Where Caring Is Sharing: Evolving Ethical Considerations in Tuberculosis Prevention Among Healthcare Workers.

In many settings, the dedication of healthcare workers (HCWs) to the treatment of tuberculosis exposes them to serious risks. Current ethical considerations related to tuberculosis prevention in HCWs involve the threat posed by comorbidities, issues of power and space, the implications of intersectoral collaborations, (de)professionalization, just remuneration, the duty to care, and involvement in research. Emerging ethical considerations include mandatory vaccination and the use of geolocalization services and information technologies. The following exploration of these various ethical considerations demonstrates that the language of ethics can fruitfully be deployed to shed new light on policies that have repercussions on the lives of HCWs in underresourced settings. The language of ethics can help responsible parties get a clearer sense of what they owe HCWs, particularly when these individuals are poorly compensated, and it shows that it is essential that HCWs' contribution be acknowledged through a shared commitment to alleviate ethically problematic aspects of the environments within which they provide care. For this reason, there is a strong case for the community of bioethicists to continue to take greater interest both in the micro-level (eg, patient-provider interactions) and macro-level (eg, injustices that occur as a result of the world order) issues that put HCWs working in areas with high tuberculosis prevalence in ethically untenable positions. Ultimately, appropriate responses to the various ethical considerations explored here must vary based on the setting, but, as this article shows, they require thoughtful reflection and courageous action on the part of governments, policy makers, and managers responsible for national responses to the tuberculosis epidemic.

Pediatric intensive care in South Africa: an account of making optimum use of limited resources at the Red Cross War Memorial Children's Hospital*.

OBJECTIVE: To develop explicit criteria for patient admission in order to optimize utilization of PICU facilities in the face of increasing demand outstripping resources. SETTING: Multidisciplinary PICU in a university-affiliated referral hospital in Cape Town, South Africa. DESIGN: Retrospective description of policy development and implementation PATIENTS: All patients referred to the Paediatric Intensive Care Unit of the Red Cross War Memorial Children's Hospital. INTERVENTIONS: Development and application of admission policy. MEASUREMENTS AND MAIN RESULTS: In consultation with clinicians at the hospital, principles for utilization of PICU resources were established and then translated into specific policies for prioritization of admission of particular groups of patients. The hospital team developed and implemented: criteria for intensive care admission; prioritization for certain categories of patients (including those scheduled for elective surgery); processes for refusing intensive care admission to other categories of patients; and processes to review implementation. These criteria and procedures were made explicit to clinicians, administrators, and managers and eventually agreed to by them. It was challenging to obtain "buy-in" from all potential stakeholders in the process and also to implement such policies under conditions of high stress. CONCLUSION: Development and implementation of explicit policies for utilization of PICU resources provide a "reasonable" process for fair and equitable utilization of scarce resources. The factors that have to be considered while developing these policies may extend beyond the priorities of individual patients. Implementation is still fraught with problems. Development of explicit admission policies that consider the needs of individual patients and also the longer term development of healthcare services may enable the retention of small but essential services.

Global health and justice: re-examining our values.

Widening disparities in health within and between nations reflect a trajectory of 'progress' that has 'run its course' and needs to be significantly modified if progress is to be sustainable. Values and a value system that have enabled progress are now being distorted to the point where they undermine the future of global health by generating multiple crises that perpetuate injustice. Reliance on philanthropy for rectification, while necessary in the short and medium terms, is insufficient to address the challenge of economic and other systems spinning out of control. Innovative approaches are required and it is suggested that these could best emerge from in-depth multidisciplinary research supported by endeavours to promote a 'global mind-set.'

Global health and the global economic crisis.

Although the resources and knowledge for achieving improved global health exist, a new, critical paradigm on health as an aspect of human development, human security, and human rights is needed. Such a shift is required to sufficiently modify and credibly reduce the present dominance of perverse market forces on global health. New scientific discoveries can make wide-ranging contributions to improved health; however, improved global health depends on achieving greater social justice, economic redistribution, and enhanced democratization of production, caring social institutions for essential health care, education, and other public goods. As with the quest for an HIV vaccine, the challenge of improved global health requires an ambitious multidisciplinary research program.

Human rights abuses: toward balancing two perspectives.

