'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.

Vaccine Passports and Political Legitimacy: A Public Reason Framework for Policymakers.

As the COVID-19 pandemic continues to evolve, taking its toll on people's lives around the world, vaccine passports remain a contentious topic of debate in most liberal democracies. While a small literature on vaccine passports has sprung up over the past few years that considers their ethical pros and cons, in this paper we focus on the question of when vaccine passports are politically legitimate. Specifically, we put forward a 'public reason ethics framework' for resolving ethical disputes and use the case of vaccine passports to demonstrate how it works. The framework walks users through a structured analysis of a vaccine passport proposal to determine whether the proposal can be publicly justified and is therefore legitimate. Use of this framework may also help policymakers to design more effective vaccine passports, by incorporating structured input from the public, and thereby better taking the public's interests and values into account. In short, a public reason ethics framework is meant to encourage better, more legitimate decision-making, resulting in policies that are ethically justifiable, legitimate and effective.

Ethical and economic implications of the adoption of novel plant-based beef substitutes in the USA: a general equilibrium modelling study.

BACKGROUND: Slowing climate change is crucial to the future wellbeing of human societies and the greater environment. Current beef production systems in the USA are a major source of negative environmental impacts and raise various animal welfare concerns. Nevertheless, beef production provides a food source high in protein and many nutrients as well as providing employment and income to millions of people. Cattle farming also contributes to individual and community identities and regional food cultures. Novel plant-based meat alternatives have been promoted as technologies that could transform the food system by reducing negative environmental, animal welfare, and health effects of meat production and consumption. Recent studies have conducted static analyses of shifts in diets globally and in the USA, but have not considered how the whole food system would respond to these changes, nor the ethical implications of these responses. We aimed to better explore these dynamics within the US food system and contribute a multiple perspective ethical assessment of plant-based alternatives to beef. METHODS: In this national modelling analysis, we explored multiple ethical perspectives and the implications of the adoption of plant-based alternatives to beef in the USA. We developed USAGE-Food, a modified version of USAGE (a detailed computable general equilibrium model of the US economy), by improving the representation of sector interactions and dependencies, and consumer behaviour to better reflect resource use across the food system and the substitutability of foods within households. We further extended USAGE, by linking estimates of the environmental footprint of US agriculture, to estimate how changes across the agriculture sector could alter the environmental impact of primary food production across the whole sector, not only the beef sector. Using USAGE-Food, we simulated four beef replacement scenarios against a baseline of current beef demand in the USA: BEEF10, in which beef expenditure is replaced by other foods and three scenarios wherein 10%, 30%, or 60% of beef expenditure is replaced by plant-based alternatives. FINDINGS: The adoption of plant-based beef alternatives is likely to reduce the carbon footprint of US food production by 2·5-13·5%, by reducing the number of animals needed for beef production by 2-12 million. Impacts on other dimensions are more ambiguous, as the agricultural workforce and natural resources, such as water and cropland, are reallocated across the food system. The shifting allocation of resources should lead to a more efficient food system, but could facilitate the expansion of other animal value chains (eg, pork and poultry) and increased exports of agricultural products. In aggregate, these changes across the food system would have a small, potentially positive, impact on national gross domestic product. However, they would lead to substantial disruptions within the agricultural economy, with the cattle and beef processing sectors decreasing by 7-45%, challenging the livelihoods of the more than 1·5 million people currently employed in beef value chains (primary production and animal processing) in the USA. INTERPRETATION: Economic modelling suggests that the adoption of plant-based beef alternatives can contribute to reducing greenhouse gas emissions from the food system. Relocation of resources across the food system, simulated by our dynamic modelling approach, might mitigate gains across other environmental dimensions (ie, water or chemical use) and might facilitate the growth of other animal value chains. Although economic consequences at the country level are small, there would be concentrated losses within the beef value chain. Reduced carbon footprint and increased resource use efficiency of the food system are reasons for policy makers to encourage the continued development of these technologies. Despite this positive outcome, policy makers should recognise the ethical assessment of these transitions will be complex, and should remain vigilant to negative outcomes and be prepared to target policies to minimise the worst effects. FUNDING: The Stavros Niarchos Foundation, the Bill & Melinda Gates Foundation, Johns Hopkins University, the Commonwealth Scientific and Industrial Research Organisation, Cornell University, and Victoria University.

