20-01-23 - Ethics - Global Health Flashcards
Learning outcomes
- Name key international documents (conventions and declarations) which refer to health as a human right
- Explain why infectious diseases are an important area in global health ethics
- Discuss six conditions that would have to be met for the use of enforced isolation or quarantine to be employed ethically
- Explain the difficulty and yet importance of obtaining valid consent, community engagement and benefit to participants, when carrying out research in developing countries
- Describe the problem, highlighted in the 1997 AZT trials, that can be posed by the “control” used in some international drug trials
- Recognise that internationally, medical personnel are protected under the Red Cross/Crescent/Crystal and that their primary task (WMA) is to “preserve health and save life”.
- Explain the dilemmas that medical students undertaking electives in resource-poor countries may face and discuss how best they may ethically address them
- Describe some of the ethical issues encountered during the medical response to the 2014 Ebola outbreak
What is global health?
What are 3 reasons we should care about global health?
- Global health is the health of the populations in the worldwide context; it has been defined as “the area of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide”
- 3 reasons we should care about global health:
1) It benefits us
2) Humanitarian duty of assistance (Peter Singer)
3) Justice:
1) No moral significance to country boundaries
2) Legacy & reparation
3) Human rights & global responsibility to their realisation
What 4 international documents deal with global health?
What is stated in the:
1) WHO constitution (2006):
2) Universal Declaration of Human Rights (UN) (1948)
3) International Covenant on Economic, Social & Cultural Rights (1976)
4) UN Convention on the Rights of the Child (1990)?
- 4 international documents that deal with global health:
1) WHO constitution (2006):
* The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.
2) Universal Declaration of Human Rights (UN) (1948)
* Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
* Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.
3) International Covenant on Economic, Social & Cultural Rights (1976)
* The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.
4) UN Convention on the Rights of the Child (1990)
* States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services
What are 4 reasons why infectious diseases are a global ethical issue?
- 4 reasons why infectious diseases are a global ethical issue:
1) “Unrivalled consequences”
2) Control measures raise important questions re: violation of important rights –
* Right to freedom of movement
* Right to privacy
* Right to informed consent
3) Justice
4) Diseases do not respect boundaries
Ethics of violation and quarantine.
What 6 considerations does Michael Selgelid list regarding quarantine?
- Ethics of violation and quarantine.
- 6 considerations Michael Selgelid lists regarding quarantine:
1) Must be effective in controlling the disease
2) If less restrictive measures achieve the same effect, use them
3) Consequences of not quarantining must be severe
4) Must be implemented in an equitable manner
5) Must be minimally burdensome
6) Those contained must receive compensation
What are 3 good moral reasons for carrying out research in developing countries?
What 3 other reasons are also considered when carrying out research in developing countries (often cited in relation to clinical trials)?
- 3 good moral reasons for carrying out research in developing countries:
1) Global health inequalities
* May have a greater effect in these areas
2) Disproportionate burden of disease
3) Value of research in developing countries*
- 3 other reasons also considered when carrying out research in developing countries (often cited in relation to clinical trials):
1) Less stringent ethical standards
2) Cost
3) Number of participants, particularly drug-naïve
What are 6 important considerations in research and clinical trials?
- 6 important considerations in research and clinical trials:
1) Ethical review & protection of participants
2) Healthcare infrastructure – Let’s talk “controls” in clinical trials
3) Valid consent
4) Community engagement
5) Benefits to participants after trial/research is over
6) The importance of collaborating with local scientists
- Recall back to Declaration of Helsinki (2013)
What is the control question in clinical trials?
When was this issue raised?
What does the Declaration of Helsinki (2013) say on this topic?
- Control question in clinical trials:
- Key trial: 076 protocol (1994) – concerns published 1997 NEJM around ongoing trials in developing countries AZT and maternal-child transmission of HIV
- What is the correct control to use?
- Placebo v experimental treatment, or standard treatment v experimental treatment?
- This issue was also raised during Ebola outbreak
- The updated Declaration of Helsinki (2013) allows flexibility (section 33):
- Section 33 MD3002 18 Use of Placebo 33.
