Socially optimal dosing for scarce vaccines: Ethical analysis through the principlism framework.

RATIONALE, AIMS, AND OBJECTIVES: Under conditions of vaccine scarcity, the socially optimal dosing (SOD) strategy administers a lower dose of vaccine to a larger number of people than the individually optimal dosing (IOD) strategy, which administers a higher dose of vaccine to a smaller number of people. In the context of vaccines that generate diminishing returns of effectiveness with each additional dose beyond the first, SOD therefore generates a greater total amount of vaccine-induced protection than IOD and, as such, constitutes the socially optimal strategy. While the clinical and public health arguments in favour of SOD have previously been outlined, this article conducts an ethical analysis of SOD for scarce vaccines through the ethical framework of principlism. METHODS: SOD is examined with regard to each principle within the principlism framework-nonmaleficence, beneficence, autonomy, and justice. RESULTS: SOD is found to satisfy each of the ethical requirements under examination. Regarding nonmaleficence, SOD induces less iatrogenic harm than IOD since the dose of vaccine administered to each individual is lower in the former than the latter. Furthermore, both the good and bad effects of SOD are foreseen while only the good effects are intended, meaning this strategy simultaneously satisfies the doctrine of double effect. Regarding autonomy, SOD makes vaccine-induced protection available to a greater number of individuals who wish to receive it, thereby respecting their capacity for self-determination and to make independent decisions. Regarding beneficence, SOD renders the good-namely the protection of health-more widely available to the individuals that constitute the population in question. Finally, SOD promotes theories of justice that treat individuals equally and is unlikely to reduce the effectiveness of other distribution policies that allocate scarce vaccines in a just manner. CONCLUSION: In conditions of vaccine scarcity, SOD favourably satisfies the ethical framework of principlism.

Questões éticas sobre o tratamento da tuberculose: o Programa Nacional de Controle da Tuberculose do Brasil / Ethical issues about tuberculosis treatment: the Brazilian National Tuberculosis Control Program

A tuberculose (TB) é uma doença infecciosa, causada pelo bacilo Mycobacterium tuberculosis (MTB), que atinge os pulmões durante o contágio inicial e que pode ser transmitida através da tosse, fala ou espirro. A Organização Mundial da Saúde (WHO, 2019) classificou a TB como a principal causa de morte no mundo por único agente etiológico, à frente do Vírus da Imunodeficiência Humana (HIV), sendo ainda considerada como grave problema de Saúde Pública, e declarou, em 1993, a TB como estado de emergência mundial, diante dos altos índices de incidência e mortalidade existentes à época. Em 1999, o Brasil normatizou seu Programa Nacional de Controle da Tuberculose (PNCT) e isso aconteceu diante da permanência do "problema da TB", com índices elevados de abandono do tratamento, redução na taxa de cura e de identificação dos casos. O PNCT introduziu: a extensão da cobertura (com a distribuição de medicamentos gratuitamente), o tratamento diretamente observado (no qual o paciente deve tomar a medicação diante de um agente de saúde) e a busca ativa por pessoas portadoras de infecção latente da TB (ILTB). Há, de fato, questões sociais, políticas e econômicas que ainda influenciam na permanência da TB, considerada como Determinante Social de Saúde (DSS). Contudo, há questões éticas envolvidas na maneira como a TB é abordada pela Saúde Pública, tanto pelo PNCT quanto pela OMS, e que também influenciam nas altas taxas de casos de TB na sociedade e na diferenciação desta sociedade. Mesmo com medicamentos eficazes (incluindo o tratamento da ILTB), a TB permanece como um desafio ético para o governo pois, na prática, foi o governo que permitiu que o indivíduo ficasse doente. O principialismo, por ser uma das referências bioéticas da prática médica no Brasil, será a base dessa reflexão, com o intuito de ajudar na compreensão de como as políticas públicas de saúde são feitas no Brasil e quais devem ser suas prioridades, conciliando os interesses da sociedade e do indivíduo. A comparação com outras realidades que enfrentam o mesmo problema, como a Inglaterra, o debate sobre as justificativas da OMS para sua estratégia pelo Fim da TB e os direitos dos pacientes com TB igualmente contribuirão pela busca de quais são essas questões éticas e como podem colaborar na abordagem e erradicação da TB no mundo, mudando a narrativa e a perspectiva de como "enxergar" a doença e o doente. (AU)