Moral Reasons for Individuals in High-Income Countries to Limit Beef Consumption.

This paper argues that individuals in many high-income countries typically have moral reasons to limit their beef consumption and consume plant-based protein instead, given the negative effects of beef production and consumption. Beef production is a significant source of agricultural greenhouse gas emissions and other environmental impacts, high levels of beef consumption are associated with health risks, and some cattle production systems raise animal welfare concerns. These negative effects matter, from a variety of moral perspectives, and give us collective moral reasons to reduce beef production and consumption. But, as some ethicists have argued, we cannot draw a straight line from the ethics of production to the ethics of consumption: even if a production system is morally impermissible, this does not mean that any given individual has moral reasons to stop consuming the products of that system, given how miniscule one individual's contributions are. This paper considers how to connect those dots. We consider three distinct lines of argument in support of the conclusion that individuals have moral reasons to limit their beef consumption and shift to plant-based protein, and we consider objections to each argument. This argument applies to individuals in high beef-consuming and high greenhouse gas-emitting high-income countries, though we make this argument with a specific focus on the United States. Supplementary Information: The online version contains supplementary material available at 10.1007/s41055-022-00100-8.

The Racialized Marketing of Unhealthy Foods and Beverages: Perspectives and Potential Remedies.

We propose that marketing of unhealthy foods and beverages to Black and Latino consumers results from the intersection of a business model in which profits come primarily from marketing an unhealthy mix of products, standard targeted marketing strategies, and societal forces of structural racism, and contributes to health disparities.

Assessing the Governance of Digital Contact Tracing in Response to COVID-19: Results of a Multi-National Study.

This paper describes the results of a multi-country survey of governance approaches for the use of digital contact tracing (DCT) in response to the COVID-19 pandemic. We argue that the countries in our survey represent two distinct models of DCT governance, both of which are flawed. The "data protection model" emphasizes privacy protections at the expense of public health benefit, while the "emergency response model" sacrifices transparency and accountability, prompting concerns about excessive governance surveillance. The ethical and effective use of DCT in the future requires a new governance approach that is better suited to this novel use of mobile phone data to promote public health."

How animal agriculture stakeholders define, perceive, and are impacted by antimicrobial resistance: challenging the Wellcome Trust's Reframing Resistance principles.

Humans, animals, and the environment face a universal crisis: antimicrobial resistance (AR). Addressing AR and its multi-disciplinary causes across many sectors including in human and veterinary medicine remains underdeveloped. One barrier to AR efforts is an inconsistent process to incorporate the plenitude of stakeholders about what AR is and how to stifle its development and spread-especially stakeholders from the animal agriculture sector, one of the largest purchasers of antimicrobial drugs. In 2019, The Wellcome Trust released Reframing Resistance: How to communicate about antimicrobial resistance effectively (Reframing Resistance), which proposed the need to establish a consistent and harmonized messaging effort that describes the AR crisis and its global implications for health and wellbeing across all stakeholders. Yet, Reframing Resistance does not specifically engage the animal agriculture community. This study investigates the gap between two principles recommended by Reframing Resistance and animal agriculture stakeholders. For this analysis, the research group conducted 31 semi-structured interviews with a diverse group of United States animal agriculture stakeholders. Participants reported attitudes, beliefs, and practices about a variety of issues, including how they defined AR and what entities the AR crisis impacts most. Exploration of Reframing Resistance's Principle 2, "explain the fundamentals succinctly" and Principle 3, "emphasis that this is universal issue; it can affect anyone, including you" reveals disagreement in both the fundamentals of AR and consensus of "who" the AR crisis impacts. Principle 2 may do better to acknowledge that animal agriculture stakeholders espouse a complex array of perspectives that cannot be summed up in a single perspective or principle. As a primary tool to combat AR, behavior change must be accomplished first through outreach to stakeholder groups and understanding their perspectives.

Physician perspectives on placebo ethics.

