Ethical considerations during Mpox Outbreak: a scoping review.

BACKGROUND: Historically, epidemics have been accompanied by the concurrent emergence of stigma, prejudice, and xenophobia. This scoping review aimed to describe and map published research targeting ethical values concerning monkeypox (mpox). In addition, it aimed to understand the research gaps related to mpox associated stigma. METHODS: We comprehensively searched databases (PubMed Central, PubMed Medline, Scopus, Web of Science, Ovid, and Google Scholar) to identify published literature concerning mpox ethical issues and stigma from May 6, 2022, to February 15, 2023. The key search terms used were "monkeypox", "ethics", "morals", "social stigma", "privacy", "confidentiality", "secrecy", "privilege", "egoism", and "metaethics". This scoping review followed the framework proposed by Arksey and O'Malley in 2005 and was further improved by the recommendations of Levac et al. in 2010. RESULTS: The search strategies employed in the scoping review yielded a total of 454 articles. We analyzed the sources, types, and topics of the retrieved articles/studies. The authors were able to identify 32 studies that met inclusion criteria. Six of the 32 included studies were primary research. The study revealed that the ongoing mpox outbreak is contending with a notable surge in misinformation and societal stigma. It highlights the adverse impacts of stigma and ethical concerns associated with mpox, which can negatively affect people with the disease. CONCLUSION: The study's findings underscore the imperative need to enhance public awareness; involve civil society; and promote collaboration among policymakers, medical communities, and social media platforms. These collective endeavors are crucial for mitigating stigma, averting human-to-human transmission, tackling racism, and dispelling misconceptions associated with the outbreak.

Contractualist age rationing under outbreak circumstances.

Age rationing is a central issue in the health care priority-setting literature, but it has become ever more salient in the light of the Covid-19 outbreak, where health authorities in several countries have given higher priority to younger over older patients. But how is age rationing different under outbreak circumstances than under normal circumstances, and what does this difference imply for ethical theories? This is the topic of this paper. The paper argues that outbreaks such as that of Covid-19 involve special circumstances that change how age should influence our prioritization decisions, and that while this shift in circumstances poses a problem for consequentialist views such as utilitarianism and age-weighted consequentialism, contractualism is better equipped to cope with it. The paper then offers a contractualist prudential account of age rationing under outbreak circumstances.

Social value, clinical equipoise, and research in a public health emergency.

The 2016 CIOMS International ethical guidelines for health-related research involving humans states that 'health-related research should form an integral part of disaster response' and that, 'widespread emergency use [of unproven interventions] with inadequate data collection about patient outcomes must therefore be avoided' (Guideline 20). This position is defended against two lines of criticism that emerged during the 2014 Ebola outbreak. One holds that desperately ill patients have a moral right to try unvalidated medical interventions (UMIs) and that it is therefore unethical to restrict access to UMIs to the clinical trial context. The second holds that clinical trials in contexts of high-mortality diseases are morally suspect because equipoise does not exist between a standard of care that offers little prospect of clinical benefit and a UMI that might offer some clinical advantage.

Ethics preparedness: facilitating ethics review during outbreaks - recommendations from an expert panel.