Tuberculosis (TB) is an infectious disease caused by the bacillus Mycobacterium tuberculosis (MTB), which affects the lungs during the initial contagion and can be transmitted through coughing, talking, or sneezing. The World Health Organization (WHO, 2019) classified TB as the leading cause of death in the world by a single etiological agent, ahead of the Human Immunodeficiency Virus (HIV), still being considered a serious Public Health problem and, in 1993, declared TB a global state of emergency, given the high incidence and mortality rates existing at the time. In 1999, Brazil standardized its National Tuberculosis Control Program (PNCT) and this happened in the face of the permanence of the "TB problem", with high rates of treatment abandonment, reduction in the cure rate, and identification of cases. The PNCT introduced: the extension of coverage (with free distribution of medication), directly observed treatment (in which the patient must take the medication in front of a health agent), and the active search for people with latent TB infection (LTBI). There are, in fact, social, political, and economic issues that still influence the permanence of TB, considered a Social Determinant of Health (SDH). However, there are ethical issues involved in the way TB is approached by Public Health, both by the PNCT and the WHO, which also influence the high rates of TB cases in society and the differentiation of this society. Even with effective drugs (including LTBI treatment), TB remains an ethical challenge for the government because, in practice, it was the government that allowed the individual to get sick. Principlism, as one of the bioethical references of medical practice in Brazil, will be the basis of this reflection, to help understand how public health policies are carried out in Brazil and what their priorities should be, reconciling the interests of society and the individual. In comparison with other realities that face the same problem, such as England, the debate on the justifications of the WHO for its End TB Strategy and the rights of patients with TB will also contribute to the search for what these ethical issues are and how they can collaborate in the approach and eradication of TB in the world, changing the narrative and perspective of how to "see" the disease and the sick person. (AU)

Resolução de conflitos familiares por adolescentes e defesa do domínio pessoal / Adolescents' family conflict resolution and defense of personal domain / Resolución de conflictos familiares por adolescentes y defensa del dominio personal

Compreender as estratégias de resolução de conflitos utilizadas por adolescentes na relação com seus pais é fundamental para entender como ocorre seu desenvolvimento saudável. Este artigo investigou a resolução de conflitos de adolescentes em situações de confronto entre o seu domínio pessoal e o controle parental. 36 adolescentes com idades entre 15 e 17 anos, divididos igualmente conforme o sexo, responderam a uma entrevista semiestruturada, que continha quatro situações de conflito hipotéticas. Os dados foram submetidos à análise de conteúdo semântica e a testes não paramétricos. Os resultados foram categorizados em sete estratégias: Assunção de culpa, Submissão, Mentira, Hostilidade, Diálogo/Explicação, Negociação e Outra. A forma predominante de resolução utilizada foi o Diálogo/Explicação, considerada como uma forma recorrente de defender o domínio pessoal. Foram encontradas diferenças em relação ao sexo dos participantes e à situação hipotética. Por fim, os resultados são discutidos em termos de grau de autonomia e tipo de defesa do domínio pessoal.(AU)

Understanding the conflict resolution strategies used by adolescents in their relationship with their parents is fundamental to understanding how their healthy development occurs. This article investigated the resolution of conflicts by adolescents in confrontation situations between their personal domain and parental control. A total of 36 adolescents, aged 15 to 17 years, divided equally according to sex, answered a semi-structured interview that contained four hypothetical conflict situations. Data were subjected to semantic content analysis and non-parametric tests. The results were categorized into seven strategies: Assumption of Guilt, Submission, Lie, Hostility, Dialogue/Explanation, Negotiation, and Other. The predominant form of resolution used was Dialogue/Explanation, considered a recurrent form of defense of the personal domain. Differences were found depending on the participants' gender and the hypothetical situation. Finally, the results are discussed regarding the degree of autonomy and type of defense of the personal domain.(AU)