Clinical use of placebos is controversial among bioethicists. While placebos have been shown to provide benefit for patients with some conditions, offering placebos to patients without disclosing that they are placebos raises ethical concerns, including the concern that this lack of transparency about the nature of placebos amounts to deceiving patients. Some have proposed open-label placebos (OLPs) as an ethically preferable alternative: patients are offered placebos and told that the treatment being offered is a placebo. To contribute to the ongoing discussion about the ethics and feasibility of clinical use of placebos, we conducted focus groups to explore physician attitudes about clinical use of placebos, including non-disclosed and OLPs, and physician attitudes about the underlying ethical issues. We found that while the non-transparency and deceptiveness of offering non-disclosed placebos was a concern for some physicians, their primary focus when considering both non-disclosed and OLPs was identifying and weighing potential harms and benefits to patients. Some participants also felt further research and training in prescribing OLPs would be needed before they would be willing to use them in their practice.

SARS-CoV-2 safer infection sites: moral entitlement, pragmatic harm reduction strategy or ethical outrage?

The pandemic of SARS-CoV-2 has led to unprecedented changes to society, causing unique problems that call for extraordinary solutions. We consider one such extraordinary proposal: 'safer infection sites' that would offer individuals the opportunity to be intentionally infected with SARS-CoV-2, isolate, and receive medical care until they are no longer infectious. Safer infection could have value for various groups of workers and students. Health professionals place themselves at risk of infection daily and extend this risk to their family members and community. Similarly, other essential workers who face workplace exposure must continue their work, even if have high-risk household members and live in fear of infecting. When schools are kept closed because of the fear that they will be sites of significant transmission, children and their families are harmed in multiple ways and college students who are living on campus, whether or not they are attending classes in person, are contributing to high rates of transmission and experiencing high rates of exposure. We consider whether offering safer infection sites to these groups could be ethically defensible and identify the empirical unknowns that would need to resolve before reaching definitive conclusions. This article is not an endorsement of intentional infection with the coronavirus, but rather is meant to spark conversation on the ethics of out-of-the-box proposals. Perhaps most meaningfully, our paper explores the value of control and peace of mind for those among us most impacted by the pandemic: those essential workers risking the most to keep us safe.

Ethical Considerations for Food and Beverage Warnings.

Several countries have implemented warnings on unhealthy foods and beverages, with similar policies under consideration in the U.S. and around the world. Research demonstrating food warnings' effectiveness is emerging, but limited scholarship has evaluated the ethics of food warning policies. Using a public health ethics framework for evaluating obesity prevention policies, we assessed the ethical strengths and weaknesses of food warnings along multiple dimensions: 1) Health behaviors and physical health, 2) Psychosocial well-being, 3) Social and cultural values, 4) Informed choice, 5) Equality, 6) Attributions of responsibility, 7) Liberty, and 8) Privacy. Our analysis identifies both ethical strengths and weaknesses of food warnings, including that: 1) warnings are likely to generate important benefits including increased consumer understanding and informed choice, healthier purchases, and potential reductions in obesity prevalence; 2) warnings evoke negative emotional reactions, but these reactions are an important mechanism through which food warnings encourage healthier behaviors and promote informed choice; 3) warnings appear unlikely to have ethically unacceptable effects on social and cultural values, attributions of responsibility, liberty, or privacy. Current research suggests we continue to pursue food warnings as a policy option for improving public health while simultaneously conducting additional research on the ethics of these policies. Future research is especially needed to clarify warnings' effects on stigma and to characterize the balance and distribution of costs of and benefits from implementing warning policies.

Food Waste: Ethical Imperatives & Complexities.

We identify multiple ways in which food waste matters ethically: because of its direct negative environmental effects, because of the environmental impacts of excess food production, and because of the foregone benefits that could have been achieved if wasted food had been consumed. The issue of food waste is complicated by competing views on how to define food waste; we suggest that food waste could be defined as edible and nutritive plant, animal, mineral, or fungal materials used in ways that do not provide sufficient benefit and value. We also consider ways of reframing the issue of food waste, such as shifting the focus from food "waste" to food "conservation," allowing our emphasis to be redirected toward the resources that ought to be treated with greater care. Finally, we discuss ethical concerns with food waste-reduction efforts, which may have unintended consequences or may be minimally effective.

Grappling With Complex Food Systems to Reduce Obesity: A US Public Health Challenge.

