Tailoring Public Health Policies.

In an effort to contain the spread of COVID-19, many states and countries have adopted public health restrictions on activities previously considered commonplace: crossing state borders, eating indoors, gathering together, and even leaving one's home. These policies often focus on specific activities or groups, rather than imposing the same limits across the board. In this Article, I consider the law and ethics of these policies, which I call tailored policies.In Part II, I identify two types of tailored policies: activity-based and group-based. Activity-based restrictions respond to differences in the risks and benefits of specific activities, such as walking outdoors and dining indoors. Group-based restrictions consider differences between groups with respect to risk and benefit. Examples are policies that treat children or senior citizens differently, policies that require travelers to quarantine when traveling to a new destination, and policies that treat individuals differently based on whether they have COVID-19 symptoms, have tested positive for COVID-19, have previous COVID-19 infection, or have been vaccinated against COVID-19. In Part III, I consider the public health law grounding of tailored policies in the principles of "least restrictive means" and "well-targeting." I also examine how courts have analyzed tailored policies that have been challenged on fundamental rights or equal protection grounds. I argue that fundamental rights analyses typically favor tailored policies and that equal protection does not preclude the use of tailored policies even when imperfectly crafted. In Part IV, I consider three critiques of tailored policies, centering on the claims that they produce inequity, cause harm, or unacceptably limit liberty. I argue that we must evaluate restrictions comparatively: the question is not whether tailored policies are perfectly equitable, wholly prevent harm, or completely protect liberty, but whether they are better than untailored ones at realizing these goals in a pandemic. I also argue that evaluation must consider indirect harms and benefits as well as direct and apparent ones.

Examining Public Concerns and Attitudes toward Unfair Events Involving Elderly Travelers during the COVID-19 Pandemic Using Weibo Data.

The Chinese government has launched a digital health code system to detect people potentially exposed to the coronavirus 2019 (COVID-19) disease and to curb its spread. Citizens are required to show the health code on their smartphones when using public transport. However, many seniors are not allowed to use public transport due to their difficulties in obtaining health codes, leading to widespread debates about these unfair events. Traditionally, public perceptions and attitudes toward such unfair events are investigated using analytical methods based on interviews or questionnaires. This study crawled seven-month messages from Sina Weibo, the Chinese version of Twitter, and developed a hybrid approach integrating term-frequency-inverse-document-frequency, latent Dirichlet allocation, and sentiment classification. Results indicate that a rumor about the unfair treatment of elderly travelers triggered public concerns. Primary subjects of concern were the status quo of elderly travelers, the provision of transport services, and unfair event descriptions. Following the government's responses, people still had negative attitudes toward transport services, while they became more positive about the status quo of elderly travelers. These findings will guide government authorities to explore new forms of automated social control and to improve transport policies in terms of equity and fairness in future pandemics.

Lay evaluations of police and civilian use of force: Action severity scales.

In modern societies, citizens cede the legitimate use of violence to law enforcement agents who act on their behalf. However, little is known about the extent to which lay evaluations of forceful actions align with or diverge from official use-of-force policies and heuristics that officers use to choose appropriate levels of responsive force. Moreover, it is impossible to accurately compare official policies and lay intuitions without first measuring the perceived severity of a set of representative actions. To map these psychometric scale values precisely, we presented participants (N = 411 Amazon Mechanical Turk workers, N = 395 undergraduates) with minimal vignettes describing officer and civilian actions that span the entire range of force options (from polite dialogue to lethal force), and asked them to rate physical magnitude and moral appropriateness. We used Bayesian methods to model the ratings as functions of simultaneously estimated scale values of the actions. Results indicated that the perceived severity of actions across all physical but nonlethal categories clustered tightly together, while actions at the extreme levels were relatively spread out. Moreover, less normative officer actions were perceived as especially morally severe. Broadly, our findings reveal divergence between lay perceptions of force severity and official law enforcement policies, and they imply that the groundwork for disagreement about the legitimacy of police and civilian actions may be partially rooted in the differential way that action severity is perceived by law enforcement relative to civilian observers. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Use of pellet guns for crowd control in Kashmir: How lethal is "non-lethal"?