Enterarse de las estrategias de resolución de conflictos que los adolescentes utilizan en la relación con sus padres es fundamental para comprender cómo ocurre el desarrollo saludable de los adolescentes. A partir de una entrevista semiestructurada, presentamos cuatro situaciones hipotéticas de conflicto que fueron analizadas y respondidas por 36 adolescentes de entre 15 y 17 años, divididos según el género. Los datos se sometieron a un análisis de contenido semántico y a pruebas no paramétricas. Los resultados se categorizaron en siete estrategias de resolución de conflictos: Asunción de culpa, Sumisión, Mentira, Hostilidad, Diálogo/Explicación, Negociación y Otros. La forma de resolución más utilizada fue Diálogo/Explicación, y esta categoría fue una forma de defensa del dominio personal. Asimismo, se encontraron diferencias en función del género de los participantes y conforme la situación hipotética. Los resultados se discuten en términos de grado de autonomía y tipo de defensa del dominio personal.(AU)

Principles and Duties: A Critique of Common Morality Theory.

Tom Beauchamp and James Childress's revolutionary textbook, Principles of Biomedical Ethics, shaped the field of bioethics in America and around the world. Midway through the Principle's eight editions, however, the authors jettisoned their attempt to justify the four principles of bioethics -autonomy, beneficence, nonmaleficence, justice-in terms of ethical theory, replacing it with the idea that these principles are part of a common morality shared by all rational persons committed to morality, at all times, and in all places. Other commentators contend that their theory has never been empirically confirmed and is unfalsifiable, since counterexamples can be deemed irrational, or as held by those living lives not committed to morality. The thesis of this paper is that common morality theory is the artifact of a category mistake-conflating common areas regulated by moral norms with common norms regulating moral conduct-that accords mid-twentieth century American liberal morality the status of transcultural, transtemporal, eternal moral truths. Such a conception offers bioethicists no tools for analyzing moral change-moral progress, regress, reform, evolution, devolution, or revolution-no theoretical basis for deconstructing structural classicism, racism, and sexism, or for facilitating international cooperation on ethical issues in the context of culturally based moral differences.

How to Deal with Counter-Examples to Common Morality Theory: A Surprising Result.

Tom Beauchamp and James Childress are confident that their four principles-respect for autonomy, beneficence, non-maleficence, and justice-are globally applicable to the sorts of issues that arise in biomedical ethics, in part because those principles form part of the common morality (a set of general norms to which all morally committed persons subscribe). Inevitably, however, the question arises of how the principlist ought to respond when presented with apparent counter-examples to this thesis. I examine a number of strategies the principlist might adopt in order to retain common morality theory in the face of supposed counter-examples. I conclude that only a strategy that takes a non-realist view of the common morality's principles is viable. Unfortunately, such a view is likely not to appeal to the principlist.

Applying Bioethics Across Cultures.

BACKGROUND: In our multicultural society, as well as when working internationally, emergency physicians (EPs) frequently see patients from cultures with communitarian or hierarchal structures. These groups may rely on traditional medical practices and view health care decisions through a lens other than patient autonomy. This leads to uncertainty about who can legitimately make decisions for patients and how to apply basic ethical principles. Because the commonly taught ethical principles (autonomy, beneficence, nonmaleficence, and distributive justice) are loosely defined, they provide little help to EPs when working with cultures that de-emphasize Western individualism. CASE REPORT: The case illustrates this complexity by detailing how visiting EPs dealt with leaders from a communitarian culture who demanded that a preteen be treated for a femur fracture by a traditional bone healer rather than with modern techniques. DISCUSSION: The Western-trained clinicians struggled with their ethical responsibility to protect the child's welfare within the social setting: What should beneficence look like in this situation and to whom did it apply? More broadly, this paper examines the bases on which health care professionals might justify overruling parental decisions. It also asks whether the lack of clarity of the most used Western ethical principles suggests the need to broaden clinical ethics education to include issues from other cultures and settings. CONCLUSIONS: Despite principlism's shortcomings, the ease of teaching ethics to health care providers by grouping basic philosophical ideas suggests that we continue to use its structure. As educators and practitioners, we should, however, expand the concept of principlism to better address ethical values and issues found across different cultures.

Mistrust and inconsistency during COVID-19: considerations for resource allocation guidelines that prioritise healthcare workers.

