The bioethics of loneliness.

This article poses an invitation for bioethicists to engage with loneliness as a bioethics and public health concern. I argue that loneliness is a relevant issue for bioethicists for three main reasons: it causes ill-health; particularly in the age of Covid-19, it is becoming prominent on the clinical and public health agenda, affecting millions worldwide; and it engenders several ethical and philosophical questions as a social determinant of health with a rich conceptual background. In what follows I first review the link between loneliness and ill-health and argue that it should concern bioethicists because of this link. I also demonstrate how pertinent the issue of loneliness is being considered nowadays, and mark this as another reason for bioethicists to become engaged. I then move on to define loneliness and its various forms, drawing from modern and contemporary philosophers. The way we choose to cope with the pandemic of loneliness depends in part on its theoretical underpinnings, as well as its empirical scope. Theory thus combines with empirical data in order to devise and implement a rational public health policy, necessitating the kind of interdisciplinary approach that is the bedrock of bioethics. I conclude by suggesting future areas of research and recommendations.

Rights to social determinants of flourishing? A paradigm for disability and public health research and policy.

BACKGROUND: The term evidence based medicine was introduced in the early 1990s in clinical medicine to educate clinicians about how to assess the 'credibility' of research to ensure best treatments for their patients. The evidence based medicine paradigm has become more diffuse in times of austerity and randomised controlled designs are being used to address complex issues in public health and disability research. This research is not addressing inequalities in terms of disability nor how people can live well with disabilities. MAIN TEXT: We argue that there are four ways that public health research needs to change if it wants to address inequalities linked to disability: 1) rethinking theoretical connections between public health and disability; 2) building ethics and equity into interventions through a human rights approach; 3) ensuring ethical inclusion through intersectionality; and 4) evaluating policy and other social impacts to ensure they capture diversity. We argue that these are key issues to building a social determinants of flourishing. CONCLUSIONS: We need to understand how disability might have an accumulative impact across the life course, as well as how to ensure equity for people living with disabilities. This means conceptualising a social determinants of flourishing where we evaluate how exactly randomised controlled trials and public health interventions, not only lead to greater equality but also ensure rights to health and wellbeing.

Partiality, impartiality and the ethics of triage.

In this paper, I discuss the question of partiality and impartiality in the application of triage. Triage is a process in medical research which recommends that patients should be sorted for treatment according to the degree or severity of their injury. In employing the triage protocol, however, the question of partiality arises because socially vulnerable groups will be neglected since there is the likelihood that the social determinants of a patient's health may diminish her chance of survival. As a process that is based on the severity of a patient's injury, triage will be unfair, and hence negatively partial, to socially vulnerable people. Thus, I aim in this paper to show that the triage protocol fails as an impartial evaluative process because its only aim is to maximize survivability. I contend that: (i) triage would lead to the neglect of the social condition of patients or victims, and (ii) it will only serve the utilitarian purpose of maximization of outcomes which may not be justified in some cases.

Shrinking Poor White Life Spans: Class, Race, and Health Justice.

An absolute decline in US life expectancy in low education whites has alarmed policy makers and attracted media attention. Depending on which studies are correct, low education white women have lost between 3 and 5 years of lifespan; men, between 6 months and 3 years. Although absolute declines in life expectancy are relatively rare, some commentators see the public alarm as reflecting a racist concern for white lives over black ones. How ought we ethically to evaluate this lifespan contraction in low education whites? Should we care, or is it racist to care? Does it constitute an injustice or reflect justice being done? I argue that the lifespan contraction in low education whites violates key normative criteria used to make determinations of health justice, and that these judgments do not vitiate concerns about racism. I conclude with reflections on US population health policy and building an inclusive health equity movement.

How does social accountability contribute to better maternal health outcomes? A qualitative study on perceived changes with government and civil society actors in Gujarat, India.

BACKGROUND: Social accountability mechanisms have been highlighted as making a contribution to improving maternal health outcomes and reducing inequities. But there is a lack of evidence on how they contribute to such improvements. This study aims to explore social accountability mechanisms in selected districts of the Indian state of Gujarat in relation to maternal health, the factors they address and how the results of these mechanisms are perceived. METHODS: We conducted qualitative research through in-depth interviews and focus group discussions with actors of civil society and government health system. Data were analyzed using a framework of social determinants of maternal health in terms of structural and intermediary determinants. RESULTS: There are social accountability mechanisms in the government and civil society in terms of structure and activities. But those that were perceived to influence maternal health were mainly from civil society, particularly women's groups, community monitoring and a maternal death review. The social accountability mechanisms influenced structural determinants - governance, policy, health beliefs, women's status, and intermediary determinants - social capital, maternal healthcare behavior, and availability, accessibility and the quality of the health service delivery system. These further positively influenced the increased use of maternal health services. The social accountability mechanisms, through the process of information, dialogue and negotiation, particularly empowered women to make collective demands of the health system and brought about changed perceptions of women among actors in the system. It ultimately improved relations between women and the health system in terms of trust and collaboration, and generated appropriate responses from the health system to meeting women's groups' demands. CONCLUSION: Social accountability mechanisms in Gujarat were perceived to improve interaction between communities and the health system and contribute to improvements in access to and use of maternal health services. The influence of social accountability appeared to be limited to the local/district level and there was lack of capacity and ownership of the government structures.

