Smoking & autonomy: the generational tobacco endgame.

New Zealand and Malaysia have abandoned plans to introduce a generational smoking ban because of concerns that such a policy is incompatible with liberal democracy as it undermines autonomy. This paper challenges this claim by showing that smoking is not an autonomous act. Autonomy requires a deliberation of preferences, wills and inclinations. This does not occur in smokers because of three related factors: nicotine addiction, cognitive biases and psychosocial development in addiction. Nicotine addiction results in strong physical and psychological desires to seek pleasure and to avoid withdrawal. This is further potentiated by conditioned behaviour. Cognitive biases explain why smokers act in ways that are detrimental to their health. Psychosocial development explains how the brains of smokers are unable to make rational decisions. This combination renders smokers unable to reflect on their actions and thus act autonomously. This stance is compatible with Mill's view that actions that devalue autonomy cannot be considered autonomous. Defenders of liberalism should not be quick to dismiss a smoking ban and can instead foster autonomy by supporting it.

Coercive public health policies need context-specific ethical justifications.

Public health policies designed to improve individual and population health may involve coercion. These coercive policies require ethical justification, and yet it is unclear in the public health ethics literature which ethical concepts might justify coercion, and what their limitations are in applying across contexts. In this paper, we analyse a number of concepts from Western bioethics, including the harm principle, paternalism, the public interest, and a duty of easy rescue. We find them plausible justifications for coercion in theory, but when applied to case studies, including HIV testing in Malawi, vaccine mandates in South Africa, and prohibitions of antibiotic use in livestock in the EU, their limitations become clear. We argue that the context-specificity of ethical justifications for coercion has been overlooked, and there is more work needed to identify context-relevant ethical justifications for coercive policies in various settings and for various populations, rather than relying on universalising Western bioethical justifications across all contexts.

Obesity, Metabolic Syndrome, and Sugar-Sweetened Beverages (SSBs) in America: A Novel Bioethical Argument for a Radical Public Health Proposal.

The prevalence of obesity, metabolic syndrome, and the associated long-term chronic diseases (cardiovascular disease, type II diabetes, cancer, Alzheimer's disease, depression) have reached epidemic levels in the United States and Western nations. In response to this public health calamity, the author of this paper presents and defends a novel bioethical argument: the consistency argument for outlawing SSBs (sugar-sweetened beverages) for child consumption (the "consistency argument"). This argument's radical conclusion states that the government is justified in outlawing SSBs consumption for child consumption. The reasoning is as follows: if one accepts that the physical harm caused by chronic alcohol consumption justifies the government outlawing alcoholic beverages for child consumption, and there is strong evidence that comparable physical harms result from chronic SSBs consumption, then, mutatis mutandis, the government is also justified in outlawing child consumption of SSBs. To support this argument, the author provides extensive evidence based on epidemiological observational studies, interventional studies, controlled trials, large meta-analyses, and the pathophysiology and biological mechanisms of action behind SSBs and chronic disease. Chronic consumption of large doses of SSBs and alcoholic beverages both drive the same diseases: obesity and insulin resistance, cardiovascular disease, hypertension, and cancer. Chronic SSB consumption carries the additional risk of Alzheimer's disease, dementia, and depression. The author concludes this paper by considering prominent objections to the consistency argument, and then demonstrating that each objection is unsound.

"Lives versus livelihoods": Conflict and coherence between policy objectives in the COVID-19 pandemic.

Many policies were put in place during the COVID-19 pandemic in the United States to manage the negative impact of the coronavirus. Limiting severe illness and death was one important objective of these policies, but it is widely acknowledged by public health ethicists that pandemic policies needed to consider other factors. Drawing on semi-structured interviews with 38 people across 17 states who participated in the state-level COVID-19 pandemic policy process, we examine how those actors recounted their engagement with four different objectives over the course of the pandemic: protecting public health with respect to COVID-19 (which we refer to as pathogen-focused disease prevention), protecting the economy, promoting the public's broader health and wellbeing, and preserving and restoring individual freedoms. We describe the different ways that pathogen-focused disease prevention was thought to have conflicted with, or to have been coherent with, the other three policy objectives over the course of the pandemic. In tracing the shifting relationships between objectives, we highlight four reasons put forward by the participants for why policy changes occurred throughout the pandemic: a change on the part of decisionmaker(s) regarding the perceived acceptability of the negative effects of a policy on one or more policy objectives; a change in the epistemic context; a change in the 'tools in the toolbox'; and a change in the public's attitudes that affected the feasibility of a policy. We conclude by considering the ethical implications of the shifting relationships that were described between objectives over the course of the pandemic.