As the USA contends with another surge in COVID-19 cases, hospitals may soon need to answer the unresolved question of who lives and dies when ventilator demand exceeds supply. Although most triage policies in the USA have seemingly converged on the use of clinical need and benefit as primary criteria for prioritisation, significant differences exist between institutions in how to assign priority to patients with identical medical prognoses: the so-called 'tie-breaker' situations. In particular, one's status as a frontline healthcare worker (HCW) has been a proposed criterion for prioritisation in the event of a tie. This article outlines two major grounds for reconsidering HCW prioritisation. The first recognises trust as an indispensable element of clinical care and mistrust as a hindrance to any public health strategy against the virus, thus raising concerns about the outward appearance of favouritism. The second considers the ways in which proponents of HCW prioritisation deviate from the very 'ethics frameworks' that often preface triage policies and serve to guide resource allocation-a rhetorical strategy that may undermine the very ethical foundations on which triage policies stand. By appealing to trust and consistency, we re-examine existing arguments in favour of HCW prioritisation and provide a more tenable justification for adjudicating on tie-breaker events during crisis standards of care.

Surgery during COVID-19 crisis conditions: can we protect our ethical integrity against the odds?

COVID-19 is reducing the ability to perform surgical procedures worldwide, giving rise to a multitude of ethical, practical and medical dilemmas. Adapting to crisis conditions requires a rethink of traditional best practices in surgical management, delving into an area of unknown risk profiles. Key challenging areas include cancelling elective operations, modifying procedures to adapt local services and updating the consenting process. We aim to provide an ethical rationale to support change in practice and guide future decision-making. Using the four principles approach as a structure, Medline was searched for existing ethical frameworks aimed at resolving conflicting moral duties. Where insufficient data were available, best guidance was sought from educational institutions: National Health Service England and The Royal College of Surgeons. Multiple papers presenting high-quality, reasoned, ethical theory and practice guidance were collected. Using this as a basis to assess current practice, multiple requirements were generated to ensure preservation of ethical integrity when making management decisions. Careful consideration of ethical principles must guide production of local guidance ensuring consistent patient selection thus preserving equality as well as quality of clinical services. A critical issue is balancing the benefit of surgery against the unknown risk of developing COVID-19 and its associated complications. As such, the need for surgery must be sufficiently pressing to proceed with conventional or non-conventional operative management; otherwise, delaying intervention is justified. For delayed operations, it is our duty to quantify the long-term impact on patients' outcome within the constraints of pandemic management and its long-term outlook.

Compensation models in emergency medicine: An ethical perspective.

There is considerable diversity in compensation models in the specialty of Emergency Medicine (EM). We review different compensation models and examine moral consequences possibly associated with the use of various models. The article will consider how different models may promote or undermine health care's quadruple aim of providing quality care, improving population health, reducing health care costs, and improving the work-life balance of health care professionals. It will also assess how different models may promote or undermine the basic bioethical principles of beneficence, non-maleficence, respect for autonomy, and justice.

Subsidizing PGD: The Moral Case for Funding Genetic Selection.

Preimplantation genetic diagnosis (PGD) allows the detection of genetic abnormalities in embryos produced through in vitro fertilization (IVF). Current funding models in Australia provide governmental subsidies for couples undergoing IVF, but do not extend to PGD. There are strong reasons for publicly funding PGD that follow from the moral principles of autonomy, beneficence and justice for both parents and children. We examine the objections to our proposal, specifically concerns regarding designer babies and the harm of disabled individuals, and show why these are substantially outweighed by arguments for subsidizing PGD. We argue that an acceptance of PGD is aligned with present attitudes towards procreative decision making and IVF use, and that it should therefore receive government funding.

Do Community Treatment Orders in Psychiatry Stand Up to Principalism: Considerations Reflected through the Prism of the Convention on the Rights of Persons with Disabilities.

