of aerial pesticides, and the introduction of genetically modified mosquitoes. A case study of Zika virus disease highlights specific ethical challenges surrounding the safety of insect repellent use in pregnancy and the complex issue of women’s reproductive rights arising in a fast-moving epidemic. The chapter emphasizes the need for community engagement at all levels of mosquito control interventions, and it highlights the disproportionate impact of mosquito-borne disease on the poor, calling to action the need to strengthen health systems in low- and middle-income countries.
Cost-effectiveness analysis (CEA) is an analytical tool in health economics. One of the most important objections to it is that its use can lead to unjust discrimination against people with disabilities. This chapter evaluates this objection. It begins by clarifying its nature, then it examines some alleged forms of discrimination. It argues that they are either not cases of unjust discrimination, or they are based on misunderstandings of CEA. However, the chapter does point out that there is one case in which the use of CEA may disadvantage people with disabilities. It goes on to consider several proposals for explaining the wrongness of discrimination but argues that none of them accommodates this case. It concludes that the case should not be thought as a matter of unjust discrimination; rather, it should be thought of as raising an issue for justice in the allocation of health-care resources.
It has been argued that dignity is a useless concept that adds nothing to existing moral vocabulary: it is just a slogan. In this chapter, it is argued that only a concept of dignity can adequately explain a serious moral wrong inflicted on people with disabilities, namely their relegation to inferior social status. Far from being useless, it uniquely explains why fundamental changes to social relations are needed to secure justice. Moreover, dignity matters just as much for people with cognitive impairments as it does for everyone else. As such, fraught debates about the moral standing of people with severe cognitive impairment are largely irrelevant to explaining why they, too, should be treated as social equals.