BACKGROUND: Ensuring that countries have adequate research capacities is essential for an effective and efficient response to infectious disease outbreaks. The need for ethical principles and values embodied in international research ethics guidelines to be upheld during public health emergencies is widely recognized. Public health officials, researchers and other concerned stakeholders also have to carefully balance time and resources allocated to immediate treatment and control activities, with an approach that integrates research as part of the outbreak response. Under such circumstances, research "ethics preparedness" constitutes an important foundation for an effective response to infectious disease outbreaks and other health emergencies. MAIN TEXT: A two-day workshop was convened in March 2018 by the World Health Organisation Global Health Ethics Team and the African coaLition for Epidemic Research, Response and Training, with representatives of National Ethics Committees, to identify practical processes and procedures related to ethics review preparedness. The workshop considered five areas where work might be undertaken to facilitate rapid and sound ethics review: preparing national ethics committees for outbreak response; pre-review of protocols; multi-country review; coordination between national ethics committees and other key stakeholders; data and benefit sharing; and export of samples to third countries. In this paper, we present the recommendations that resulted from the workshop. In particular, the participants recommended that Ethics Committees would develop a formal national standard operating procedure for emergency response ethical review; that there is a need to clarify the terminology and expectations of pre-review of generic protocols and agree upon specific terminology; that there is a need to explore mechanisms for multi-country emergency ethical consultation, and to establish procedures for communication between national ethics committees and other oversight bodies and public health authorities. In addition, it was suggested that ethics committees should request from researchers, at a minimum, a preliminary data sharing and sample sharing plan that outlines the benefit to the population from which data and samples are to be drawn. This should be followed in due time by a full plan. CONCLUSION: It is hoped that the national ethics committees, supported by the WHO, relevant collaborative research consortia and external funding agencies, will work towards bringing these recommendations into practice, for supporting the conduct of effective research during outbreaks.

Ethics of Outbreaks Position Statement. Part 1: Therapies, Treatment Limitations, and Duty to Treat.

OBJECTIVES: Outbreaks of disease, especially those that are declared a Public Health Emergency of International Concern, present substantial ethical challenges. Here we start a discourse (with a continuation of the dialogue in Ethics of Outbreaks Position Statement. Part 2: Family-Centered Care) concerning the ethics of the provision of medical care, research challenges and behaviors during a Public Health Emergency of International Concern with a focus on the proper conduct of clinical or epidemiologic research, clinical trial designs, unregistered medical interventions (including vaccine introduction, devices, pharmaceuticals, who gets treated, vulnerable populations, and methods of data collection), economic losses, and whether there is a duty of health care providers to provide care in such emergencies, and highlighting the need to understand cultural diversity and local communities in these efforts. DESIGN: Development of a Society of Critical Care Medicine position statement using literature review and expert consensus from the Society of Critical Care Medicine Ethics committee. The committee had representation from ethics, medical philosophy, critical care, nursing, internal medicine, emergency medicine, pediatrics, anesthesiology, surgery, and members with international health and military experience. SETTING: Provision of therapies for patients who are critically ill or who have the potential of becoming critically ill, and their families, regarding medical therapies and the extent of treatments. POPULATION: Critically ill patients and their families affected by a Public Health Emergency of International Concern that need provision of medical therapies. INTERVENTIONS: Not applicable. MAIN RESULTS: Interventions by high income countries in a Public Health Emergency of International Concern must always be cognizant of avoiding a paternalistic stance and must understand how families and communities are structured and the regional/local traditions that affect public discourse. Additionally, the obligations, or the lack of obligations, of healthcare providers regarding the treatment of affected individuals and communities must also be acknowledged. Herein, we review such matters and suggest recommendations regarding the ethics of engagement in an outbreak that is a Public Health Emergency of International Concern.

Ethics, health policy, and Zika: From emergency to global epidemic?

Zika virus was recognised in 2016 as an important vector-borne cause of congenital malformations and Guillain-Barré syndrome, during a major epidemic in Latin America, centred in Northeastern Brazil. The WHO and Pan American Health Organisation (PAHO), with partner agencies, initiated a coordinated global response including public health intervention and urgent scientific research, as well as ethical analysis as a vital element of policy design. In this paper, we summarise the major ethical issues raised during the Zika epidemic, highlighting the PAHO ethics guidance and the role of ethics in emergency responses, before turning to ethical issues that are yet to be resolved. Zika raises traditional bioethical issues related to reproduction, prenatal diagnosis of serious malformations and unjust disparities in health outcomes. But the epidemic has also highlighted important issues of growing interest in public health ethics, such as the international spread of infectious disease; the central importance of reproductive healthcare in preventing maternal and neonatal morbidity and mortality; diagnostic and reporting biases; vector control and the links between vectors, climate change, and disparities in the global burden of disease. Finally, there are controversies regarding Zika vaccine research and eventual deployment. Zika virus was a neglected disease for over 50 years before the outbreak in Brazil. As it continues to spread, public health agencies should promote gender equity and disease control efforts in Latin America, while preparing for the possibility of a global epidemic.