Compulsory psychiatric treatment is the norm in many Western countries, despite the increasingly individualistic and autonomous approach to medical interventions. Community Treatment Orders (CTOs) are the singular best example of this, requiring community patients to accept a variety of interventions, both pharmacological and social, despite their explicit wish not to do so. The epidemiological, medical/treatment and legal intricacies of CTOs have been examined in detail, however the ethical considerations are less commonly considered. Principlism, the normative ethical code based on the principles of autonomy, beneficence, non-maleficence and justice, underpins modern medical ethics. Conflict exists between patient centred commentary that reflects individual autonomy in decision making and the need for supported decision making, as described in the Convention on the Rights of Persons with Disabilities (CRPD) and the increasing use of such coercive measures, which undermines this principle. What appears to have been lost is the analysis of whether CTOs, or any coercive measure in psychiatric practice measures up against these ethical principles. We consider whether CTOs, as an exemplar of coercive psychiatric practice, measures up against the tenets of principalism in the modern context in order to further this debate.

Survey on Using Ethical Principles in Environmental Field Research with Place-Based Communities.

Researchers of the Northeast Ethics Education Partnership (NEEP) at Brown University sought to improve an understanding of the ethical challenges of field researchers with place-based communities in environmental studies/sciences and environmental health by disseminating a questionnaire which requested information about their ethical approaches to these researched communities. NEEP faculty sought to gain actual field guidance to improve research ethics and cultural competence training for graduate students and faculty in environmental sciences/studies. Some aspects of the ethical challenges in field studies are not well-covered in the literature. More training and information resources are needed on the bioethical challenges in environmental field research relating to maximizing benefits/reducing risks to local inhabitants and ecosystems from research; appropriate and effective group consent and individual consent processes for many diverse communities in the United States and abroad; and justice considerations of ensuring fair benefits and protections against exploitation through community-based approaches, and cultural appropriateness and competence in researcher relationships.

Principialismo, bioética personalista y principios de acción en medicina y en servicios de salud / Principlism, Personalist Bioethics and Principles of Action in Medicine and Health Services / Principialismo, bioética personalista e princípios de ação em medicina e serviços de saúde

Resumen Dado que hay una brecha y diferencias entre conceptos bioéticos y otros principios de acción provenientes de la práctica de la medicina moderna, su comparación es razonable. La medicina moderna ha generado principios de acción basados en la evidencia y principios de calidad en medicina, y la argumentación bioética recurre frecuentemente al principialismo, o a la bioética personalista. Este artículo pretende ilustrar las características de las relaciones entre estos conceptos y su potencial enriquecimiento mutuo. Se propone una matriz de comparación simple y práctica, para cotejar la relación entre los principios. Estos conceptos tienen una superposición significativa. Sin embargo, tanto en la historia de las ideas como en su formulación son muy diferentes. Se enfatiza el valor contextual de este análisis dado por las tendencias de la salud global, y algunas implicaciones para la medicina de bioética personalista.

Abstract Since there is a gap and differences between bioethical concepts and other principles of action arising from the practice of modern medicine, their comparison is reasonable. Modern medicine has created principles of action based on evidence and principles of quality in medicine, and bioethical argumentation frequently resorts to principlism or personalist bioethics. This article intends to illustrate the characteristics of the relationships between these concepts and their potential mutual enrichment. A simple, practical comparison matrix is proposed to compare the relationship between principles. These concepts have a significant overlap; however, both in the history of ideas and in their formulation, they are very dissimilar. Emphasis is placed on the contextual value of this analysis given by global health trends and some implications for medicine from personalist bioethics.

Resumo Dado que existe uma brecha e diferenças entre conceitos bioéticos e outros princípios de ação que provêm da prática da medicina moderna, a comparação deles é razoável. A medicina moderna gerou princípios de ação baseados em evidências e princípios de qualidade na medicina, e a argumentação bioética frequentemente recorre ao principialismo ou à bioética personalista. Este artigo tem como objetivo ilustrar as características das relações entre esses conceitos e seu potencial de enriquecimento mútuo. Uma matriz de comparação simples e prática é proposta para comparar a relação entre os princípios. Esses conceitos têm uma sobreposição significativa. No entanto, tanto na história das ideias como na sua formulação, são muito diferentes. O valor contextual, dado pelas tendências globais de saúde, e algumas implicações para a medicina bioética personalista são enfatizados nesta análise.

