New Zealand community pharmacists' perspectives on supplying smoked tobacco as an endgame initiative: a qualitative analysis.

INTRODUCTION: Tobacco endgame strategies often include measures to reduce tobacco availability by decreasing retailer numbers. Recently, some US pharmacies have delisted tobacco, though overall retailer numbers have not reduced markedly. Paradoxically, others have suggested limiting tobacco sales to pharmacies, to reduce supply and support cessation. We explored how pharmacists from Aotearoa New Zealand, a country planning to reduce tobacco supply, perceived supplying tobacco. METHODS: We undertook in-depth interviews with 16 pharmacists from Otepoti Dunedin; most served more deprived communities with higher smoking prevalence. We probed participants' views on supplying tobacco, explored factors that could limit implementation of this policy, and analysed their ethical positions. We used qualitative description to analyse data on limiting factors and reflexive thematic analysis to interpret the ethical arguments adduced. RESULTS: Most participants noted time, space and safety concerns, and some had strong moral objections to supplying tobacco. These included concerns that supplying tobacco would contradict their duty not to harm patients, reduce them to sales assistants, undermine their role as health experts, and tarnish their profession. A minority focused on the potential benefits of a pharmacy supply measure, which they thought would use and extend their skills, and improve community well-being. CONCLUSIONS: Policy-makers will likely encounter strongly expressed opposition if they attempt to introduce a pharmacy supply measure as an initial component of a retail reduction strategy. However, as smoking prevalence falls, adopting a health-promoting supply model, using pharmacies that chose to participate, would become more feasible and potentially enhance community outreach and cessation support.

The precautionary principle in public health emergency regime: Ethical and legal examinations of Vietnamese and global response to COVID-19.

Responses to the COVID-19 pandemic have been widely criticized for being too delayed and indecisive. As a result, the precautionary principle has been endorsed, applauded, and proposed to guide future responses to global public health emergencies. Drawing from controversial issues in response to COVID-19, especially in Vietnam, this paper critically discusses some key ethical and legal issues of employing the precautionary principle in public health emergencies. Engaging with discussions concerning this principle, especially in environmental law where the precautionary principle first appeared as a guiding principle with objective content(s), this paper formulates the precautionary principle as 'in dubio pro salus', which is about advising, justifying and demanding states to proactively prepare for scenarios arising out of any public health emergency. It distinguishes the precautionary principle into moderate and hard versions. A moderate version largely takes a holistic approach and fulfils a series of criteria specified in this paper, while a hard version either permits restrictive measures to be deployed primarily on a hypothetic basis or expresses an instrumental mentality. The hard version should be rejected because of the ethical and legal problems it raises, including risk-risk tradeoffs, internal paradoxes, unjustified causing of fear and unreasonable presupposition. Ultimately, this paper defends the moderate version.

An Analysis of Arguments Advanced via Twitter in an Advocacy Campaign to Promote Electronic Nicotine Delivery Systems.

INTRODUCTION: Advocates of electronic nicotine delivery systems (ENDS) increasingly use Twitter to promote liberal ENDS policies. "World Vape Day" (WVD) is an annual campaign organized by pro-ENDS advocacy groups, some of which have links to the nicotine industry (eg, via funding from the "Foundation for a Smoke-Free World"). In 2020, the campaign used dedicated social media accounts to disseminate WVD-branded images and campaign messages. We examined tweets posted as part of WVD 2020 to identify and analyze pro-ENDS policy arguments. AIMS AND METHODS: We extracted tweets posted between 26 May and 3 June 2020 that included the hashtag #WorldVapeDay. We used qualitative thematic analysis to code a random sample (n = 2200) of approximately half the original English language tweets (n = 4387) and used descriptive analysis to identify the most frequently used co-hashtags. RESULTS: Arguments related to four themes: harm reduction, smoking cessation, rights and justice, and opposition to ENDS restrictions. Tweets criticized individuals and groups perceived as opposing liberal ENDS regulation, and used personal testimonials to frame ENDS as a harm reduction tool and life-saving smoking cessation aid. Tweets also advanced rights-based arguments, such as privileging adults' rights over children's rights, and calling for greater recognition of consumers' voices. Tweets frequently used hashtags associated with the WHO and World No Tobacco Day (WNTD). CONCLUSIONS: The WVD campaign presented a series of linked pro-ENDS arguments seemingly aimed at policy-makers, and strategically integrated with the WHO's WNTD campaign. Critically assessing pro-ENDS arguments and the campaigns used to promote these is vital to helping policy actors develop proportionate ENDS policy. IMPLICATIONS: Social media platforms have considerable potential to influence policy actors. Tweets are easily generated and duplicated, creating an impression of sizeable and influential stakeholders. Evidence that the "World Vape Day" campaign was supported by groups with industry links, and targeted-at least in part-at WHO officials and those who follow the WHO World No Tobacco Day campaign, highlights the importance of critically reviewing such campaigns. Further research could examine how health advocates could engage in pro-ENDS campaigns to support balanced messaging and informed policy-making.

