Proposed Principles for International Bioethics Conferencing: Anti-Discriminatory, Global, and Inclusive.

This paper opens a critical conversation about the ethics of international bioethics conferencing and proposes principles that commit to being anti-discriminatory, global, and inclusive. We launch this conversation in the Section, Case Study, with a case example involving the International Association of Bioethics' (IAB's) selection of Qatar to host the 2024 World Congress of Bioethics. IAB's choice of Qatar sparked controversy. We believe it also may reveal deeper issues of Islamophobia in bioethics. The Section, Principles for International Bioethics Conferencing, sets forth and defends proposed principles for international bioethics conferencing. The Section, Applying Principles to Site Selection applies the proposed principles to the case example. The Section, Applying Principles Beyond Site Selection addresses other applications of the proposed principles. The Section, Objections responds to objections. We close (in the Section, Conclusion) by calling for a wider discussion of our proposed principles. One-Sentence Capsule Summary: How should bioethicists navigate the ethics of global bioethics conferencing?

Research ethics and artificial intelligence for global health: perspectives from the global forum on bioethics in research.

BACKGROUND: The ethical governance of Artificial Intelligence (AI) in health care and public health continues to be an urgent issue for attention in policy, research, and practice. In this paper we report on central themes related to challenges and strategies for promoting ethics in research involving AI in global health, arising from the Global Forum on Bioethics in Research (GFBR), held in Cape Town, South Africa in November 2022. METHODS: The GFBR is an annual meeting organized by the World Health Organization and supported by the Wellcome Trust, the US National Institutes of Health, the UK Medical Research Council (MRC) and the South African MRC. The forum aims to bring together ethicists, researchers, policymakers, research ethics committee members and other actors to engage with challenges and opportunities specifically related to research ethics. In 2022 the focus of the GFBR was "Ethics of AI in Global Health Research". The forum consisted of 6 case study presentations, 16 governance presentations, and a series of small group and large group discussions. A total of 87 participants attended the forum from 31 countries around the world, representing disciplines of bioethics, AI, health policy, health professional practice, research funding, and bioinformatics. In this paper, we highlight central insights arising from GFBR 2022. RESULTS: We describe the significance of four thematic insights arising from the forum: (1) Appropriateness of building AI, (2) Transferability of AI systems, (3) Accountability for AI decision-making and outcomes, and (4) Individual consent. We then describe eight recommendations for governance leaders to enhance the ethical governance of AI in global health research, addressing issues such as AI impact assessments, environmental values, and fair partnerships. CONCLUSIONS: The 2022 Global Forum on Bioethics in Research illustrated several innovations in ethical governance of AI for global health research, as well as several areas in need of urgent attention internationally. This summary is intended to inform international and domestic efforts to strengthen research ethics and support the evolution of governance leadership to meet the demands of AI in global health research.

Digital tools for youth health promotion: principles, policies and practices in sub-Saharan Africa.

Although digital health promotion (DHP) technologies for young people are increasingly available in low- and middle-income countries (LMICs), there has been insufficient research investigating whether existing ethical and policy frameworks are adequate to address the challenges and promote the technological opportunities in these settings. In an effort to fill this gap and as part of a larger research project, in November 2022, we conducted a workshop in Cape Town, South Africa, entitled 'Unlocking the Potential of Digital Health Promotion for Young People in Low- and Middle-Income Countries'. The workshop brought together 25 experts from the areas of digital health ethics, youth health and engagement, health policy and promotion and technology development, predominantly from sub-Saharan Africa (SSA), to explore their views on the ethics and governance and potential policy pathways of DHP for young people in LMICs. Using the World Café method, participants contributed their views on (i) the advantages and barriers associated with DHP for youth in LMICs, (ii) the availability and relevance of ethical and regulatory frameworks for DHP and (iii) the translation of ethical principles into policies and implementation practices required by these policies, within the context of SSA. Our thematic analysis of the ensuing discussion revealed a willingness to foster such technologies if they prove safe, do not exacerbate inequalities, put youth at the center and are subject to appropriate oversight. In addition, our work has led to the potential translation of fundamental ethical principles into the form of a policy roadmap for ethically aligned DHP for youth in SSA.

Governing the Access to COVID-19 Tools Accelerator: towards greater participation, transparency, and accountability.

The Access to COVID-19 Tools Accelerator (ACT-A) is a multistakeholder initiative quickly constructed in the early months of the COVID-19 pandemic to respond to a catastrophic breakdown in global cooperation. ACT-A is now the largest international effort to achieve equitable access to COVID-19 health technologies, and its governance is a matter of broad public importance. We traced the evolution of ACT-A's governance through publicly available documents and analysed it against three principles embedded in the founding mission statement of ACT-A: participation, transparency, and accountability. We found three challenges to realising these principles. First, the roles of the various organisations in ACT-A decision making are unclear, obscuring who might be accountable to whom and for what. Second, the absence of a clearly defined decision making body; ACT-A instead has multiple centres of legally binding decision making and uneven arrangements for information transparency, inhibiting meaningful participation. Third, the nearly indiscernible role of governments in ACT-A, raising key questions about political legitimacy and channels for public accountability. With global public health and billions in public funding at stake, short-term improvements to governance arrangements can and should now be made. Efforts to strengthen pandemic preparedness for the future require attention to ethical, legitimate arrangements for governance.