- The benefits, risks, burdens and effectiveness of a new intervention must be tested against those of the best proven intervention(s), except in the following circumstances: Where no proven intervention exists, the use of placebo, or no intervention, is acceptable; or Where for compelling and scientifically sound methodological reasons the use of any intervention less effective than the best proven one, the use of placebo, or no intervention is necessary to determine the efficacy or safety of an intervention and the patients who receive any intervention less effective than the best proven one, placebo, or no intervention will not be subject to additional risks of serious or irreversible harm as a result of not receiving the best proven intervention. Extreme care must be taken to avoid abuse of this option.
What projects look into ethics in disaster and war?
What are the medical ethics in times of armed conflict?
According to WMA guidelines:
* What is a physicians primary obligation?
* What is the primary task of the medial profession?
* What bodies are medial personnel protected under?
- What is a physicians primary obligation?
- What is the primary task of the medial profession?
- What bodies are medial personnel protected under?
- ELAC Humanitarian Ethics project (Oxford) -“Aid Agencies and Moral Choices in War and Disaster” looks into ethics during war and disaster
- Medial ethics in times of armed conflict - “identical to medical ethics in times of peace, as stated in the International Code of Medical Ethics of the WMA.”
- According to WMA guidelines:
1) A physician’s primary obligation is to their patients
2) The primary task of the medical profession is to preserve health and save life
3) Medical personnel protected under Red Cross & Red Crescent, and also now Red Crystal (Geneva Convention)
What 3 areas of medical ethics did the Ebola outbreak highlight issue in?
- 3 areas of medical ethics the Ebola outbreak highlighted issue in:
1) Health and human rights
2) Quarantine/isolation
3) Justice: access to medication
What are 4 examples of where the Ebola outbreak highlighted inequalities and issues around justice?
- 4 examples of where the Ebola outbreak highlighted inequalities and issues around justice:
1) Ebola outbreak centred around some of the poorest countries in the world
* Lack of basic healthcare facilities to treat patients
* Lack of basic disease response infrastructure
2) Originally not regarded as a Western problem (until cases emerged in the US and Spain)
3) Should Western healthcare workers working in affected countries be transferred to back to Western healthcare facilities?
4) Who should receive the limited (experimental) treatments?
How did the Ebola outbreak highlight problems in medical ethics regarding quarantine/isolation?
- How the Ebola outbreak highlighted problems in medical ethics regarding quarantine/isolation:
- Should healthcare workers returning from Ebola treatment centres be quarantined?
- Following the return of a doctor (Craig Spencer) who developed Ebola on return to New York there was then debate over ‘isolation’ policies
- Kaci Hickox was quarantined against her will after returning from West Africa
- Hickox then challenged Maine’s requirements that people who have had contact with Ebola patients be ‘isolated’ through quarantine.
- (Note: Pauline Cafferkey, Scottish nurse who worked in Sierra Leone, was in isolation for a month after being diagnosed with Ebola)
How did the Ebola outbreak highlight problems in medial ethics regarding justice: access to mediation?
- How the Ebola outbreak highlighted problems in medical ethics regarding justice: access to mediation
- Several promising drugs and treatments, which were not yet been evaluated for safety and efficacy in humans
- Panel was convened by the WHO in August 2014 to determine whether it was ethical to administer these despite the potential for unknown adverse effects and to determine who should receive priority – concluded Ebola outbreak was exceptional and it was ethically acceptable to offer unproven (but promising) interventions but ethical standards (such as informed consent, fairness, autonomy) must be maintained
- Study design was also controversial (RCT ‘gold standard’ or not)
What do we need to consider regarding short term projects in developing countries?
What are 4 parts to the BMA tool kit?
What does toolkit also mention?
- In regards to short term projects in developing countries, we must consider BMA toolkit for “Ethics & medical electives in resource poor countries”, for example:
1) Stay within your competence
2) Maintain ethical standards
3) Develop “cultural competence” (Bowman, 2011)
4) Minimise burden on host country & healthcare system
- Toolkit also mentions communication & emergencies
