In This Together: Navigating Ethical Challenges Posed by Family Clustering during the Covid-19 Pandemic.

Harrowing stories reported in the media describe Covid-19 ravaging through families. This essay reports professional experiences of this phenomenon, family clustering, as encountered during the pandemic's spread across Southern California. We identify three ethical challenges following from it: Family clustering impedes shared decision-making by reducing available surrogate decision-makers for incapacitated patients, increases the emotional burdens of surrogate decision-makers, and exacerbates health disparities for and the suffering of people of color at increased likelihood of experiencing family clustering. We propose that, in response to these challenges, efforts in advance care planning be expanded, emotional support offered to surrogates and family members be increased, more robust state guidance be issued on ethical decision-making for unrepresented patients, ethics consultation be increased in the setting of conflict following from family clustering dynamics, and health care professionals pay more attention to systemic and personal racial biases and inequities that affect patient care and the surrogate experience.

COVID-19 and Health Disparities: Structural Evil Unmasked.

Background: Incidence and mortality from COVID-19 are starkly elevated in poor, minority and marginalized communities. These differences reflect longstanding disparities in income, housing, air quality, preexisting health status, legal protections, and access to health care. The COVID-19 pandemic and its economic consequences have made these ancient disparities plainly visible. Methodology: As scholars in Catholic research universities committed to advancing both scientific knowledge and social justice, we examined these disparities through the lenses of both epidemiology and ethics. Findings: We see these widening disparities as not only as threats to human health, societal stability, and planetary health, but also as moral wrongs - outward manifestations of unrecognized privilege and greed. They are the concrete consequences of policies that promote structural violence and institutionalize racism. Recommendations: We encourage governments to take the following three scientific and ethical justified actions to reduce disparities, prevent future pandemics, and advance the common good: (1) Invest in public health systems; (2) Reduce economic inequities by making health care affordable to all; providing education, including early education, to all children; strengthening environmental and occupational safeguards; and creating more just tax structures; and (3) Preserve our Common Home, the small blue planet on which we all live.

NIMHD Transdisciplinary Collaborative Centers for Health Disparities Research Focused on Precision Medicine.

The NIMHD Transdisciplinary Collaborative Centers for Health Disparities Research Focused on Precision Medicine (PM TCCs) comprise regional coalitions of research institutions and consortium partners focused on priority research topics in minority health and health disparities. In April 2016, NIMHD, in partnership with the National Human Genome Research Institute (NHGRI) and the National Cancer Institute (NCI), launched the PM TCC program to fund five centers across the United States to stimulate health disparities research with an emphasis on precision medicine to address one or more documented health disparities. The programs draw on expertise in genomics and other 'omics, physiology and medicine, population health disparities, behavioral and social sciences, and the science of translation, implementation and dissemination. The TCC program's overarching goal is to develop and disseminate effective interventions that can be implemented in real-world settings with the goal of promoting health equity and reducing health disparities. This special issue of Ethnicity & Disease is dedicated to cutting-edge research conducted by the five PM TCCs at the intersection between precision medicine and health disparities. Articles in this issue will enhance knowledge in a variety of research topics from perspectives on precision medicine among different health disparity populations to methods for reducing inequities in protocols, interventions, and health information and further efforts to promote inclusion of all populations, especially the most vulnerable.

Análisis ético del principio de vulnerabilidad sanitaria / Ethical analysis of the principle of health vulnerability

El concepto de vulnerabilidad ha determinado múltiples actuaciones en el ámbito sanitario. En los últimos años este concepto ha originado diversos modelos holísticos que oscilan entre considerar la vulnerabilidad como un elemento descriptivo de una situación accidental hasta su consideración como principio orientador de la práctica médica. Se percibe la necesidad de profundizar en este fenómeno desde el punto de vista de la filosofía moral. La reflexión moral revela un desequilibrio en el binomio autonomía-dependencia, generando soluciones opuestas en la toma de decisiones. Aunque la autonomía ha fundamentado hasta ahora gran parte de la acción médica, la dependencia plantea una nueva óptica sobre la vulnerabilidad, ra-dicada en la ética del cuidado. Esta perspectiva permite superar la consideración de la vulnerabilidad como una característica, un accidente o un principio. La vulnerabilidad aparece como una dimensión intrínseca del ser humano que, lejos de alterar su dignidad o su autonomía, permite evidenciar la necesidad de los otros para alcanzar su plenitud

The concept of vulnerability has determined multiple actions in the health field. In recent years, this concept has originated various holistic models that oscillate between considering vulnerability as a descriptive element of an accidental situation until it is considered a guiding principle of medical practice. The need to deepen this phenomenon from the point of view of moral philosophy is perceived. The moral reflection reveals an imbalance in the binomial autonomy-dependence, generating opposite solutions in decision-making. Although autonomy has so far supported much of the medical action, the dependency raises a new perspective on vulnerability, rooted in the ethics of care. This perspective allows us to overcome the consideration of vulnerability as a characteristic, an accident or a principle. Vulnerability appears as an intrinsic dimension of the human being that, far from altering its dignity or autonomy, makes it possible to demonstrate the need of others to reach their fullness

Urban Bioethics: A Call for the Prestige.