The use of pellet guns during the recent unrest in Kashmir as a method of crowd control has been questioned because of several deaths and numerous injuries. Across the world, these rubber pellets have been shown to inflict serious injuries, permanent disability, and death. The volatility of mob violence, inaccuracies in aim of the pellets, over-use of the pellet guns, and the perception of their harmlessness enhances the destructive potential of these so-called non-lethal weapons. There is also the larger ethical question whether any form of pain, however minimal, could be inflicted to control violent crowds.

Ethical dilemmas related to predictions and warnings of impending natural disaster.

Scientists and policy makers issuing predictions and warnings of impending natural disaster are faced with two major challenges, that is, failure to warn and issuing a false alarm. The consequences of failure to warn can be serious for society overall, for example, significant economic losses, heavy infrastructure and environmental damage, large number of human casualties, and social disruption. Failure to warn can also have serious for specific individuals, for example, legal proceedings against disaster research scientists, as in the L'Aquila earthquake affair. The consequences of false alarms may be less serious. Nevertheless, false alarms may violate the principle of nonmaleficence (do no harm), affect individual autonomy (eg, mandatory evacuations), and may result in the "cry wolf" effect. Other ethical issues associated with natural disasters include the promotion of global justice through international predisaster technical assistance and postdisaster aid. Social justice within a particular country is promoted through greater postdisaster aid allocation to the less privileged.

Periculosidade versus cidadania: os sentidos da atenção à crise nas práticas discursivas dos profissionais de um Centro de Atenção Psicossocial / Periculosity and citizenship: the meanings of attention to the crisis in the discursive practices of the Psychosocial Healthcare Centers professionals

A crise, considerada a expressão da doença psíquica, refere-se a situações em que, no curso do desenvolvimento de vida, ocorrem vivências conflitivas que geram rupturas com a realidade socialmente aceita e com os laços afetivos que sustentam a pessoa. Esta pesquisa objetiva conhecer os sentidos presentes nas práticas discursivas dos profissionais acerca da atenção à crise nos Centros de Atenção Psicossocial (CAPS). Caracteriza-se por uma abordagem qualitativa que utiliza a perspectiva teórica do Construcionismo Social. Os dados utilizados fazem parte do banco de dados da pesquisa Avaliação dos Centros de Atenção Psicossocial da Região Sul do Brasil (CAPSUL). No presente estudo, analisamos 27 entrevistas realizadas com profissionais do Centro de Atenção Psicossocial de Alegrete e três diários de campo com o registro de 390 horas de observação. A análise dos dados identificou sentidos - periculosidade e cidadania - que foram discutidos na busca de compreender sua influência na construção de práticas de atenção à crise.

The crisis, considered the expression of mental illness, refers to situations in which, during the development of life, there are conflicting experiences that generate ruptures with the socially accepted reality and the emotional ties that sustain the person. This study aims at getting to know the meanings present in the discursive practices of professionals concerning the attention to the crisis in the Psychosocial Healthcare Centers (CAPS). It is characterized by a qualitative approach that uses the theoretical perspective of social constructionism. The data used are part of the database research Evaluation of Psychosocial Healthcare Centers in Southern part of Brazil - CAPSUL. In this study, 27 interviews with professionals from the Psychosocial Healthcare Center of Alegrete city and three field diaries with the record of 390 observation hours were analyzed. Data analysis identified the meanings - periculosity and citizenship - which were discussed in an attempt to understand their influence on the construction of attention practices to the crisis.

Isolamento social, sociabilidades e redes sociais de cuidados / Social isolation, sociability and social care networks

Este trabalho examina, em caráter exploratório, experiências de isolamento social vividas por indivíduos portadores de hanseníase, internados na ex-colônia Tavares de Macedo, em Itaboraí, onde foram mantidas da década de 1930 até os dias de hoje, para problematizar noções sobre segregação e discriminação social presentes nesse meio. Para tanto, examina sociabilidades e redes sociais de cuidados estabelecidas na vida em comum nessa "ex-colônia de leprosos", quase sempre como alternativas às condições oferecidas pelos sistemas públicos de proteção social. Faz isso com base em narrativas de alguns desses sujeitos, vistos em suas diferenças - nas interseções das relações por sexos, classes, raças/etnias, gerações, e também por religiões e graus de escolaridade. Recorre à história oral, modo de oferecer novas interpretações qualitativas de processos histórico-sociais evidenciados nessas sociabilidades e redes, nem sempre visíveis como formas singulares de proteção social da vida em comum.