Ethics and ENDS.

As debate persists over regulating electronic nicotine delivery systems (ENDS), those favouring liberal ENDS policies have advanced rights-based arguments privileging harm reduction to people who smoke over harm prevention to children and never-smokers. Recent ethical arguments advocate regulating ENDS to prioritise their harm reduction potential for people who currently smoke over any future harm to young never-smokers. In this article, we critically assess these arguments, in particular, the assumption that ethical arguments for prioritising the interests of young people do not apply to ENDS. We argue that, when the appropriate comparators are used, it is not clear the weight of ethical argument tips in favour of those who currently smoke and against young never-smokers. We also assert that arguments from a resource prioritisation context are not appropriate for analysing ENDS regulation, because ENDS are not a scarce resource. Further, we reject utilitarian arguments regarding maximising net population health benefits, as these do not adequately consider vulnerable groups' rights, or address the population distribution of benefits and harms. Lastly, we argue that one-directional considerations of harm reduction do not recognise that ENDS potentially increase harm to those who do not smoke and who would not otherwise have initiated nicotine use.

We want to help: ethical challenges of medical migration and brain waste during a pandemic.

Health worker shortages in many countries are reaching crisis levels, exacerbated by factors associated with the COVID-19 pandemic. In New Zealand, the medical specialists union has called for a health workforce emergency to be declared, yet at the same time, many foreign-trained healthcare workers are unable to stay in the country or unable to work. While their health systems differ, countries such as New Zealand, the USA and the UK at least partially rely on international medical graduates (IMGs) to ensure access to health services, particularly in underserved communities. This paper focuses on the challenges faced by many IMGs, particularly those that constrain their capacity to live and work in the countries that rely on their skills. These challenges give rise to two ethical problems. First, they represent a failure of reciprocity towards IMGs; second, they represent a source of harm, both to IMGs themselves and to communities whose healthcare service depends on contributions made by IMGs. We argue that brain waste and disvaluing the contributions of IMGs and other foreign-trained health professionals have significant costs for maintaining a functional healthcare system, costs which must be adequately recognised and counted.

How do New Zealand youth perceive the smoke-free generation policy? A qualitative analysis.

INTRODUCTION: Aotearoa New Zealand (NZ) plans to introduce a smoke-free generation (SFG) policy, alongside denicotinisation and reducing the availability of tobacco products. The SFG has a clear rationale, yet we know little about how young people, those the policy targets, perceive it. To inform policy design, communication and implementation, we explored how NZ youth perceived the SFG. METHODS: We undertook in-depth interviews with a sample of 20 youth aged 17 or 18 and explored their knowledge of the SFG, and how they perceived its individual and societal implications. We interpreted the data using a reflexive thematic analysis approach. RESULTS: We identified two overarching themes. The first theme, 'societal good and protection from harm', reflected benefits participants associated with the SFG, which outweighed perceptions of lost freedoms. The second theme, 'privileging personal choice', corresponded to two small groups within the sample. The first preferred measures they considered less restrictive, such as increasing the purchase age, and some came to support the SFG as they rationalised their views. The second subgroup expressed more entrenched opposition and felt the SFG deprived them of a choice. CONCLUSIONS: Young people's deep reflection on the SFG led most to view it as liberating rather than restrictive. Communications that avoid prompting heuristic-based responses could encourage youth to reflect on the policy and elicit strong support from the group the SFG aims to benefit.

Equity and preventive regulations.

In 'Obesity, equity and choice' (J Med Ethics 2018;0:1-7. doi:10.1136/medethics-2018-104848), Timothy Wilkinson argues that preventive regulations to address obesity, such as taxes on sugary drinks, are at worst inequitable and at best fail to increase or improve equity. He concludes that we do not yet have good reasons to adopt them. I argue that equity considerations are not as problematic for preventive regulations as Wilkinson suggests.

How Do Past Immunization Strategies Compare With the COVID-19 Immunization Rollout: A New Zealand Analysis.

OBJECTIVE: The aim of this study was to compare past New Zealand immunization strategies with the New Zealand coronavirus disease 2019 (COVID-19) immunization roll-out. METHODS: Using the READ document analysis method, 2 New Zealand immunization strategies (for influenza and measles) were analyzed for how the disease, context, vaccine supply and demand, ethical principles (equity, individual autonomy, and maximizing benefits), and the Treaty of Waitangi impacted the immunization programs. The findings were compared with the ongoing COVID-19 mass immunization program in New Zealand, as of October 15, 2021. RESULTS: Several themes common to the case-studies and the COVID-19 pandemic were identified including the importance of equity, obligations under the Treaty of Waitangi, ethical mandates, and preparedness. CONCLUSIONS: Future emergency planning should integrate learnings from other infectious disease responses and immunization programs to avoid repeating mistakes and to create better health outcomes. This study has provided a basis for ongoing research into how an appropriate immunization plan can be developed that incorporates ethical values, the Treaty of Waitangi (in the NZ context), and evidence-based research to increase trust, equity, health, and preparedness for future outbreaks.