Public values to guide childhood vaccination mandates: A report on four Australian community juries.

OBJECTIVE: Governments use vaccination mandates, of different degrees of coerciveness, to encourage or require childhood vaccination. We elicited the views of well-informed community members on the public acceptability of using childhood vaccination mandates in Australia. METHODS: Four community juries were conducted in Canberra, Launceston, Cairns and Melbourne, Australia between 2021 and 2022. We recruited 51 participants from diverse backgrounds, genders and ages through random digit dialling and social media. Two juries were held in metropolitan areas, and two in regional/rural settings. Outcome measures included jury verdicts and reasons in response to structured questions. RESULTS: All juries were concerned about collective protection and individual rights but prioritised the former over the latter. A majority in all juries supported mandates but juries disagreed with respect to the appropriate mandate types. All juries endorsed using the least restrictive or coercive means to encourage vaccination (providing incentives or education, e.g.) before imposing penalties such as financial losses and school exclusions. The overriding view was that it is fairer to place a direct burden on parents rather than children and that mandates should be designed to avoid inequitable impacts on less advantaged groups in society. Many jurors found conscientious objection acceptable as a controlled option for resolute refusers, provided that overall vaccination coverage remains high. CONCLUSION: This paper gives policymakers access to the reasons that Australians have for supporting or opposing different mandates under conditions of high knowledge, understanding and deliberation regarding policy options. Sustaining high rates of vaccination requires high levels of co-operation between governments, public health actors and the public. Our findings highlight the importance of considering public values in the design and implementation of vaccination mandates. PATIENT AND PUBLIC INVOLVEMENT: We sought input from individuals who did and did not vaccinate during the study design. The views and perspectives of nonvaccinating parents were presented in the evidence to juries. We deliberately excluded nonvaccinating individuals from participating, as the divisive and often hostile nature of the topic, and their minority status, made it difficult to ensure they would feel safe as members of the jury without overrepresenting their perspective in the sample. Two related projects engaged directly with these parents.

Nursing vaccine mandates: Ethically justified, an infringement on autonomy, or both?

After almost a year and a half of the COVID-19 pandemic, many healthcare institutions in the United States announced that they would mandate COVID-19 vaccination, with medical and religious exceptions, as a term of employment. The mandates resulted in widely publicized protests from hospital staff, including some nurses, who argued that these medical institutions violated the ethical principle of autonomy. As the world enters the "post-pandemic period," decisions such as these, made during times of crisis, must be reviewed to provide clarity for when the next pandemic occurs. In this paper, we support the argument that such mandates are ethically justifiable. We explore the framework of objections that were brought forward by dissenters of this vaccine mandate. Next, we provide an analysis of conflicting ethical principles present when such mandates were deployed. Utilizing the American Nurses Association's Code of Ethics for Nurses, notably provisions 2, 3, and 6 we argue that it is an ethical duty of the nurse to be vaccinated. Specifically, we turn to provision two, which most explicitly underscores the necessity of vaccination as a function of the nurse's primary commitment to the patient. Next, we highlight the International Council of Nurses Code of Ethics which provides similar guidance internationally. Finally, we examine the applicability of the principles of public health, care ethics, and the nursing role as frameworks to underpin such mandates both for the current and for potential future pandemics, arguing that the nurse's ethical duty to be vaccinated spans these contexts.

Integrating Public Health Ethics into Public Health Policymaking: Being in the Room Where It Happens.

This commentary takes up a challenge posed by Franklin Miller in a 2022 essay in Bioethics Forum. Dr. Miller queried whether bioethicists could be useful in public health policy contexts and while he refrained from issuing an ultimate opinion, did identify several challenges to such utility. The current piece responds to the challenges Dr. Miller identifies and argues that with appropriate training, public health ethicists can be of service in virtually any context in which public health policies are deliberated and decided.

Beyond Trade-Offs: Autonomy, Effectiveness, Fairness, and Normativity in Risk and Crisis Communication.

