PoPulationand Public HealtH etHics

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policy essential to examine the history of biomedical ethics over the decades since the Nuremberg Code was formulated in 1947. The principles of autonomy and individual choice, as well as that of consent, have historically prevailed in 20th century bioethics frames, particularly in the Western developed countries. 6 This narrow framing of biomedical ethics around individual choice and protection of research subjects has overlooked ethics in developing or less affluent countries. It also neglected ethical issues in a context of populations. Moreover, this approach does not recognize that public health extends beyond the immediate treatment of individual patients to include crucial infrastructures in many forms and shapes: medical and health outcomes databases; population biobanks; education of medical staff and doctors; local, regional and international standards on technologies; standards on international development aid; and aid effectiveness in developing countries. 5,7,8 Indeed, the ethical concern over individual choice, autonomy and consent should be understood as being embedded within such broader health infrastructures that together constitute public health and public health ethics. Such public health infrastructures are not distributable goods, 4,5 nor do they represent targeted health interventions (e.g., unlike prescription medication) that can be subject to individual choice and consent. Public health infrastructures sustain, and are sustained by, the global or regional populations and thus raise entirely different sets of ethical issues that relate to collective action. 9,10 Collective action refers to organization of individuals’, institutions’ or governments’ goals, values and priorities to permit sufficient cooperation among them and by extension collective human agency towards common, shared and explicated targets. 9,10 The ethical issues raised by collective action such as free-riders, unlike those addressed by traditional biomedical ethics, are governed by principles such as solidarity and citizenship. 6,11,12 This case study describes malaria as endemic to, and vastly affecting public health in, tropical nations, nations that are often low- and middle-income countries (lMICs). A broad range of ethical issues seriously affecting 21st century population health in lMICs are raised in this case, issues that cannot be adequately identified or resolved successfully within the individual choice- and autonomy-based protectionist ethics frames inherited from the 20th century ethics discourse. PoPulation anD Public HealtH etHics 86
While protection of research subjects remains crucial, addressing global public health ethics responsibly demands broadening ethics frames to recognize issues that have been previously omitted from the purview of bioethics in developed affluent nations. Additionally, ethics analyses and scholarship are in need of ‘symmetry’: both protection from risks and potential benefits of global health and global science have to be considered in tandem, so as to develop a nuanced and in-depth understanding of public health ethics in lMICs. The overarching shift and transformation of 21st century bioethics towards public health ethics, summarized above, provides a crucial context for the specific analyses of the ethics issues below, as related to malaria in resourcelimited poor nations. Global public health ethics and the case of malaria While ethical issues have often been understood as ‘impacts’, ethics is not simply a consequence of, but rather is embedded in, science, technology and public health practice, and thus ‘context-emergent’. The actual global public health ethics issues can therefore be identified by empirical engagement with the real-life context of both malaria and lMICs. Moreover, because the ‘law in the books’ and the ‘law on the streets’ can be markedly different in lMICs, socio-ethical, legal and policy norms intended to protect research participants or ensure justice in the provision of public health services cannot be assumed to be uniformly applied in practice. Experience suggests that the ethical issues concerning malaria can best be identified, analyzed and addressed when ‘ethics is embedded in the design and implementation of’ research projects’ 13 and in real-life public health practice. 14 Malaria chemoprevention-related drugs have been the subject of bioethics debates in terms of equitable access, pricing and distribution of these drugs between developed countries and lMICs. However, other and low-cost public health products are also conceivable or already available for malaria prevention and control. Most notable are insecticide-treated mosquito nets but other emerging interventions such as odorants, entomopathogenic fungi and genetically modified mosquitoes are also becoming available. 15 These newer forms of interventions need to be tested, however, for their effectiveness, acceptability and unintended consequences in real-life community settings in Worldwide and local anti-malaria initiatives 87
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PoPulationand Public HealtH etHics
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contents Acknowledgements - page 5
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acknowleDgeMents The Partners would
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» Create a tool to support instruc
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Each of the discussants took on thi