Exacerbating Inequalities? Health Policy and the Behavioural Sciences.

There have been calls for some time for a new approach to public health in the United Kingdom and beyond. This is consequent on the recognition and acceptance that health problems often have a complex and multi-faceted aetiology. At the same time, policies which utilise insights from research in behavioural economics and psychology ('behavioural science') have gained prominence on the political agenda. The relationship between the social determinants of health (SDoH) and behavioural science in health policy has not hitherto been explored. Given the on-going presence of strategies based on findings from behavioural science in policy-making on the political agenda, an examination of this is warranted. This paper begins by looking at the place of the SDoH within public health, before outlining, in brief, the recent drive towards utilising behavioural science to formulate law and public policy. We then examine the relationship between this and the SDoH. We argue that behavioural public health policy is, to a certain extent, blind to the social and other determinants of health. In section three, we examine ways in which such policies may perpetuate and/or exacerbate health inequities and social injustices. We argue that problems in this respect may be compounded by assumptions and practices which are built into some behavioural science methodologies. We also argue that incremental individual gains may not be enough. As such, population-level measures are sometimes necessary. In section four we defend this contention, arguing that an equitable and justifiable public health requires such measures.

Doctors on Values and Advocacy: A Qualitative and Evaluative Study.

Doctors are increasingly enjoined by their professional organisations to involve themselves in supraclinical advocacy, which embraces activities focused on changing practice and the system in order to address the social determinants of health. The moral basis for doctors' decisions on whether or not to do so has been the subject of little empirical research. This opportunistic qualitative study of the values of medical graduates associated with the Sydney Medical School explores the processes that contribute to doctors' decisions about taking up the advocate role. Our findings show that personal ideals were more important than professional commitments in shaping doctors' decisions on engagement in advocacy. Experiences in early life and during training, including exposure to power and powerlessness, significantly influenced their role choices. Doctors included supraclinical advocacy in their mature practices if it satisfied their desire to achieve excellence. These findings suggest that common approaches to promoting and facilitating advocacy as an individual professional obligation are not fully congruent with the experiences and values of doctors that are significant in creating the advocate. It would seem important to understand better the moral commitments inherent in advocacy to inform future developments in codes of medical ethics and medical education programs.

Ethics - The Social Dimension of Health Care Ethics.

When you hear "health care ethics," I'm betting your mind goes right to clinical issues: at the bedside, in the intensive care unit, in the operating room, in the physician's office. The more fully informed might think about rationing, access or insurance. But mostly, our notions of health care ethics are rooted in an idea of the person as individual.

The ethics and politics of mindfulness-based interventions.

Recently, there has been a lot of enthusiasm for mindfulness practice and its use in healthcare, businesses and schools. An increasing number of studies give us ground for cautious optimism about the potential of mindfulness-based interventions (MBIs) to improve people's lives across a number of dimensions. This paper identifies and addresses some of the main ethical and political questions for larger-scale MBIs. First, how far are MBIs compatible with liberal neutrality given the great diversity of lifestyles and conceptions of the good characteristic of modern societies? It will be argued that the potential benefits of contemporary secular mindfulness practice are indeed of a sufficiently primary or all-purpose nature to qualify as suitable goals of liberal public policy. Second, what challenges are brought up if mindfulness is used in contexts and applications-such as military settings-whose goals seem incompatible with the ethical and soteriological views of traditional mindfulness practice? It will be argued that, given concerns regarding liberal neutrality and reasonable disagreement about ethics, MBIs should avoid strong ethical commitments. Therefore, it should, in principle, be applicable in contexts of controversial moral value. Finally, drawing on recent discussions within the mindfulness community, it is argued that we should not overstate the case for mindfulness and not crowd out discussion of organisational and social determinants of stress, lowered well-being, and mental illness and the collective measures necessary to address them.

Following the Yellow Brick Road: Next Steps in the Synthesis of Pediatric Bioethics and Child Rights.