This paper addresses the critiques based on trade-offs and normativity presented in response to our target article proposing the Public Health Emergency Risk and Crisis Communication (PHERCC) framework. These critiques highlight the ethical dilemmas in crisis communication, particularly the balance between promoting public autonomy through transparent information and the potential stigmatization of specific population groups, as illustrated by the discussion of the mpox outbreak among men who have sex with men. This critique underscores the inherent tension between communication effectiveness and autonomy versus fairness and equity. In response, our paper reiterates the adaptability of the PHERCC framework, emphasizing its capacity to tailor messages to diverse audiences, thereby reducing potential stigmatization and misinformation. Through community engagement and feedback integration, the PHERCC framework aims to optimize the effectiveness of communication strategies while addressing ethical concerns. Furthermore, by involving affected communities in the communication strategy from the onset, the framework seeks to minimize ethical trade-offs and enhance the acceptance and effectiveness of public health messages.

Stewardship according to context: Justifications for coercive antimicrobial stewardship policies in agriculture and their limitations.

Antimicrobial resistance (AMR) is an urgent, global threat to public health. The development and implementation of effective measures to address AMR is vitally important but presents important ethical questions. This is a policy area requiring further sustained attention to ensure that policies proposed in National Action Plans on AMR are ethically acceptable and preferable to alternatives that might be fairer or more effective, for instance. By ethically analysing case studies of coercive actions to address AMR across countries, we can better inform policy in a context-specific manner. In this article, I consider an example of coercive antimicrobial stewardship policy in Canada, namely restrictions on livestock farmers' access to certain antibiotics for animal use without a vet's prescription. I introduce and analyse two ethical arguments that might plausibly justify coercive action in this case: the harm principle and a duty of collective easy rescue. In addition, I consider the factors that might generally limit the application of those ethical concepts, such as challenges in establishing causation or evidencing the scale of the harm to be averted. I also consider specifics of the Canadian context in contrast to the UK and Botswana as example settings, to demonstrate how context-specific factors might mean a coercive policy that is ethically justified in one country is not so in another.

The Ethics of Time: Towards Temporal Bioethics.

In this paper I discuss the important yet overlooked role played by time in public health ethics, clinical ethics, and personal ethics, and present an exploratory analysis of temporal inequalities and temporal autonomy.

Social Distance Warriors Should Not Be Regarded as Moral Exemplars in a Pandemic Nor as Paragons of Politeness: A Response to Shaw.

In a recent article, Shaw contrasts his own supposed good behaviour, as that of a self-proclaimed "social distance warrior" with the alleged rude behaviour of one of his relatives, Jack, at social events in the former's house in Scotland in the early stages of the COVID-19 pandemic. He does so to illustrate and support his claims that it was wrong and rude to fail to comply with the governmental advice regarding social distancing because we had a responsibility "to minimize risk" and not wrong nor rude to challenge and cajole those people who failed to do so. This article shows that his claims are contestable. It suggests that his own behaviour was no better than Jack's.

A Scalar Approach to Vaccination Ethics.

Should people get vaccinated for the sake of others? What could ground-and limit-the normative claim that people ought to do so? In this paper, we propose a reasons-based consequentialist account of vaccination for the benefit of others. We outline eight harm-based and probabilistic factors that, we argue, give people moral reasons to get vaccinated. Instead of understanding other-directed vaccination in terms of binary moral duties (i.e., where people either have or do not have a moral duty to get vaccinated), we develop a scalar approach according to which people can have stronger or weaker moral reasons to get vaccinated in view of the moral good of vaccination. One advantage of our approach is that it can capture why a person might have strong moral reasons to get vaccinated with Vaccine A, but only weak moral reasons to get vaccinated with Vaccine B. We discuss theoretical strengths of our approach and provide a case study of vaccination against COVID-19 to demonstrate its practical significance.

Digital Humans to Combat Loneliness and Social Isolation: Ethics Concerns and Policy Recommendations.

Social isolation and loneliness are growing concerns around the globe that put people at increased risk of disease and early death. One much-touted approach to addressing them is deploying artificially intelligent agents to serve as companions for socially isolated and lonely people. Focusing on digital humans, we consider evidence and ethical arguments for and against this approach. We set forth and defend public health policies that respond to concerns about replacing humans, establishing inferior relationships, algorithmic bias, distributive justice, and data privacy.

Cause for coercion: cause for concern?