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Twenty years on, things have change
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intervention (say reduction in mort
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ethics understands dilemmas not onl
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priority setting. 17 Once more, usi
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6 See for example the WHO Commissio
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obesity surveillance in scHool cHil
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esearch 2 Inevitably children will
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esearch Case discussion in response
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It would be ideal to get active inf
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esearch participation, leading to a
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to sHare or not to sHare? Secondary
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esearch Scenario shift » What if t
Page 36 and 37: esearch Many different parties have
Page 38 and 39: esearch of his concern for people w
Page 40 and 41: esearcH etHics anD conFlicts oF int
Page 42 and 43: esearch and non-public information
Page 44 and 45: esearch reFerences 1 Public Health
Page 46 and 47: esearch Key ethical dimensions Perh
Page 48 and 49: esearch such support, seen across t
Page 50 and 51: esearch Proposed resolution Enablin
Page 52 and 53: a tool For etHical analysis oF Publ
Page 54 and 55: esearch are explicit. In Quebec, su
Page 56 and 57: esearch reFerences 1 Bayer, R. and
Page 58 and 59: Part two Policy
Page 60 and 61: policy being increasingly introduce
Page 62 and 63: policy behaviour. Therefore, the et
Page 64 and 65: policy 18 Chapman, S. and Freeman,
Page 66 and 67: policy through outdoor smoking, any
Page 68 and 69: policy that this is an injustice. W
Page 70 and 71: DeFerring blooD Donation FroM Men w
Page 72 and 73: policy 26 per cent of new infection
Page 74 and 75: policy 6 NHS Blood and Transplant.
Page 76 and 77: policy public trust might also incl
Page 78 and 79: policy lived in certain regions in
Page 80 and 81: policy 4 Zou, S., Musavi, F., Notar
Page 82 and 83: policy Case description For nearly
Page 84 and 85: policy 3 Economic conditions could
Page 88 and 89: policy lMICs. Evidence-based introd
Page 90 and 91: policy governments, regional develo
Page 92 and 93: First nations Drinking water Polici
Page 94 and 95: policy federal government was aware
Page 96 and 97: policy reFerences 1 Health Canada.
Page 98 and 99: policy Core issue Case study author
Page 100 and 101: policy Additional issues It may be
Page 102 and 103: policy Arguably, an exception might
Page 104 and 105: policy Case Following the pharmaceu
Page 106 and 107: policy 3 What potential harms may b
Page 108 and 109: policy in the “anti-cancer vaccin
Page 110 and 111: policy adults may choose for themse
Page 112 and 113: policy Men also suffer some HPV-cau
Page 114 and 115: ManDatory iMMunization oF local Pub
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Page 118 and 119: policy Case discussion in response
Page 120 and 121: policy the degree of infringement o
Page 122 and 123: Part tHree Practice
Page 124 and 125: practice Case The Inquiry found tha
Page 126 and 127: practice Questions for discussion 1
Page 128 and 129: practice is a basic ethical obligat
Page 130 and 131: practice harm is remote, the cost/b
Page 132 and 133: practice that the professional plac
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practice Questions for discussion 1
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practice In what follows, I will de
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practice will end up having to comp
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practice Getting Clear on What’s
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using PersonalizeD letters oF invit
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practice Cervical cancer is relativ
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practice Case discussion in respons
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practice principle should only be t
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practice potentially cause the gene
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practice Nations’ constitutional
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practice Questions for discussion 1
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practice sanitation and poor housin
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practice Decision making While the
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alberta oil sanDs A toxic mixture o
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practice resolution calling for the
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practice Second, the process of oil
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practice contributing to “contrac
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practice How might the decision and
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wHose role is it to Deal witH socie
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practice same artisanal miners to d
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practice The ethical principle of b
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practice Identify the options avail
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