Relação entre tempo de exercício profissional e ocorrências éticas em enfermagem / Relationship between length of service and ethics violations in nursing / Relación entre tiempo de ejercicio profesional y ocurrencias éticas en enfermería

Objetivo: analisar a relação entre tempo de exercício na profissão e ocorrências éticas de profissionais de enfermagem envolvidos em denúncias registradas no Conselho Regional de Enfermagem de Mato Grosso do Sul (COREN/MS). Método: trata-se de pesquisa documental, descritiva e retrospectiva, sendo analisadas as denúncias registradas junto ao COREN/MS, no período de 2003 a 2013. Pesquisa aprovada por Comitê de Ética em Pesquisa. Resultados: foram analisadas 111 denúncias, envolvendo 68 enfermeiros, 41 técnicos e 41 auxiliares de enfermagem. O grupo de profissionais com 1 a 5 anos de formação envolveu-se mais em ocorrências éticas (44,7%). Conclusão: o predominante envolvimento de profissionais de enfermagem recém-formados em ocorrências éticas indica que é imperativa a realização de mais pesquisas sobre a bioética na formação da enfermagem brasileira, seja para conhecer a real situação, quanto para fornecer subsídios para a tomada de decisão da equipe de enfermagem.

Objective: to examine the relationship between length of service and ethics violations by nursing personnel involved in complaints filed with the Mato Grosso do Sul Regional Nursing Council (COREN/MS). Method: this retrospective, descriptive, documentary study examined complaints filed with the COREN/MS, from 2003 to 2013. The study was approved by the research ethics committee. Results: 111 complaints were filed from 2003 to 2013, relating mostly to mid-level workers (54.6%). Personnel with 1-5 years of training were involved in more ethics complaints (44.7%). Conclusion: ethics complaints involved predominantly newly-graduated nurses, indicating that further bioethics research is imperative in Brazilian nursing training, both to learn the real situation and to provide input to nursing teams' decision-making.

Objetivo: analizar la relación entre tiempo de ejercicio profesional y ocurrencias éticas de profesionales de enfermería involucrados en denuncias registradas en el Consejo Regional de Enfermería de Mato Grosso do Sul (COREN/MS). Método: se trata de investigación documental, descriptiva y retrospectiva, donde se analizaron las denuncias registradas junto al COREN/MS, en el período de 2003 a 2013. Investigación aprobada por Comité de Ética en Investigación. Resultados: se analizaron 111 denuncias, involucrando a 68 enfermeros, 41 técnicos y 41 auxiliares de enfermería. El grupo de profesionales, que tenían de 1 a 5 años de recibidos, se involucró en mayor número en ocurrencias éticas (44,7%). Conclusión: la predominante implicación de los profesionales de enfermería recién recibidos en ocurrencias éticas indica que es imperativa la realización de más investigaciones sobre la bioética en la formación de la enfermería brasileña, ya sea para conocer la real situación, como para proporcionar subsidios para la toma de decisión del equipo de enfermería.

A qualitative study of Institutional Ethics Committees: Members' understanding of research guidelines, privacy, and challenges to privacy protection.

Right to privacy of health-related information is a foundational bioethical principle. In India, the importance of protecting privacy is included in law and ethical guidelines. Institutional Ethics Committees (IECs) are entrusted with the responsibility of protecting fundamental ethical principles, including privacy and confidentiality. The present qualitative study was designed to understand IECs' privacy-related obligations and the members' experience in implementing ethical guidelines and privacy protections in their institutions. An interview guide was prepared regarding knowledge of ethical guidelines. Interviews of nineteen IEC members were recorded, transcribed, and translated. Interviews were analysed using thematic analysis. Themes related to these issues were extracted after analysis: awareness, understanding, and implementation of ethical guidelines; understanding of privacy-related obligations and their implementation; and juridical risks to privacy of patients and research participants. The results suggest that training programmes and awareness workshops should be organised for IEC members to protect the rights of research participants, especially in confidentiality issues.

'Despite Circumstance': The Principles of Medical Ethics and the Role of Hope.

In this paper, I will examine how the role of hope can inform our interpretation of the classical principles of medical ethics. Defining hope as a future-oriented expectation for the good, I will look at how it can shape our understanding of justice, beneficence, respect for autonomy and non-maleficence. I will suggest that ethically engaging with these principles in medical practice requires placing value on the patient-practitioner relation as a mode of hope. Engaging the writings of Emmanuel Lévinas and Søren Kierkegaard, I will show how hope reveals itself through responsible and expectant relationship, even in the midst of suffering.