Many teaching hospitals in the United States were founded on philanthropic principles and aimed to aid the urban poor and underserved. However, as times have changed, there has been a divide created between the urban poor and teaching hospitals. There is a plethora of reasons why this is the case. This paper will specifically focus on the histories of ten hospitals and medical schools and the effect that white flight, segregation, elitism, and marginalization had on healthcare institutions all over the United States. It will call for a reexamination of the values of Ivy League and Ivy Plus teaching hospitals and medical schools and for them to take an intentional look into their communities.

Racism & Health: A public health perspective on racial discrimination.

Racial discrimination has been increasingly reported to have a causal link with morbidity and mortality of Black Americans, yet this issue is rarely addressed in a public health perspective. Racism affects health at different levels: institutional racism is a structural and legalized system that results in differential access to health services; cultural racism refers to the negative racial stereotypes, often reinforced by media, that results in poorer psychological and physiological wellbeing of the minorities. Lastly, interpersonal racism refers to the persistence of racial prejudice that seriously undermines the doctor-patient relationship. After analysing these concepts with examples and relevant studies, this paper explores current literature. Racism as a Determinant of Health: A Systematic Review and Meta-Analyses (Paradies et al, 2015) is the most recent and comprehensive research on the issue, yet it cannot be used to base public health interventions as it contains several limitations. Forward Through Ferguson: A Path Toward Racial Equity (Ferguson Commission, 2015) is a report that identifies 4 priority areas for framing public health interventions: Racial Equity, Justice for All, Youth at the Centre and Opportunity to Thrive. This study represents an important milestone in the application of public health on racial injustices, yet racism must be tackled with a sustained, multilevel, and interdisciplinary approach. In conclusion, this paper addresses how public health interventions can empower Black minorities and bring forward long-term policies. Racism is a structural and long-standing system that can be eliminated only with the collective effort.

Attitudes Toward Alzheimer's Care-Seeking Among Korean Americans: Effects of Knowledge, Stigma, and Subjective Norm.

PURPOSE: Early detection of Alzheimer's disease (AD) ensures that affected individuals and their caregivers can make appropriate plans for health care needs, yet many ethnic minorities delay seeking care for AD until the disease has progressed. This study examined attitudes toward care-seeking for AD among Korean Americans (KAs) and identified factors affecting their attitudes. METHODS: A cross-sectional survey was used to collect data from 234 KA adults. We conducted hierarchical regression analyses to examine the effects of sociocultural background (age, gender, education, cultural orientation), AD knowledge and exposure to AD, and beliefs about AD (stigma of pity, shame, and public avoidance) and AD care (subjective norm) on KAs' attitudes toward seeking AD care from primary care physicians (PCPs) and AD specialists. We also tested whether knowledge of AD moderated the impact of beliefs about AD and AD care on KAs' attitudes toward seeking AD care. RESULTS: For both PCPs and AD specialists, the subjective norm had the strongest effect on KAs' attitudes toward care seeking (ß = 0.557 for PCPs, ß = 0.360 for specialists). Effects of stigma beliefs disappeared in the presence of the subjective norm. AD knowledge moderated the impact of the subjective norm on the attitudes toward both PCPs (ß = -1.653) and specialists (ß = -1.742). IMPLICATIONS: The significance of the subjective norm in KAs' attitudes toward AD care-seeking underscores the importance of public education, and our study suggests that increasing AD knowledge could facilitate a change in public attitudes toward seeking AD care.

Implementing and evaluating an interprofessional minority health conference for social work and healthcare professionals.

Interprofessional education (IPE) is one strategy for addressing health inequities; however, little attention has been paid to continuing IPE for practicing social work and healthcare professionals. This article offers guidance to faculty in social work and health-related academic units on offering continuing IPE on the topic of minority health. An interprofessional group of faculty offered a day-long conference on minority health, ethics, and social justice. The conference goal was to promote interprofessional communication in a co-learning environment and promote dialogue on social determinants of health and health equity in the state. Data were obtained from surveys and analysis of work plans developed during the conference. Workshop participants were majority White (62%), social workers (79%), and practiced for 14 years on average. The most useful topics were dementia and polypharmacy. Takeaway strategies included interprofessional work, being mindful of access to resources, and engagement in continuing education. Lessons learned include plan in advance for all professions; recruit faculty and students from multiple departments to increase interprofessional diversity; offer strategies and incentives to increase student participation; be strategic about conference location and format; and identify a strategic format and theme. IPE is a means of preparing learners for working together in their future careers to provide high-quality patient-centred care and reduce health disparities. Professional development can provide an opportunity to enhance skills to address health disparities, and learning can be significantly enhanced when participants connect with colleagues from different professions, discuss diverse opinions, and share successful practices.