In his 2000 book, From Chaos to Coercion: Detention and the Control of Tuberculosis, Richard Coker makes a number of important observations and arguments regarding the use of coercive public health measures in response to infectious disease threats. In particular, Coker argues that we have a tendency to neglect public health threats and then demand immediate action, which can leave policymakers with fewer effective options and may require (or may be perceived as requiring) more aggressive, coercive measures to achieve public health goals. While Coker makes a convincing case as to why we should find it ethically problematic when governments find themselves in this position and resort to coercion, left outstanding is the question of whether this should preclude governments and health authorities from using coercion if and when they do find themselves in this position. In this paper, I argue that, while we should consider it ethically objectionable when governments resort to coercion because they have neglected a public health threat, its causes, and other possible responses to that threat, this should not then necessarily rule out the use of coercion in such circumstances; that there are ethically objectionable antecedents for why coercion is being considered should not necessarily or automatically cause us to think coercion in such cases cannot be justified. I address an objection to this argument and draw several conclusions about how governments' use of coercion in public health should be evaluated.

'Staying in the lane' of public health? Boundary-work in the roles of state health officials and experts in COVID-19 policymaking.

The state-level COVID-19 response in the United States necessitated collaboration between governor' offices, health departments and numerous other departments and outside experts. To gain insight into how health officials and experts contributed to advising on COVID-19 policies, we conducted semi-structured interviews with 25 individuals with a health specialisation who were involved in COVID-19 policymaking, taking place between February and December 2022. We found two diverging understandings of the role of health officials and experts in COVID-19 policymaking: the role of 'staying in the lane' of public health in terms of the information that they collected, their advocacy for policies and their area of expertise and the role of engaging in the balancing of multiple considerations, such as public health, feasibility and competing objectives (such as the economy) in the crafting of pandemic policy. We draw on the concept of boundary-work to examine how these roles were constructed. We conclude by considering the appropriateness as well as the ethical implications of these two approaches to public health policymaking.

Proposing a Principle-Based Approach for Teaching AI Ethics in Medical Education.

The use of artificial intelligence (AI) in medicine, potentially leading to substantial advancements such as improved diagnostics, has been of increasing scientific and societal interest in recent years. However, the use of AI raises new ethical challenges, such as an increased risk of bias and potential discrimination against patients, as well as misdiagnoses potentially leading to over- or underdiagnosis with substantial consequences for patients. Recognizing these challenges, current research underscores the importance of integrating AI ethics into medical education. This viewpoint paper aims to introduce a comprehensive set of ethical principles for teaching AI ethics in medical education. This dynamic and principle-based approach is designed to be adaptive and comprehensive, addressing not only the current but also emerging ethical challenges associated with the use of AI in medicine. This study conducts a theoretical analysis of the current academic discourse on AI ethics in medical education, identifying potential gaps and limitations. The inherent interconnectivity and interdisciplinary nature of these anticipated challenges are illustrated through a focused discussion on "informed consent" in the context of AI in medicine and medical education. This paper proposes a principle-based approach to AI ethics education, building on the 4 principles of medical ethics-autonomy, beneficence, nonmaleficence, and justice-and extending them by integrating 3 public health ethics principles-efficiency, common good orientation, and proportionality. The principle-based approach to teaching AI ethics in medical education proposed in this study offers a foundational framework for addressing the anticipated ethical challenges of using AI in medicine, recommended in the current academic discourse. By incorporating the 3 principles of public health ethics, this principle-based approach ensures that medical ethics education remains relevant and responsive to the dynamic landscape of AI integration in medicine. As the advancement of AI technologies in medicine is expected to increase, medical ethics education must adapt and evolve accordingly. The proposed principle-based approach for teaching AI ethics in medical education provides an important foundation to ensure that future medical professionals are not only aware of the ethical dimensions of AI in medicine but also equipped to make informed ethical decisions in their practice. Future research is required to develop problem-based and competency-oriented learning objectives and educational content for the proposed principle-based approach to teaching AI ethics in medical education.

The PHERCC Matrix. An Ethical Framework for Planning, Governing, and Evaluating Risk and Crisis Communication in the Context of Public Health Emergencies.