A Radical Approach to Ebola: Saving Humans and Other Animals.

As the usual regulatory framework did not fit well during the last Ebola outbreak, innovative thinking still needed. In the absence of an outbreak, randomised controlled trials of clinical efficacy in humans cannot be done, while during an outbreak such trials will continue to face significant practical, philosophical, and ethical challenges. This article argues that researchers should also test the safety and effectiveness of novel vaccines in wild apes by employing a pluralistic approach to evidence. There are three reasons to test vaccines in wild populations of apes: i) protect apes; ii) reduce Ebola transmission from wild animals to humans; and iii) accelerate vaccine development and licensing for humans. Data obtained from studies of vaccines among wild apes and chimpanzees may even be considered sufficient for licensing new vaccines for humans. This strategy will serve to benefit both wild apes and humans.

Addressing vaccine hesitancy requires an ethically consistent health strategy.

BACKGROUND: Vaccine hesitancy is a growing threat to public health. The reasons are complex but linked inextricably to a lack of trust in vaccines, expertise and traditional sources of authority. Efforts to increase immunization uptake in children in many countries that have seen a fall in vaccination rates are two-fold: addressing hesitancy by improving healthcare professional-parent exchange and information provision in the clinic; and, secondly, public health strategies that can override parental concerns and values with coercive measures such as mandatory and presumptive vaccination. MAIN TEXT: It is argued that such conflicting, parallel approaches seriously risk undermining trust that is crucial for sustaining herd immunity. Although public health strategies can be ethically justified in limiting freedoms, a parent-centered approach seldom acknowledges how it is impacted by contemporaneous coercive measures. In addition, the clinical encounter is not well suited to helping parents consider the public dimensions of vaccination, despite these being important for trust formation and informed decision-making. Efforts to address vaccine hesitancy require more consistent engagement of parental and citizen views. Along with evidence-based information, debates need to be informed by ethical support that equips parents and professionals to respond to the private and public dimensions of vaccination in a more even-handed, transparent manner. CONCLUSION: Efforts to address vaccine hesitancy need to avoid simple reliance on either parental values or coercive public policies. To do this effectively requires increasing citizen engagement on vaccination to help inform a parent-centered approach and legitimize public policy measures. In addition, cultivating a more ethically consistent strategy means moving beyond the current silos of health ethics - clinical and public health ethics.

Factors influencing emergency nurses' ethical problems during the outbreak of MERS-CoV.

BACKGROUND: Whenever there has been a worldwide contagious disease outbreak, there have been reports of infection and death of healthcare workers. Particularly because emergency nurses have contact with patients on the front line, they experience ethical problems in nursing while struggling with infectious diseases in an unfavorable environment. OBJECTIVE: The objective of this study was to explore emergency nurses' ethical problems and to identify factors influencing these problems during the outbreak of Middle East respiratory syndrome-coronavirus in Korea. DESIGN AND SAMPLE: For this cross-sectional study, a questionnaire survey was conducted with emergency nurses working in six hospitals selected through convenience sampling from the hospitals designated for Middle East respiratory syndrome-coronavirus patients in the capital area. METHODS: Data were collected from 169 emergency nurses in Korea during August 2015. Ethical considerations: This research was approved by the Institutional Review Board of G University in Korea. RESULTS: The findings of this study suggest that during the Middle East respiratory syndrome-coronavirus outbreak, emergency nurses experienced ethical problems tied to a mind-set of avoiding patients. Three factors were found to influence emergency nurses' ethical problems (in order of influence): cognition of social stigmatization, level of agreement with infection control measures, and perceived risk. CONCLUSION: Through this study, we obtained information on emergency nurses' ethical problems during the Middle East respiratory syndrome-coronavirus outbreak and identified the factors that influence them. As found in this study, nurses' ethical problems were influenced most by cognitions of social stigmatization. Accordingly, to support nurses confidently care for people during future health disasters, it is most urgent to promote appropriate public consciousness that encourages healthcare workers.