The Symposium on "The Interface of Child Rights and Pediatric Bioethics in the Clinical Setting" brought together a diverse group of pediatric bioethicists and child rights advocates to explore how the junction of these disciplines could inform their respective work. In retrospect, it is clear how the diversity of personal histories, professional disciplines, knowledge, experience, language, culture, and politics of the participants influenced the outcomes of the Symposium and provided both challenges and opportunities for further collaboration. Several themes emerged from the meeting, including the relevance of the U.N. Convention on the Rights of the Child (CRC), the role of the family, and consideration of the best interests of the child to complex medical decision-making; research ethics; and the applicability of the principles of bioethics and child rights to the social determinants of health. This essay poses questions related to each of these themes that can serve as a framework for further collaboration. It concludes with a statement by Da Silva and his coauthors that the CRC and the principles of child rights can provide "increased conceptual clarity and a widely endorsed language that can assist pediatric bioethicists in clinical, organizational, and international consultations, as well as in education and policy development."

Moving Bioethics Toward Its Better Self: a sociologist's perspective.

The value and belief questions with which bioethics deals have social, cultural, moral, and societal implications that are not confined to certain spheres of biology and medicine, health and illness, and the delivery of medical care. And yet, throughout its history, the field has continued to be focused on a narrow array of medically associated phenomena to which it has applied a limited set of ethical precepts that originate in Western and American philosophical thought. It has done so in an intellectual atmosphere that has not been characterized by vigorous debate. This paper reflects on these attributes of bioethics, offers some suggestions about how it might expand its topical, ethical, cross-cultural, and international orbit, and invites participants in the field to bring this about through a self-critical process.

Toward a Child Rights Theory in Pediatric Bioethics.

This article offers a child rights theory in pediatric bioethics, applying the principles, standards, and norms of child rights, health equity, and social justice to medical and ethical decision-making. We argue that a child rights theory in pediatric bioethics will help pediatricians and pediatric bioethicists analyze and address the complex interplay of biomedical and social determinants of child health. These core principles, standards and norms, grounded in the U.N. Convention on the Rights of the Child (CRC), provide the foundational elements for the theory and a means for better understanding the complex determinants of children's health and well-being. Rights-based approaches to medical and ethical decision-making provide strategies for applying and translating these elements into the practice of pediatrics and pediatric bioethics by establishing a coherent, consistent, and contextual theory that is relevant to contemporary practice. The proposed child rights theory extends evolving perspectives on the relationship between human rights and bioethics to both child rights and pediatric bioethics.

Developing the concept of sustainability in nursing.

Sustainability, and the related concept of climate change, is an emerging domain within nursing and nurse education. Climate change has been posited as a serious global health threat requiring action by health professionals and action at international level. Anåker & Elf undertook a concept analysis of sustainability in nursing based on Walker and Avant's framework. Their main conclusions seem to be that while defining attributes and cases can be established, there is not enough research into sustainability in the nursing literature. This paper seeks to develop their argument to argue that sustainability in nursing can be better understood by accessing non-nursing and grey literature and, for example, the literature in the developing web-based 'paraversity'. Without this understanding, and application in nursing scholarship, nurses will have a rather narrow understanding of sustainability and its suggested links with social and health inequalities and the dynamics underpinning unsustainable neoliberalist political economy. This understanding is based on the social and political determinants of health approach and the emerging domain of planetary health. However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge, a reflection which might reject sustainability and political economy as irrelevant to much of nursing practice.

Standard of Care in Pediatrics: Integrating Family-Centred Care and Social Determinants of Health.

In pediatric healthcare, there is a recognized need to address social determinants of health (SDOH) to positively influence child health and development. In addition, family-centred care (FCC) recognizes the value of the family unit in affecting individual patient experiences of illness and care. However, pediatric healthcare that incorporates principles of FCC and SDOH may be interpreted as calling on clinicians to deviate from or add to practices that form an accepted standard of care. This paper explores the legal and ethical considerations of doing so and describes practical responses to these challenging situations.

Social determinants of health in the Mixtec and Zapotec community in Ventura County, California.