Risk and crisis communication (RCC) is a current ethical issue subject to controversy, mainly due to the tension between individual liberty (a core component of fairness) and effectiveness. In this paper we propose a consistent definition of the RCC process in public health emergencies (PHERCC), which comprises six key elements: evidence, initiator, channel, publics, message, and feedback. Based on these elements and on a detailed analysis of their role in PHERCC, we present an ethical framework to help design, govern and evaluate PHERCC strategies. The framework aims to facilitate RCC, incorporating effectiveness, autonomy, and fairness. It comprises five operational ethical principles: openness, transparency, inclusivity, understandability, and privacy. The resulting matrix helps understanding the interplay between the PHERCC process and the principles of the framework. The paper includes suggestions and recommendations for the implementation of the PHERCC matrix.

The Ethics of Population Policy for the Two Worlds of Population Conditions.

Population policy has taken two divergent trajectories. In the developing part of the world, controlling population growth has been a major tune of the debate more than a half-century ago. In the more developed part of the world, an inverse pattern results in the discussion over the facilitation of population growth. The ethical debates on population policy have primarily focused on the former and ignored the latter. This paper proposes a more comprehensive account that justifies states' population policy interventions. We first consider the reasons that support pro-natalist policies to enhance fertility rates and argue that these policies are ethically problematic. We then establish an ethics of population policy grounded on account of self-sustaining the body politic, which consists of four criteria: survival, replacement, accountability, and solidarity. We discuss the implications of this account regarding birth-control and pro-natalist policies, as well as non-procreative policies such as immigration, adoption, and unintended baby-saving strategies.

Toward Consent in Molecular HIV Surveillance?: Perspectives of Critical Stakeholders.

BACKGROUND: The emergence of molecular HIV surveillance (MHS) and cluster detection and response (CDR) programs as key features of the United States (US) HIV strategy since 2018 has caused major controversies. HIV surveillance programs that re-use individuals' routinely collected clinical HIV data do not require consent on the basis that the public benefit of these programs outweighs individuals' rights to opt out. However, criticisms of MHS/CDR have questioned whether expanded uses of HIV genetic sequence data for prevention reach beyond traditional public health ethics frameworks. This study aimed to explore views on consent within MHS/CDR among critical stakeholders. METHODS: In 2021 we interviewed 26 US HIV stakeholders who identified as being critical or concerned about the rollout of MHS/CDR. Stakeholders included participants belonging to networks of people living with HIV, other advocates, academics, and public health professionals. This analysis focused on identifying the range of positions among critical and concerned stakeholders on consent affordances, opt-outs, how to best inform people living with HIV about how data about them are used in public health programs, and related ethical issues. RESULTS: Participants were broadly supportive of introducing some forms of consent into MHS/CDR. However, they differed on the specifics of implementing consent. While some participants did not support introducing consent affordances, all supported the idea that people living with HIV should be informed about how HIV surveillance and prevention is conducted and how individuals' data are used. CONCLUSIONS: MHS/CDR has caused sustained controversy. Among critical stakeholders, consent is generally desirable but contested, although the right for people living with HIV to be informed was centrally supported. In an era of big data-driven public health interventions and routine uses of HIV genetic sequence data in surveillance and prevention, CDC and other agencies should revisit public health ethics frameworks and consider the possibility of consent processes.

Building solidarity during COVID-19 and HIV/AIDS.

While the WHO, public health experts, and political leaders have referenced solidarity as an important part of our responses to COVID-19, I consider how we build solidarity during pandemics in order to improve the effectiveness of our responses. I use Prainsack and Buyx's definition of solidarity, which highlights three different tiers: (1) interpersonal solidarity, (2) group solidarity, and (3) institutional solidarity. Each tier of solidarity importantly depends on the actions and norms established at the lower tiers. Although empathy and solidarity are distinct moral concepts, I argue that the affective component of solidarity is important for motivating solidaristic action, and empathetic accounts of solidarity help us understand how we actually build solidarity from tier to tier. During pandemics, public health responses draw on different tiers of solidarity depending on the nature, scope, and timeline of the pandemic. Therefore, I analyze both COVID-19 and HIV/AIDS using this framework to learn lessons about how solidarity can more effectively contribute to our ongoing public health responses during pandemics. Whereas we used institutional solidarity during COVID-19 in a top-down approach to building solidarity that often overlooked interpersonal and group solidarity, we used those lower tiers during HIV/AIDS in a bottom-up approach because governments and public health institutions were initially unresponsive to the crisis. Thus, we need to ensure that we have a strong foundation of respect, trust, and so forth, on which to build solidarity from tier to tier and promote whichever tiers of solidarity are lacking during a given pandemic to improve our responses.