This exploratory work examines the social isolation experienced by individuals with leprosy admitted to the former colony Tavares de Macedo, Itaboraí, where they were kept from the 1930s until the present day, to question notions of segregation and social discrimination present in this environment. So it analyzes sociabilities and social care networks established in the common life in this "ex-leper colony," usually as alternatives to the conditions offered by the public systems of social protection. The work is based on stories of some of the subjects, seen in their differences - at intersection of gender relations, classes, races/ethnicities, generations and also by religions and educational backgrouns. It adopts the oral history, so as to offer new qualitative interpretations of social and historical processes shown in these networks and sociability, not always visible as unique forms of social protection of life in groups.

[Acceptability of harm reduction interventions: contributions of members of the population to the debate about public health ethics]. / Acceptabilité des interventions en réduction des méfaits: contributions de la population aux débats ethiques de santé publique.

OBJECTIVE: To explore convergence and divergence in ethical stances of public health and of members of the population regarding acceptability of harm reduction interventions, in particular needle exchange programs. METHODS: Forty-nine semi-structured interviews were conducted with French-speaking residents of Quebec City. Content analysis was done to explore the views of the respondents with regard to injection drug users (IDUs) and interventions addressed to them, as well as Quebec policies on harm reduction. RESULTS: Four main categories of social representations about IDUs have emerged from the discourses of the respondents. IDU were represented as: suffering from a disease (n = 17); victim of a situation that they could not control (n = 14); having chosen to use drugs (n = 12); or delinquent people (n = 6). Those social representations were associated with different ethical stances regarding acceptability of harm reduction interventions. Main divergences between respondents' ethical positions on harm reduction and public health discourses were related to the value of tolerance and its limits. CONCLUSIONS: The Quebec City population interviewed in this study had a high level of tolerance regarding needle distribution to drug addicts. Applied ethics could be a useful way to understand citizens' interpretation of public health interventions.

[Asymmetric policies for merit-goods: harmonizing individual and social preferences in public health]. / Políticas tutelares asimétricas: conciliando preferencias individuales y sociales en salud pública.

Behavior is a major determinant of health, but changes in individual conduct are difficult, and health promotion lacks effectiveness. State intervention in the last century, rooted in the modernist movement, went far beyond dealing with externalities and built the framework of the welfare state. The crisis of the welfare state and post modernity after the 1970s led to a weakness of ideologies and values, narcissistic individualism, and lack of trust in institutions, all of which hampered the ability of society's perspective to influence individual behavior. A review of health economics (especially merit goods) and public health (ethics and values of health promotion and prevention) may be useful to understand certain dilemmas in the balance between public intervention and individual autonomy. Given that many unhealthy decisions come from biased or irrational individual preferences, a promising new field in public health interventions is being developed, known as <>, or, more appropriately, as <>, which allow society to selectively influence those individuals whose decision biases lead to self-harming behavior, without constraining the autonomy of well informed autonomous individuals (even though their preferences may not coincide with society's recommended preferences).

Authoritative regulation and the stem cell debate.