Using typing techniques in a specific outbreak: the ethical reflection of public health professionals.

Typing techniques are laboratory methods used in outbreak management to investigate the degree to which microbes found within an outbreak are related. Knowledge about relational patterns between microbes benefits outbreak management, but inevitably also tells us something about the relational patterns of the people hosting them. Since the technique is often used without explicit consent of all individuals involved, this may raise ethical questions. The aim of this study was to unravel the complex ethical deliberation of professionals over the use of such techniques. We organised group discussions (n = 3) with Dutch outbreak managers (n = 23). The topic list was based on previously identified ethical issues and discussions were analysed for recurrent themes. We found that outbreak managers first and foremost reflect on the balance of individual harm with public health benefit. This key question was approached by way of discussing four more specific ethical themes: (1) justification of governmental intervention, (2) responsibility to prevent infections, (3) scientific uncertainty and (4) legal consequences. The themes found in this study, rephrased into accessible questions, represent the shared ethical understanding of professionals and can help to articulate the ethical dimensions of using molecular science in response to infectious disease outbreaks.

Publication ethics in public health emergencies.

In this article, we describe and analyse three issues in publication ethics that are raised when conducting research in emergencies and disasters. These include reluctance to share data and samples because of concerns about publications, loss of individual authorship in high high-profile multi-entity publications, and the deaths of authors during dangerous research projects. An emergency research pledge may be useful in avoiding some of these issues.

Ethical challenges for international collaborative research partnerships in the context of the Zika outbreak in the Dominican Republic: a qualitative case study.

BACKGROUND: The establishment of international collaborative research partnerships in times of infectious disease outbreaks of international importance has been considered an ethical imperative. Frail health research systems in low- and middle-income countries can be an obstacle to achieve the goal of knowledge generation and the search for health equity before, during and after infectious disease outbreaks. METHODS: A qualitative case study was conducted to identify the challenges and opportunities facing the Dominican Republic with regards to developing international collaborative research partnerships in the context of the Zika outbreak and its ethical implications. Researchers conducted 34 interviews (n = 30 individual; n = 4 group) with 39 participants (n = 23 males; n = 16 females) representing the government, universities, international donor agencies, non-governmental organisations, community-based organisations and medical societies, in two metropolitan cities. RESULTS: Five international collaborative research projects related to the Zika virus were identified. Major ethical challenges were linked to the governance of health research, training of human resources, the institutionalisation of scientific activity, access to research funds and cultural aspects. Capacity-building was not necessarily a component of some partnership agreements. With few exceptions, local researchers were merely participating in data collection and less on defining the problem. Opportunities for collaborative work included the possibility of participation in international research consortiums through calls for proposals. CONCLUSIONS: The Dominican government and research stakeholders can contribute to the international response to the Zika virus through active participation in international collaborative research partnerships; however, public recognition of the need to embrace health research as part of public policy efforts is warranted. A working group led by the government and formed by national and international research stakeholders will be key to identify ways in which the country could respond to the ethical demand of generating new knowledge in times of outbreaks.

Bioethics meets Ebola: exploring the moral landscape.

INTRODUCTION: The Ebola Virus Disease (EVD) outbreak in West Africa raised ethical issues about structural disadvantage; the duty to care of healthcare workers; the use and study of unregistered agents; the use of restrictive measures like mass quarantine and the importance of public trust. SOURCES OF DATA: WHO reports, literature on EVD and ethics. AREAS OF AGREEMENT: The use of restrictive measures and the testing of unregistered agents is ethical if support for individuals or communities is provided. AREAS OF CONTROVERSY: Controversy exists over ethical trial design for the study of unregistered agents and over the limits of the duty to care. GROWING POINTS: The role of the WHO in outbreak control and research oversight needs rethinking and further support. Solidarity in global health needs fostering. AREAS TIMELY FOR DEVELOPING RESEARCH: Research is needed on how to restore and enhance health systems and public trust in EVD-affected countries.