Despite 2 decades of effort by the public health community to combat obesity, obesity rates in the United States continue to rise. This lack of progress raises fundamental questions about the adequacy of our current approaches. Although the causes of population-wide obesity are multifactorial, attention to food systems as potential drivers of obesity has been prominent. However, the relationships between broader food systems and obesity are not always well understood. Our efforts to address obesity can be advanced and improved by the use of systems approaches that consider outcomes of the interconnected global food system, including undernutrition, climate change, the environmental sustainability of agriculture, and other social and economic concerns. By implementing innovative local and state programs, taking new approaches to overcome political obstacles to effect policy, and reconceptualizing research needs, we can improve obesity prevention efforts that target the food systems, maximize positive outcomes, and minimize adverse consequences. We recommend strengthening innovative local policies and programs, particularly those that involve community members in identifying problems and potential solutions and that embrace a broad set of goals beyond making eating patterns healthier. We also recommend undertaking interdisciplinary research projects that go beyond testing targeted interventions in specific populations and aim to build an understanding of the broader social, political, and economic context.

The evidence-and acceptability-of taxes on unhealthy foods.

The global obesity pandemic has public advocates and policymakers grappling with the question of how best to respond. Among the various policy options, unhealthy food and beverage taxes have gained attention as a potentially effective intervention to reduce non-nutritive caloric intake, while raising government funds for health promotion programs at the community level. Yet in many countries, including in Israel, such proposals have not gained broad support. Cities in both United States and Mexico have found that taxes on sugar-sweetened beverages reduce consumption. Yet the food industry has successfully fought many such policies. Looking forward, those supporting taxation policies will need to provide clear evidence, a compelling use of funds raised, a convincing answer to industry claims, and attention to equity in implementation. With no easy fixes in sight to obesity, it is likely that taxes will remain viable - if contested - options for the foreseeable future.

Do Infant Formula Giveaways Undermine or Support Women's Choices?

Eliminating formula giveaways ("banning the bag") has been embraced as a way to reduce the influence of formula marketing in hospitals and to increase breastfeeding rates among new mothers, but the policy raises ethical concerns in the mind of some, notably because it denies a useful benefit to mothers who have trouble affording formula. Hospital policies to promote breastfeeding, including banning the bag, should be sensitive to the economic and other costs associated with breastfeeding and should be consciously designed to make breastfeeding easier and not just to make formula feeding more difficult. We recommend that hospitals evaluate the negative impacts of banning the bag on their patient population in order to ensure that families are not being negatively affected.

Examining the use of 'natural' in breastfeeding promotion: ethical and practical concerns.

References to the 'natural' are common in public health messaging about breastfeeding. For example, the WHO writes that 'Breast milk is the natural first food for babies' and the U.S. Department of Health and Human Services has a breastfeeding promotion campaign called 'It's only natural', which champions breastfeeding as the natural way to feed a baby. This paper critically examines the use of 'natural' language in breastfeeding promotion by public health and medical bodies. A pragmatic concern with selling breastfeeding as 'natural' is that this may reinforce the already widespread perspective that natural options are presumptively healthier, safer and better, a view that works at cross-purposes to public health and medicine in other contexts. An additional concern is that given the history of breastfeeding in the USA, 'natural' evokes specific and controversial conceptions of gender and motherhood.

The Ethics of Infection Challenges in Primates.

In the midst of the recent Ebola outbreak, scientific developments involving infection challenge experiments on nonhuman primates (NHPs) sparked hope that successful treatments and vaccines may soon become available. Yet these studies pose a stark ethical quandary. On the one hand, they represent an important step in developing novel therapies and vaccines for Ebola and the Marburg virus, with the potential to save thousands of human lives and to protect whole communities from devastation; on the other hand, they intentionally expose sophisticated animals to severe suffering and a high risk of death. Other studies that infect NHPs with a lethal disease in order to test interventions that may prove beneficial for humans pose the same ethical difficulty. Some advocates have argued that all research on primates should be phased out, and ethicists have questioned whether a moral justification of primate research is possible. A 2010 European Union directive banned virtually all research on great apes, and 2013 guidelines from the National Institutes of Health (NIH), based upon recommendations in an influential 2011 Institute of Medicine (IOM) report, eliminated most biomedical research with chimpanzees in the United States. But studies involving other NHPs face no comparable restrictions. Should research on NHPs other than great apes be subject to tighter restrictions than it currently is? In this article, we explore this general question in the context of one particular type of biomedical research: infection challenge studies. We advocate a presumptive prohibition on infection challenge experiments in NHPs, but we also argue that exceptions to this prohibition are permissible, subject to strict substantive and procedural safeguards, when necessary to avert substantial loss of human life or severe morbidity for a substantial number of people.