The need to nurture Aotearoa New Zealand's healthcare workforce.

This commentary examines the ethical significance of recently published research demonstrating the extent to which healthcare workers experienced stress and increased challenges in the workplace due to inadequate access to personal protective equipment (PPE) during the first COVID-19 surge in Aotearoa New Zealand. The inadequate state of New Zealand's PPE stockpile and distribution system at the beginning of the pandemic was a critical signal, a "canary in the coalmine", of broader challenges facing the New Zealand healthcare system, particularly for healthcare worker safety and wellbeing. As New Zealand reforms its health system with the aim of improving access to and equity of care, an opportunity exists to apply critical lessons learnt from the COVID-19 pandemic about the need to prioritise the wellbeing of the healthcare workers we are dependent upon to deliver that care. Failure to apply this new knowledge will see the system similarly unprepared for future public health emergencies, which are likely to be imminent, and potentially with healthcare workers less willing to accept the burdens placed on them. The Nurture Framework, which has emerged from the voices of healthcare workers within this research, should be adopted as part of health reforms and ongoing emergency preparedness planning. Trust, transparency, respect and safety, the four values of the Framework, are fundamental for all workers who contribute their skills, knowledge and time to our healthcare organisations.

Conditions of Global Health Crisis Decision-Making-An Ethical Analysis.

The circumstances of a public health emergency (PHE) shape reasoning and decision-making in ways that deviate from routine circumstances, where adherence to established values, principles, and methodologies is expected. Understanding what drives these deviations is critical to assessing their ethical consequences. In this paper we describe four conditions that influence decision-making during PHEs, in particular regarding the deployment and conduct of research on experimental or novel biomedical interventions. These four conditions are politicization, urgency, uncertainty, and fear. We argue that taken together these four conditions create pressure to address the most visible targets of immediate crisis events, driving emphasis on research and development of biomedical interventions. However, this emphasis raises ethical concerns regarding the extent to which attention to and investment in the underlying causes of PHEs, particularly impoverished global public health infrastructure, is diminished as a result.

The perils of failing to enhance: a response to Persson and Savulescu.

Ingmar Persson and Julian Savulescu argue that non-traditional forms of cognitive enhancement (those involving genetic engineering or pharmaceuticals) present a serious threat to humanity, since the fruits of such enhancement, accelerated scientific progress, will give the morally corrupt minority of humanity new and more effective ways to cause great harm. And yet it is scientific progress, accelerated by non-traditional cognitive enhancement, which could allow us to dramatically morally enhance human beings, thereby eliminating, or at least reducing, the threat from the morally corrupt minority. I argue that this apparently intractable dilemma is less difficult to resolve than Persson and Savulescu suppose. Their analysis of non-traditional cognitive enhancement overstates the risks and undervalues the benefits that such enhancement might provide. Once the benefits are better described, it is clear that non-traditional cognitive enhancement could be the means of our survival, not of our destruction.

Management of personal protective equipment in New Zealand during the COVID-19 pandemic: report from the Auditor-General.

In June 2020 the Office of the Auditor-General released its report on the management of personal protective equipment (PPE) in New Zealand during the COVID-19 pandemic. The report raises three issues of ethical concern: inadequate stock, inequity and complacency. Acting on the report's recommendations is a critical step in strengthening New Zealand's preparedness for future public health crises.

Bioethics & human rights: access to health-related goods.

There are many good reasons for a merger between bioethics and human rights. First, though, significant philosophical groundwork must be done to clarify what a human right to health would be and--if we accept that it exists--exactly how it might influence the practical decisions we face about who gets what in very different contexts.

Liberal eugenics and human nature. Against Habermas.

In the course of developing his arguments against making genetic enhancements to one's children, Habermas assumes that a clear line can be drawn between the natural and the manufactured. But given the current state of medical science, this is precisely what we can no longer take for granted.

Mind the Gap: ethical issues of private treatment in the public health system.

The funding of expensive new cancer treatments is a difficult health policy issue in New Zealand and around the world. Since the public health system cannot afford to fund every new treatment, complex decisions must be made about which treatments to fund publicly, and whether and how to make unfunded treatments available to people who may wish to fund them themselves. One recent proposal is that unfunded treatments be made available to patients privately through the local public hospital. Although ultimately declined by the health minister, this proposal merits serious debate, since it is likely to continue to attract attention as a policy option. While the integration of public and private delivery systems has clear benefits for patients with the means to purchase additional treatments, its overall effect may be to exacerbate existing inequities in the New Zealand health sector. This paper briefly explores the wider ramifications of such schemes as part of the ongoing public discussion that should inform the development of health policy on this issue.