Rethinking solidarity towards equity in global health: African views.

When the COVID-19 pandemic first took the world by storm, the World Health Organization (WHO) issued a Solidarity Call to Action to realize equitable global access to COVID-19 health technologies through pooling of knowledge, intellectual property and data. At the dawn of 2022, 70% of rich countries' populations were vaccinated but only 4.6% of poor countries (Our World In Data, Coronavirus (COVID-19) vaccinations, 2022). Vaccine nationalism and rampant self-interest grew and our ineffective global response led to new variants of concern - like Omicron - emerging. Rather than abandon the idea of solidarity in global health, we believe that the international community must embrace it. Solidarity, with its emphasis on relationality and recognition of similarities, could offer fertile ground for building an ethical framework for an interconnected and interdependent world. Such a framework would be better than a framework that focuses principally on individual entitlements. To defend this view, we draw on African relational views of personhood and morality. When humans are conceived of as essentially relational beings, solidarity occupies a central role in moral behaviour. We argue that part of the reason appeals to solidarity have failed may be traced to an inadequate conceptualization of solidarity. For as long as solidarity remains a beautiful notion, practiced voluntarily by generous and kindhearted persons, in a transient manner to respond to specific challenges, it will never be able to offer an adequate framework for addressing inequities in global health in a systematic and permanent way. Drawing on this understanding of solidarity, we propose pathways to respond creatively to the risks we face to ensure equitable access to essential health for all.

Towards a new model of global health justice: the case of COVID-19 vaccines.

This paper questions an exclusively state-centred framing of global health justice and proposes a multilateral alternative. Using the distribution of COVID-19 vaccines to illustrate, we bring to light a broad range of global actors up and down the chain of vaccine development who contribute to global vaccine inequities. Section 1 (Background) presents an overview of moments in which diverse global actors, each with their own priorities and aims, shaped subsequent vaccine distribution. Section 2 (Collective action failures) characterises collective action failures at each phase of vaccine development that contributed to global vaccine disparities. It identifies as critical the task of establishing upstream strategies to coordinate collective action at multiple stages across a range of actors. Section 3 (A Multilateral model of global health governance) takes up this task, identifying a convergence of interests among a range of stakeholders and proposing ways to realise them. Appealing to a responsibility to protect (R2P), a doctrine developed in response to human rights atrocities during the 1990s, we show how to operationalise R2P through a principle of subsidiarity and present ethical arguments in support of this approach.

Preparing ethical review systems for emergencies: next steps.

Ethical review systems need to build on their experiences of COVID-19 research to enhance their preparedness for future pandemics. Recommendations from representatives from over twenty countries include: improving relationships across the research ecosystem; demonstrating willingness to reform and adapt systems and processes; and making the case robustly for better resourcing.

Global sharing of COVID-19 therapies during a "New Normal".

This paper argues for global sharing of COVID-19 treatments during the COVID-19 pandemic and beyond based on principles of global solidarity. It starts by distinguishing two types of COVID-19 treatments and models sharing strategies for each in small-group scenarios, contrasting groups that are solidaristic with those composed of self-interest maximizers to show the appeal of solidaristic reasoning. It then extends the analysis, arguing that a similar logic should apply within and between nations. To further elaborate global solidarity, the paper distinguishes morally voluntary, sliding-scale, and mandatory versions. It argues for an all-hands-on-deck approach and gives examples to illustrate. The paper concludes that during the COVID-19 crisis, global solidarity is a core value, and global sharing of COVID-19 treatments should be considered a duty of justice, not of charity.

Bioethics in Africa: A contextually enlightened analysis of three cases.

Across sub-Saharan Africa, bioethics is an emerging field of scholarly inquiry, informed by contextual features distinct to the region. A cultural mix comprised of Euro-American influences, indigenous traditions, Christian faiths and Muslim communities, a bioethics for the sub-Saharan region must be responsive to this milieu. This paper asks, what values and methods can best promote the practice of bioethics in Africa? We set forth a strategy that leans one way or another in response to contextual features of a particular setting. Since our aim is to be responsive to context, we begin with a series of cases and develop values and methods in response to each case as we work through its ethical analysis. Section I introduces a case involving setting priorities for public funding of services that produce large benefits for a small group of people, using the example of dialysis in Ghana. Section II presents a situation involving determining the permissibility of a double standard of quality for healthcare devices in rich and poor nations, using the example of explanting pacemakers from deceased people in wealthy nations for use by people in low- and middle-income nations. Section III describes a scenario where international groups clash with religious and spiritual healers over the chaining of people with severe mental illness at prayer camps and healing centers in Ghana. Section IV articulates a three-pronged strategy for engaging in bioethics brought to light by the case analyses and defends it against objections. Throughout the paper, we tag certain views 'African' and others 'Western' to indicate ethical beliefs commonly found in these regions and less commonly found elsewhere. We do not mean to imply that all Africans hold a certain ethical stance or that all Westerners do; nor do we mean to suggest that people outside these regions do not hold the views in question.