In this paper I argue that liberal democratic communities are justified in regulating the activities of their members because of the inevitable existence of conflicting conceptions of what is considered as morally right. This will often lead to tension and disputes, and in such circumstances, reliance on peaceful or orderly co-existence will not normally suffice. In such pluralistic societies, the boundary between permissible and impermissible activities will be unclear; and this becomes a particular concern in controversial issues which raise specific anxieties and uncertainty. One context that has repeatedly raised issues in this regard is that of biotechnology and, in particular, the recent stem cell debate, on which this paper concentrates. While such developments have the potential to make significant improvements to therapeutic progress, we should also be sceptical because predicting the impact of these developments remains uncertain and complex. For the sake of socio-political stability, it will therefore be necessary to enact and enforce rules which limit these competing claims in public policy but which may not be compatible with what individual moral commitments ideally permit. One way to achieve this is to establish procedural frameworks to resolve potential disputes in the public sphere about what is right, wrong, or permissible conduct. I argue that for one to commit to authoritative regulation, an idea of harm prevention through state intervention is necessary; and that this requires optimum mechanisms of procedure which allow the individual the opportunity to compromise and yet to continue to oppose or fight for changes as demanded by his or her moral position.

Do controle social à gestão participativa: perspectivas pós-soberanas para a participação política no SUS / From the Social Control to the Participative Management: post sovereignty perspectives for political participation in the SUS

Este trabalho parte da hipótese de que discutir a participação política no SUS exige a problematização das opções e concepções que orientam sua definição como controle social, operacionalizado por meio de mecanismos de representação de interesses. Desta forma, a intenção de promover uma reflexão sobre a participação política no SUS é remetida ao cotidiano institucional, como desafio de construção de modos de gestão participativos. A proposta metodológica baseia-se em uma abordagem filosófica, que tem por objetivo delinear os conceitos e dispositivos de gestão propostos no campo da Saúde Coletiva, as inovações teóricas que ofertam ao debate sobre a gestão em saúde, tendo por marcador o tema da política. Nesse sentido, elegemos como perspectiva de análise as rupturas e os planos que constituem este campo, procurando mapear o que essa produção faz emergir como oportunidade de constituição de novas práticas sociais e dispositivos institucionais de gestão. Denominamos matrizes conceituais os dois planos filosóficos que selecionamos para estudo no campo da Saúde Coletiva, a saber, o Planejamento em Saúde e o Modelo Assistencial em Defesa da Vida. Por fim a pesquisa procura dialogar com as produções teóricas analisadas, tendo por referência a definição de política como experimentação, invenção de territórios existenciais, criação de valor inerente às implicações normativas da atividade, o que nos coloca o problema da transformação dos espaços institucionais e a produção das normas que os determinam...

This work is based on the hypothesis that discussing the political participation at the SUS requires problematization of options and concepts that guide its definition as social control, operated by mechanisms of interests’ representation. The promotion of a reflection on thepolitical participation at the SUS is referred to the institutional routine, as a challenge to build participative management modes. The methodological proposal is based on a philosophicalapproach, whose aim is to outline management concepts and devices proposed by Public Health, their theoretical innovations in the debate on healthcare management, marked by thetheme of politics. Conceptual matrixes are the two philosophical plans selected for study in the field of Public Health, i.e., Health Planning and the Assistance Model in Defense of Life. The concept of Politics adopted here is defined not in terms of (formal) equality as opposed to(social) differences, but as co-production of the reality built within the relations between Equality and Difference, as access and use of common goods, in their indefinite and open capacity to create values. Thinking about participation in these terms means to build participations as means of setting rules, and not only controlling the fulfillment and inspection of current rules. So we propose considering management as co-production of healthcare, from the publicization and reticulated articulation of the normative dimension of human activity, what means arguing the concrete production (thus local) of public politics and interventions. Among the main theoretical issues discussed here, we point out the articulation of cooperationnetworks and the construction of knowledge, technical support and devices that allow the production and legitimacy of the Health-value as common good. This perspective explains the implications we want to incorporate to the concept of participative management as a possible government post-authoritative technology...