There are two perspectives on the problem of human rights abuses: the perpetrator perspective and the system perspective. The perpetrator perspective focuses on the shortcomings of persons, blaming them for neglect, cruelty, or moral weakness, and it attempts correction through education, activism, and judicial intervention. The system perspective acknowledges that the social circumstances within which individuals live can surreptitiously co-opt otherwise good people into participating in human rights abuses. Here, the corrective approach needs to focus on the complex task of altering structures and functions of systems in order to overcome structurally propelled abuses of human rights, while at the same time recognizing the moral and legal importance of allocating individual blame for the violation of such rights.

Dual loyalty of physicians in the military and in civilian life.

The concept of the dual loyalty physicians may have to both a patient and a third party is important in elucidating the obligations of physicians. The extent to which loyalty may be deflected from a patient to a third party (e.g., an insurance company or a prison commander) is greatly underestimated and has not attracted significant scholarly analysis. We examined dual loyalty in civilian and military contexts and used the principles of public health ethics to construct a framework for determining the legitimacy of physicians' obligations. We illustrate the application of these principles to problems physicians encounter regarding communicable diseases, elder abuse, and driving fitness. In the complex military context, independent ethics tribunals should be created to adjudicate loyalty conflicts.

History, Structure and Agency in Global Health Governance Comment on "Global Health Governance Challenges 2016 - Are We Ready?"

Ilona Kickbusch's thought provoking editorial is criticized in this commentary, partly because she fails to refer to previous critical work on the global conditions and policies that sustain inequality, poverty, poor health and damage to the biosphere and, as a result, she misreads global power and elides consideration of the fundamental historical structures of political and material power that shape agency in global health governance. We also doubt that global health can be improved through structures and processes of multilateralism that are premised on the continued reproduction of the ecologically myopic and socially unsustainable market civilization model of capitalist development that currently prevails in the world economy. This model drives net financial flows from poor to rich countries and from the poor to the affluent and super wealthy individuals. By contrast, we suggest that significant progress in global health requires a profound and socially just restructuring of global power, greater global solidarity and the "development of sustainability."

Correction: Use of the 'Accountability for Reasonableness' Approach to Improve Fairness in Accessing Dialysis in a Middle-Income Country.

[This corrects the article DOI: 10.1371/journal.pone.0164201.].

Use of the 'Accountability for Reasonableness' Approach to Improve Fairness in Accessing Dialysis in a Middle-Income Country.

Universal access to renal replacement therapy is beyond the economic capability of most low and middle-income countries due to large patient numbers and the high recurrent cost of treating end stage kidney disease. In countries where limited access is available, no systems exist that allow for optimal use of the scarce dialysis facilities. We previously reported that using national guidelines to select patients for renal replacement therapy resulted in biased allocation. We reengineered selection guidelines using the 'Accountability for Reasonableness' (procedural fairness) framework in collaboration with relevant stakeholders, applying these in a novel way to categorize and prioritize patients in a unique hierarchical fashion. The guidelines were primarily premised on patients being transplantable. We examined whether the revised guidelines enhanced fairness of dialysis resource allocation. This is a descriptive study of 1101 end stage kidney failure patients presenting to a tertiary renal unit in a middle-income country, evaluated for dialysis treatment over a seven-year period. The Assessment Committee used the accountability for reasonableness-based guidelines to allocate patients to one of three assessment groups. Category 1 patients were guaranteed renal replacement therapy, Category 3 patients were palliated, and Category 2 were offered treatment if resources allowed. Only 25.2% of all end stage kidney disease patients assessed were accepted for renal replacement treatment. The majority of patients (48%) were allocated to Category 2. Of 134 Category 1 patients, 98% were accepted for treatment while 438 (99.5%) Category 3 patients were excluded. Compared with those palliated, patients accepted for dialysis treatment were almost 10 years younger, employed, married with children and not diabetic. Compared with our previous selection process our current method of priority setting based on procedural fairness arguably resulted in more equitable allocation of treatment but, more importantly, it is a model that is morally, legally and ethically more defensible.

Human rights in the biotechnology era 1.