African perspectives of moral status: a framework for evaluating global bioethical issues.

This paper offers an African perspective on moral status grounded on an understanding of personhood. These concepts are key to understanding the differences in emphasis and the values at play when global ethical issues are analysed within the African context. Drawing from African philosophical reflections on the descriptive and normative concepts of personhood, I propose a dual notion of subject and object moral status. I explain how object moral status, duties owed to persons, is differently grounded with respect to subject moral status, which refers to communally directed agency. This distinction influences the African way of conceptualising and addressing ethical issues, where, without ignoring rights of persons, moral consideration about the agency of right bearers is often factored into ethical deliberation. As a practical example, I look at the debate surrounding legal access to safe abortion on the African continent. I suggest a Gadamerian approach to diffuse the tensions that sometimes arise between universalist advocates of rights and cultural decolonisationists.

What's yours is ours: waiving intellectual property protections for COVID-19 vaccines.

This paper gives an ethical argument for temporarily waiving intellectual property (IP) protections for COVID-19 vaccines. It examines two proposals under discussion at the World Trade Organization (WTO): the India/South Africa proposal and the WTO Director General proposal. Section I explains the background leading up to the WTO debate. Section II rebuts ethical arguments for retaining current IP protections, which appeal to benefiting society by spurring innovation and protecting rightful ownership. It sets forth positive ethical arguments for a temporary waiver that appeal to standing in solidarity and holding companies accountable. After examining built-in exceptions to existing agreements and finding them inadequate, the paper replies to objections to a temporary waiver and concludes, in section III, that the ethical argument for temporarily waiving IP protection for COVID-19 vaccines is strong.

Articulating the sources for an African normative framework of healthcare: Ghana as a case study.

Bioethics is gradually becoming an important part of the drive to increase quality healthcare delivery in sub-Saharan African countries. Yet many healthcare service-users in Africa are familiar with incidences of questionable health policies and poor healthcare delivery, leading to severe consequences for patients. We argue that the overarching rights-based ethical administrative framework recently employed by healthcare authorities contributes to the poor uptake and enforcement of current normative tools. Taking Ghana as a case study, we focus on the cultural ethical context and we tease out the concepts of the good and the ethical among the Akan and Bulsa ethnic groups. We point out three tenets towards building a normative framework that can resonate with service-users and practitioners: ontological communitarianism; empathic humanism; and virtuous character. Finally, we indicate how these core tenets can be dovetailed into building an effective normative framework and into the training of healthcare providers.

Decolonising global health: why the new Pandemic Agreement should have included the principle of subsidiarity.

The negotiations for the WHO Pandemic Agreement have brought attention to issues of racism and colonialism in global health. Although the agreement aims to promote global solidarity, it fails to address these deeply embedded problems. This Viewpoint argues that not including the principle of subsidiarity into Article 4 of the agreement as a pragmatic strategy was a missed opportunity to decolonise global health governance and promote global solidarity. Subsidiarity, as a structural principle, empowers local units to make decisions and address issues at their level, fostering collaboration, coordination, and cooperation. By integrating subsidiarity, the agreement could have ensured contextually appropriate responses, empowered local communities, and achieved justice in global health. This paper discusses the elements of subsidiarity-namely, agency and non-abandonment-and highlights the need to strike a balance between them. It also maps the principle of subsidiarity within the Pandemic Agreement, emphasising the importance of creating a practical framework for its implementation. By integrating subsidiarity into the agreement, a just and decolonialised approach to pandemic prevention and response could have been closer to being realised, promoting global solidarity and addressing health inequities.

The hermeneutics of recovery: Facilitating dialogue between African and Western mental health frameworks.

The widespread use of faith-based and traditional healing for mental disorders within African contexts is well known. However, normative responses tend to fall within two camps: on one hand, those oriented towards the biomedical model of psychiatry stress the abuses and superstition of such healing, whilst critics adopting a more 'local' perspective have fundamentally challenged the universalist claims of biomedical diagnostic categories and psychiatric treatments. What seemingly emerges is a dichotomy between those who endorse more 'universalist' or 'relativist' approaches as an analytical lens to the challenges of the diverse healing strands within African contexts. In this article, we draw upon the resources of philosophy and existing empirical work to challenge the notion that constructive dialogue cannot be had between seemingly incommensurable healing practices in global mental health. First, we suggest the need for much-needed conceptual clarity to explore the hermeneutics of meaning, practice, and understanding, in order to forge constructive normative pathways of dialogue between seemingly incommensurable values and conceptual schemas around mental disorder and healing. Second, we contextualise the complex motives to emphasise difference amongst health practitioners within a competitive healing economy. Finally, we appeal to the notion of recovery as discovery as a fruitful conceptual framework which incorporates dialogue, comparative evaluation, and cross-cultural enrichment across divergent conceptualisations of mental health.