Um panorama do tabagismo em 16 capitais brasileiras e Distrito Federal: tendências e heterogeneidades / A overview of tobacco use in 16 Brazilian state capitals and Federal District: tendencies and heterogeneity

Esta tese inclui dois artigos que têm por objetivo apresentar um panorama das tendências e heterogeneidades do tabagismo nas capitais brasileiras e, assim, oferecer subsídios ao planejamento e avaliação de medidas de controle do tabaco no País. Utilizaram-se os dados da Pesquisa Nacional sobre Saúde e Nutrição (PNSN), e do Inquérito Domiciliar Sobre Comportamentos de Risco e Morbidade Referida de Doenças e Agravos NãoTransmissíveis (InqDANT). No primeiro artigo estimou-se a diferença na prevalência de tabagismo em 14 capitais brasileiras entre pessoas de 15 anos ou mais em 1989 (PNSN) e 2002/2003 (InqDANT) relacionando as mudanças observadas às principais medidas de controle do tabaco desenvolvidas no período. O estudo mostrou que o percentual de fumantes diminuiu de 30,2 por cento para 19,4 por cento no período. Entre homens, a prevalência passou de 37,5 por cento para 23,2 por cento (1,1 por cento /ano)e entre mulheres, de 24,3 por cento para 16,5 por cento (0,6 por cento/ano). A avaliação cronológica sugere que as principais medidas de impacto refletidas no decréscimo observado foram a lei que obriga que haja advertências sobre os malefícios do tabagismo nas embalagens e propagandas de cigarros, a restrição e proibição da propaganda de produtos do tabaco e as intervenções relacionadas à proteção ao tabagismo passivo. O declínio da prevalência observado no estudo foi um dos maiores do mundo. No segundo artigo, fez-se uma descrição da situação do tabagismo no Brasil considerando heterogeneidades regionais e de subgrupos populacionais a partir de uma amostra de 24.681 indivíduos de 15 anos ou mais residentes em 16 capitais brasileiras incluídas no InqDANT. A prevalência de tabagismo no gênero masculino variou de 17,0 por cento a 28,2 por cento e no feminino, de 10 por cento a 22,9 por cento. Entre mulheres, menores prevalências foram observadas nas regiões Norte, Nordeste e Centro-Oeste. Este padrão não se repetiu entre homens...

The Law Reform (Epidemic Preparedness) Bill--a proper response to the pandemic threat?

The ethical frameworks for public health practice are not as clearly articulated as those used in clinical medicine. This poses problems when Medical Officers of Health are required to exercise coercive powers over individuals in the context of communicable disease control. Proposed legislation exacerbates this problem. The Law Reform (Epidemic Preparedness) Bill, recently introduced into Parliament, extends coercive powers but does not provide legal protection for individuals subject to such powers. A framework exists to critique the legitimacy of coercive public health powers and includes the principles of necessity, effectiveness, proportionality, and fairness. The fairness principle is under threat in the draft Bill, which fails to provide "due process" procedures to protect the rights of individuals. Experience in managing the SARS epidemic suggests that coercive powers alone will not enhance the response to public health crises. Respect for individual rights, a positive relationship between government and the community, and the scope for review of decisions are more consistent with modern public health practice and are likely to lead to improved outcomes. In our view, the Bill should be amended to include legal protection for individuals before it is passed into law.

Tobacco taxation and public health: ethical problems, policy responses.

This article aims to describe the major ethical issues surrounding tobacco taxation, and to identify policy responses to minimise any ethical dilemmas. It uses the standard ethical framework for biomedicine (covering beneficence, non-maleficence, respect for autonomy and justice), in conjunction with relevant data on tobacco taxation from various developed countries. Tobacco taxation contributes substantial benefits at the population level by protecting health (i.e., by deterring the uptake of smoking by youth, by promoting quitting, and by reducing harm from exposure to second-hand smoke (SHS)). However, tobacco taxes can contribute to financial hardship among low-socioeconomic status populations where smoking persists. Such taxes can contribute to autonomy, by reducing SHS exposure to non-smokers, and by allowing freedom from nicotine-dependency for those who quit smoking or do not start regular smoking as a result of high tobacco prices. Furthermore, increases in tobacco taxation may reduce health inequalities and so contribute to justice. Nevertheless, the additional tax burden imposed on smokers who wish to continue to smoke, or are unable to quit, can be considered unjust. The autonomy of such smokers may be partly impaired. Although tobacco tax can be regarded as ethically justifiable because of its substantial overall benefit to society, there is substantial scope for policy changes to further reduce any harms and injustices for those populations who continue to smoke.