BACKGOUND: The concept of Human Rights has become the modern civilising standard to which all should aspire and indeed attain. DISCUSSION: In an era characterised by widening disparities in health and human rights across the world and spectacular advances in biotechnology it is necessary to reflect on the extent to which human rights considerations are selectively applied for the benefit of the most privileged people. Attention is drawn particularly to sub-Saharan Africa as a marginalised region at risk of further marginalisation if the power associated with the new biotechnology is not used more wisely than power has been used in the past. To rectify such deficiencies it is proposed that the moral agenda should be broadened and at the very least the concept of rights should be more closely integrated with duties SUMMARY: New forms of power being unleashed by biotechnology will have to be harnessed and used with greater wisdom than power has been used in the past. Widening disparities in the world are unlikely to be diminished merely by appealing to human rights. We recommend that a deeper understanding is required of the underlying causes of such disparities and that the moral discourse should be extended beyond human rights language.

Critical reflections on evidence, ethics and effectiveness in the management of tuberculosis: public health and global perspectives.

BACKGROUND: Tuberculosis is a major cause of morbidity and mortality globally. Recent scholarly attention to public health ethics provides an opportunity to analyze several ethical issues raised by the global tuberculosis pandemic. DISCUSSION: Recently articulated frameworks for public health ethics emphasize the importance of effectiveness in the justification of public health action. This paper critically reviews the relationship between these frameworks and the published evidence of effectiveness of tuberculosis interventions, with a specific focus on the controversies engendered by the endorsement of programs of service delivery that emphasize direct observation of therapy. The role of global economic inequities in perpetuating the tuberculosis pandemic is also discussed. SUMMARY: Tuberculosis is a complex but well understood disease that raises important ethical challenges for emerging frameworks in public health ethics. The exact role of effectiveness as a criterion for judging the ethics of interventions needs greater discussion and analysis. Emerging frameworks are silent about the economic conditions contributing to the global burden of illness associated with tuberculosis and this requires remediation.

Ethics, medicine, and health in South Africa.

KIE: Health care issues such as the availability of medical services, access to health care according to ability to pay, geography, and racial discrimination, segregation of public hospitals, allocation of resources and facilities, occupational health care, and the physician patient relationship are discussed within the context of the political, economic, and psychosocial forces of South Africa.^ieng

Global health, vulnerable populations, and law.

Given the fragility of individual and population wellbeing in an interdependent world threatened by many overlapping crises, the suggestion is made that new legal mechanisms have the robust potential to reduce human vulnerability locally and globally.

Improving resource allocation decisions for health and HIV programmes in South Africa: Bioethical, cost-effectiveness and health diplomacy considerations.

The escalating expenditure on patients with HIV/AIDS within an inadequately funded public health system is tending towards crowding out care for patients with non-HIV illnesses. Priority-setting decisions are thus required and should increasingly be based on an explicit, transparent and accountable process to facilitate sustainability. South Africa's public health system is eroding, even though the government has received extensive donor financing for specific conditions, such as HIV/AIDS. The South African government's 2007 HIV plan anticipated costs exceeding 20% of the annual health budget with a strong focus on treatment interventions, while the recently announced 2012-2016 National Strategic HIV plan could cost up to US$16 billion. Conversely, the total non-HIV health budget has remained static in recent years, effectively reducing the supply of health care for other diseases. While the South African government cannot meet all demands for health care simultaneously, health funders should attempt to allocate health resources in a fair, efficient, transparent and accountable manner, in order to ensure that publicly funded health care is delivered in a reasonable and non-discriminatory fashion. We recommend a process for resource allocation that includes ethical, economic, legal and policy considerations. This process, adapted for use by South Africa's policy-makers, could bring health, political, economic and ethical gains, whilst allaying a social crisis as mounting treatment commitments generated by HIV have the potential to overwhelm the health system.

From medical manners to moral reasoning: an historical overview of bioethics in the University of Cape Town's Faculty of Health Sciences.

The history of bioethics in the Faculty of Health Sciences of the University of Cape Town (UCT) follows a similar pattern to elsewhere. At first, bioethics received little formal attention, but there has been a flowering of interest over the last few decades. There has also been a shift from a professionally insular view of bioethics to one informed by non-medical disciplines. While this pattern is to be found in many parts of the world, there are some distinctive, but not unique, features of bioethics at South Africa's oldest medical school.