The patient perspective in health care networks.

BACKGROUND: Health care organization is entering a new age. Focus is increasingly shifting from individual health care institutions to interorganizational collaboration and health care networks. Much hope is set on such networks which have been argued to improve economic efficiency and quality of care. However, this does not automatically mean they are always ethically justified. A relevant question that remains is what ethical obligations or duties one can ascribe to these networks especially because networks involve many risks. Due to their often amorphous and complex structure, collective responsibility and accountability may increase while individual responsibility goes down. MAIN BODY: We argue that a business ethics approach to ethical obligations for health care networks, is problematic and we propose to opt for a patient perspective. Using the classic four principles of biomedical ethics (justice, nonmaleficence, beneficence and autonomy) it is possible to identify specific ethical duties. Based on the principle of justice, health care networks have an ethical duty to provide just and fair access for all patients and to be transparent to patients about how access is regulated. The principle of nonmaleficence implies an obligation to guarantee patient safety, whereas the principle of beneficence implies an obligation for health care networks to guarantee continuity of care in all its dimensions. Finally, the principle of autonomy is translated into a specific obligation to promote and respect patient choice. Networks that fail to meet any of these conditions are suspect and cannot be justified ethically. CONCLUSIONS: Faced with daunting challenges, the health care system is changing rapidly. Currently many hopes ride on integrated care and broad health care networks. Such networks are the topic of empirical debate, but more attention should be given to the ethical aspects. Health care networks raise new and pressing ethical issues and we are in need of a framework for assessing how and when such networks are justified.

Forensic psychiatry, one subspecialty with two ethics? A systematic review.

BACKGROUND: Forensic psychiatry is a particular subspecialty within psychiatry, dedicated in applying psychiatric knowledge and psychiatric training for particular legal purposes. Given that within the scope of forensic psychiatry, a third party usually intervenes in the patient-doctor relationship, an amendment of the traditional ethical principles seems justified. RESULTS: Thus, 47 articles, two book chapters and the guidelines produced by the World Psychiatric Association, the American Association of Psychiatry and the Law, as well as by the Royal Australian and New Zealand College of psychiatrists, were analyzed. The review revealed that the ethics of correctional forensic psychiatry and those of legal forensic psychiatry do not markedly differ from each other, but they are incongruent in terms of implementation. METHODS: In an effort to better understand which ethical principles apply to forensic psychiatry, a chronological review of the literature published from 1950 to 2015 was carried out. CONCLUSION: The ethics of correctional forensic psychiatry are primarily deontological. The principle of justice translates into the principle of health care equivalence, the principle of beneficence into providing the best possible care to patients, and the principle of respect of autonomy into ensuring confidentiality and informed consent. The ethics of legal forensic psychiatry are rather consequentialist. In this latter setting, the principle of justice is mainly characterized by professionalism, the principle of beneficence by objectivity and impartiality, and the principle of respect of autonomy by informed consent. However, these two distinct fields of forensic psychiatry share in common the principle of non maleficence, defined as the non collaboration of the psychiatrist in any activity leading to inhuman and degrading treatment or to the death penalty.

Chronic disease as risk multiplier for disadvantage.

This paper starts by establishing a prima facie case that disadvantaged groups or individuals are more likely to get a chronic disease and are in a disadvantaged position to adhere to chronic treatment despite access through Universal Health Coverage. However, the main aim of this paper is to explore the normative implications of this claim by examining two different but intertwined argumentative lines that might contribute to a better understanding of the ethical challenges faced by chronic disease health policy. The paper develops the argument that certain disadvantages which may predispose to illness might overlap with disadvantages that may hinder self-management, potentially becoming disadvantageous in handling chronic disease. If so, chronic diseases may be seen as disadvantages in themselves, describing a reproduction of disadvantage among the chronically ill and a vicious circle of disadvantage that could both predict and shed light on the catastrophic health outcomes among disadvantaged groups-or individuals-dealing with chronic disease.