School Violence, Depressive Symptoms, and Help-seeking Behavior: A Gender-stratified Analysis of Biethnic Adolescents in South Korea.

OBJECTIVES: In South Korea (hereafter Korea), the number of adolescent offspring of immigrants has rapidly increased since the early 1990s, mainly due to international marriage. This research sought to examine the association between the experience of school violence and mental health outcomes, and the role of help-seeking behaviors in the association, among biethnic adolescents in Korea. METHODS: We analyzed cross-sectional data of 3627 biethnic adolescents in Korea from the 2012 National Survey of Multicultural Families. Based on the victim's help-seeking behavior, adolescents who experienced school violence were classified into three groups: 'seeking help' group; 'feeling nothing' group; 'not seeking help' group. Multivariate logistic regression was applied to examine the associations between the experience of school violence and depressive symptoms for males and females separately. RESULTS: In the gender-stratified analysis, school violence was associated with depressive symptoms in the 'not seeking help' (odds ratio [OR], 7.05; 95% confidence interval [CI], 3.76 to 13.23) and the 'seeking help' group (OR, 2.77; 95% CI, 1.73 to 4.44) among male adolescents after adjusting for potential confounders, including the nationality of the immigrant parent and Korean language fluency. Similar associations were observed in the female groups. However, in the 'feeling nothing' group, the association was only significant for males (OR, 8.34; 95% CI, 2.82 to 24.69), but not females (OR, 0.77; 95% CI, 0.18 to 3.28). CONCLUSIONS: This study suggests that experience of school violence is associated with depressive symptoms and that the role of victims' help-seeking behaviors in the association may differ by gender among biethnic adolescents in Korea.

School Violence, Depressive Symptoms, and Help-seeking Behavior: A Gender-stratified Analysis of Biethnic Adolescents in South Korea / 예방의학회지

OBJECTIVES: In South Korea (hereafter Korea), the number of adolescent offspring of immigrants has rapidly increased since the early 1990s, mainly due to international marriage. This research sought to examine the association between the experience of school violence and mental health outcomes, and the role of help-seeking behaviors in the association, among biethnic adolescents in Korea. METHODS: We analyzed cross-sectional data of 3627 biethnic adolescents in Korea from the 2012 National Survey of Multicultural Families. Based on the victim's help-seeking behavior, adolescents who experienced school violence were classified into three groups: 'seeking help' group; 'feeling nothing' group; 'not seeking help' group. Multivariate logistic regression was applied to examine the associations between the experience of school violence and depressive symptoms for males and females separately. RESULTS: In the gender-stratified analysis, school violence was associated with depressive symptoms in the 'not seeking help' (odds ratio [OR], 7.05; 95% confidence interval [CI], 3.76 to 13.23) and the 'seeking help' group (OR, 2.77; 95% CI, 1.73 to 4.44) among male adolescents after adjusting for potential confounders, including the nationality of the immigrant parent and Korean language fluency. Similar associations were observed in the female groups. However, in the 'feeling nothing' group, the association was only significant for males (OR, 8.34; 95% CI, 2.82 to 24.69), but not females (OR, 0.77; 95% CI, 0.18 to 3.28). CONCLUSIONS: This study suggests that experience of school violence is associated with depressive symptoms and that the role of victims' help-seeking behaviors in the association may differ by gender among biethnic adolescents in Korea.

Applications of transcranial magnetic stimulation (TMS) in child and adolescent psychiatry.

Transcranial magnetic stimulation (TMS) is emerging as a new treatment and neurophysiological research tool for psychiatric disorders. Recent publications suggest that this modality will also serve as a treatment and research tool in child and adolescent psychiatry. Current reports on therapeutic trials of repetitive transcranial magnetic stimulation (rTMS) in adolescents have primarily focused on depression. However, other pilot work involves the treatment of attention-deficit/hyperactivity disorder (ADHD), autism and schizophrenia. Neurophysiological studies typically utilize single and paired-pulse TMS paradigms which index cortical excitability and inhibition. Initial studies have focused on ADHD, autism, and depression. General knowledge regarding TMS among child and adolescent psychiatrists is lacking. The aim of this review is to provide an overview of TMS in the context of child and adolescent psychiatry, discuss recent therapeutic and neurophysiological studies, and examine relevant ethical considerations.

The health disparities industry: is it an ethical conundrum?

Reducing health disparities is the purported mission of a huge network of professionals representing many specialties and organizations offering a variety of products and services. Given its elaborate infrastructure and specialized set of activities, we identity the network as the health disparities industry. In this article, we question the ethics of this industry. Specifically, we ask whether the public mission is trumped by questionable industry leadership, ethics, and quality assurances. Drawing on general principles of ethics and differentiating ethical concerns from ethical problems, we conclude that the collective behaviors within the industry may represent an ethical conundrum. The article concludes with a call for the cross-examination of the industry practices.