Ethical challenges of containing Ebola: the Nigerian experience.

Responding effectively to an outbreak of disease often requires routine processes to be set aside in favour of unconventional approaches. Consequently, an emergency response situation usually generates ethical dilemmas. The emergence of the Ebola virus in the densely populated cities of Lagos and Port Harcourt in Nigeria brought bleak warnings of a rapidly expanding epidemic. However, these fears never materialised largely due to the swift reaction of emergency response and incident management organisations, and the WHO has now declared Nigeria free of Ebola. However, numerous ethical issues arose in relation to the response to the outbreak. This paper discusses some of these ethical challenges and the vital lessons learned. Ethical challenges relating to confidentiality, the dignity of persons, non-maleficence, stigma and the ethical obligations of health workers are examined. Interventions implemented to ensure that confidentiality and the dignity of persons improved and stigma was reduced, included community meetings, knowledge communication and the training of media personnel in the ethical reporting of Ebola issues. In addition, training in infection prevention and control helped to allay the fears of health workers. A potential disaster was also averted when the use of an experimental medicine was reconsidered. Other countries currently battling the epidemic can learn a lot from the Nigerian experience.

Refugees, humanitarian aid and the right to decline vaccinations.

Recent instances of governments and others refusing humanitarian assistance to refugees and IDPs (internally-displaced persons) unless they agreed to polio immunization for their children raise difficult ethical challenges. The authors argue that states have the right and a responsibility to require such vaccinations in instances where the serious vaccine-preventable disease(s) at issue threaten others, including local populations, humanitarian workers, and others in camps or support settings.

Reconsidering the ethical permissibility of the use of unregistered interventions against Ebola virus disease.

Ethical considerations for the use of unregistered interventions for Ebola virus disease have sparked considerable debate among academic and clinical ethicists. In August 2014 the World Health Organization (WHO) convened a panel of experts to discuss approaches to the outbreak in West Africa, with the goal of determining "whether it is ethical to use unregistered interventions with unknown adverse effects for possible treatment or prophylaxis". 1 The panel concluded that there would be an ethical imperative to provide such unregistered interventions if specific criteria could be met. This paper evaluates the WHO conclusion and argues that although it may be reasonable to provide unregistered interventions considering the circumstance, there is no clear ethical imperative to do so.

Ethical issues in the response to Ebola virus disease in US emergency departments: a position paper of the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine.

The 2014 outbreak of Ebola Virus Disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged US emergency departments to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to US acute care facilities, ethical questions have been raised in both the press and medical literature as to how US emergency departments, emergency physicians, emergency nurses and other stakeholders in the healthcare system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to US emergency physicians, emergency nurses and other stakeholders in the healthcare system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to US emergency departments in how they approach preparation for and management of potential patients with EVD.

[Duties of TB patients or suspected patients and their close relations]. / Prawne obowiazki chorych lub podejrzanych o zachorowanie na gruzlice oraz osób z ich otoczenia.

The effective laws impose the duty upon TB patients or persons suspected to have TB as well as their close relations to undergo compulsory sanitary and epidemiological examinations. Furthermore, treatment is also mandatory and in case of infective patients hospitalization and isolation. Duty does not however denote enforcement, which is required in certain particularly dangerous infectious diseases. Poland operates a system of mandatory TB vaccination applicable, today, only to infants. Persons suspected of TB have the obligation to provide necessary information helping in diagnosing the disease or helping to find the source of infection and transmission of the disease. TB patients are under obligation to discontinue performing their work to prevent the disease from spreading to other persons.