INTRODUCTION: There are an estimated 165,000 indigenous Mexicans living in California, including Mixtec and Zapotec immigrant farm workers. Because many of these immigrants speak only their native non-written languages, there is little information about the needs of this community. An academic-community partnership research team developed a survey to assess basic needs that are known to be social determinants of health in the Mixtec and Zapotec community in Ventura County. METHODS: In summer 2013, Spanish-Mixteco and Spanish-Zapoteco bilingual promotoras conducted surveys in Spanish, Mixteco and Zapoteco in the greater Oxnard area in Ventura County, California to assess the following basic needs: ability of adults and children to obtain health services; household needs regarding work opportunities, food, housing, transportation, safety and education; and discrimination. Independent variables included respondent characteristics such as age, gender, marital status, living part of the year in another city, and household characteristics such as Spanish spoken in the household, number of household members and number of health care providers/agencies used. Several sets of analyses examined the relationship between basic needs and independent variables. RESULTS: Respondents (N = 989) reported insufficient employment opportunities (74%), food for the family (59%) or housing (48%), lack of transportation (59%), and discrimination or bullying (34%). Most reported access to medical care for children (90%), but only 57% of respondents were able to get health care for themselves. CONCLUSIONS: Many basic needs in the Mixtec and Zapotec community in Ventura County are unmet. It will require many different resources and services to address the needs of this community and to overcome longstanding inequities that are experienced by immigrant farm workers. Our findings will guide the development of future health programs and will serve as a baseline to evaluate the impact of services to improve the health conditions in this community.

The social determinants of health: why should we care?

A growing body of empirical research examines the effects of the so-called "social determinants of health" (SDH) on health and health inequalities. Several high-profile publications have issued policy recommendations to reduce health inequalities based on a specific interpretation of this empirical research as well as a set of normative assumptions. This article questions the framework defined by these assumptions by focusing on two issues: first, the normative judgments about the (un)fairness of particular health inequalities; and second, the policy recommendations issued on this basis. We argue that the normative underpinnings of the approach are insufficiently supported and that the policy recommendations do not necessarily follow from the arguments provided. Furthermore, while many of the policies recommended-such as improving people's living conditions and reducing inequalities in wealth and power-are justified in their own right, the way these recommendations are tied to health is problematic.

The evolving idea of social responsibility in bioethics: a welcome trend.

This article discusses the notion of social responsibility for personal health and well-being in bioethics. Although social responsibility is an intrinsic aspect of bioethics, and its role is increasingly recognized in certain areas, it can still be claimed that bioethics in general is committed to an individualistic theoretical framework that disregards the social context in which decisions, health, and well-being are situated. The philosophical premises of this framework regard individuals as rational decisionmakers who can be held accountable for their health conditions and who should be the primary objects of intervention in attempts to reduce lifestyle-associated chronic diseases. There are, however, social determinants of health that challenge this conclusion. Because their impact can be controlled, to a certain extent, by social and public policy decisions, their existence shows the inadequacy of the purely individualistic approach. I suggest, accordingly, that bioethics would benefit, both academically and societally, from a more social perspective. Bioethical studies that acknowledge, from the start, the social determinants of health would be more amenable to constructive multi- and interdisciplinarity, and a more balanced account of responsibility would further the contribution of sound bioethical work to sensible public policies.

Health promotion: an ethical analysis.

Thinking and practising ethically requires reasoning systematically about the right thing to do. Health promotion ethics - a form of applied ethics - includes analysis of health promotion practice and how this can be ethically justified. Existing frameworks can assist in such evaluation. These acknowledge the moral value of delivering benefits. But benefits need to be weighed against burdens, harms or wrongs, and these should be minimised: they include invading privacy, breaking confidentiality, restraining liberty, undermining self-determination or people's own values, or perpetuating injustice. Thinking about the ethics of health promotion also means recognising health promotion as a normative ideal: a vision of the good society. This ideal society values health, sees citizens as active and includes them in decisions that affect them, and makes the state responsible for providing all of its citizens, no matter how advantaged or disadvantaged, with the conditions and resources they need to be healthy. Ethicists writing about health promotion have focused on this relationship between the citizen and the state. Comparing existing frameworks, theories and the expressed values of practitioners themselves, we can see common patterns. All oppose pursuing an instrumental, individualistic, health-at-all-costs vision of health promotion. And all defend the moral significance of just processes: those that engage with citizens in a transparent, inclusive and open way. In recent years, some Australian governments have sought to delegitimise health promotion, defining it as extraneous to the role of the state. Good evidence is not enough to counter this trend, because it is founded in competing visions of a good society. For this reason, the most pressing agenda for health promotion ethics is to engage with communities, in a procedurally just way, about the role and responsibilities of the citizen and the state in promoting and maintaining good health.

What Would Equitable Harm Reduction Look Like?

Structural determinants of health frameworks must express antiracism to be effective, but racial and ethnic inequities are widely documented, even in harm reduction programs that focus on person-centered interventions. Harm reduction strategies should express social justice and health equity, resist stigma and discrimination, and mitigate marginalization experiences among people who use drugs (PWUD). To do so, government and organizational policies that promote harm reduction must acknowledge historical and ongoing patterns of racializing drug use. This article gives examples of such racialization and offers recommendations about how harm reduction programming can most easily and effectively motivate equitable, antiracist care for PWUD.