Ethical challenges in health care during collective hunger strikes in public or occupied spaces.

Public collective hunger strikes take place in complex social and political contexts, require medical attention and present ethical challenges to physicians. Empirical research, the ethical debate to date and existing guidelines by the World Medical Association focus almost exclusively on hunger strikes in detention. However, the public space differs substantially with regard to the conditions for the provision of health care and the diverse groups of healthcare providers or stakeholders involved. By reviewing empirical research on the experience of health professionals with public collective hunger strikes, we identified the following ethical challenges: (1) establishment of a trustful physician-striker relationship, (2) balancing of medico-ethical principles in medical decision-making, (3) handling of loyalty conflicts and (4) preservation of professional independence and the risk of political instrumentalization. Some of these challenges have already been described and discussed, yet not contextualized for public collective strikes, while others are novel. The presence of voluntary physicians may offer opportunities for a trustful relationship and, hence, for ethical treatment decisions. According to our findings, it requires more attention to how to realise autonomous medical decisions in the complex context of a dynamic, often unstructured and politically charged setting, which ethical norms should shape the professional role of voluntary physicians, and what is the influence of the hunger strikers' collective on individual healthcare decisions. Our article can serve as a starting point for further ethical discussion. It can also provide the basis for the development of potential guidelines to support health professionals involved in public collective hunger strikes.

[Reducing Health Inequalities: Development of a Stepwise Procedure from Data to Political Interventions]. / Verringerung der gesundheitlichen Ungleichheit: Entwicklung eines Stufenplans zur gesundheitspolitischen Entscheidungsfindung.

Low socioeconomic status (assessed by indicators such as educational level or income) is often associated with increased morbidity and mortality. This has been shown in many empirical studies, also in Germany. There are numerous calls for political interventions aimed at reducing these health inequalities, in scientific discussions as well as in the public. Asked for scientifically based recommendations on how to proceed 'from data to action̓, we have to admit that we are still faced with many questions and few answers. Developing these recommendations poses many challenges such as, for example, how to integrate the expertise from different public health disciplines. The present study focuses on the cooperation between social epidemiology, public health ethics and health economics, as we believe that these three disciplines are of particular importance here. We briefly outline what each of them could contribute to the development of practical interventions aimed at reducing health inequalities. We particularly emphasize the importance of public health ethics, as it focuses on questions that to date have largely been neglected in the German discussion: How can we evaluate the empirical data and the proposed political interventions from an ethical point of view? Which health inequalities are 'unjust̓, and how can this normative judgement be justified? Based on the expertise from the three disciplines mentioned above, the aim is to pave the way 'from data to action̓ by developing a well-structured stepwise procedure for interventions aimed at reducing health inequalities. The joint scheme could be very beneficial not only for developing practical interventions, but also for further developing each discipline in itself. The simple scheme proposed here could be a starting point that helps specify many open questions on this path 'from data to action̓.

[Mobile health technologies, social justice and population-based vulnerabilities : A public health ethics perspective on mHealth using the example of type 2 diabetes mellitus]. / Mobile Gesundheitstechnologien, soziale Gerechtigkeit und populationsbezogene Vulnerabilitäten : Eine Public-Health-ethische Perspektive auf mHealth am Beispiel von Diabetes mellitus Typ 2.

Mobile health technologies (mHealth) promote the trend towards personal responsibility and self-management. By using the example of type 2 diabetes mellitus (T2DM), the article aims to deepen the discussion on mHealth, personal responsibility and justice-which has so far only been rudimentary-from a public health ethical perspective. It shows that in the field of T2DM, mHealth can on the one hand improve social health justice, but on the other hand can also exacerbate social health injustices. From a justice-focused, public health ethical perspective on T2DM mHealth, it is necessary to better understand whether and how vulnerable population groups are considered in mHealth development and implementation, how these groups experience the use of the technology, what social-epidemiological impacts the increasing use of mHealth can have, which health inequalities in the area of T2DM are unfair, to what extent personal responsibility should be placed in the hands of the users, and where the limits of personal responsibility lie. Considering social diversity and the social determinants of health is an ongoing process and must permeate all phases of mHealth development and implementation.

Providing health care in politically charged contexts: a qualitative study about experiences during a public collective hunger strike of asylum seekers in Germany.

PURPOSE: Role expectations of physicians providing health care for hunger strikers have been discussed in the context of prisons and detention centres. Ethical guidance for physicians in these situations is codified in the Declaration of Malta. In the last years, new forms of collective, public hunger strikes of asylum seekers have occurred. We have aimed at reconstructing the experiences of health-care personnel involved in one of such cases. METHODS: Semi-structured interviews with nine participants (physicians and paramedics) that had been involved in a public collective hunger strike of asylum seekers in Germany were conducted. RESULTS: We identified three health-care provider groups: voluntary physicians, emergency service providers and medical consultants for the authorities. Role conflicts arising from multiple loyalty situations with obligations towards different stakeholders (e.g., strikers, employers, authorities) were perceived as the greatest challenge especially for voluntary doctor and emergency service provider participants. Such conflicts culminated in feeling instrumentalized for political goals. CONCLUSION: The results illustrate that professional challenges in the health care during a public collective hunger strike differ in various aspects from those described in the literature on custodial settings. We recommend expanding and adapting the medico-ethical guidance.

Digitally supported public health interventions through the lens of structural injustice: The case of mobile apps responding to violence against women and girls.

Mobile applications (apps) have gained significant popularity as a new intervention strategy responding to violence against women and girls. Despite their growing relevance, an assessment from the perspective of public health ethics is still lacking. Here, we base our discussion on the understanding of violence against women and girls as a multidimensional, global public health issue on structural, societal and individual levels and situate it within the theoretical framework of structural injustice, including epistemic injustice. Based on a systematic app review we previously conducted, we evaluate the content and functions of apps through the lens of structural injustice. We argue that technological solutions such as apps may be a useful tool in the fight against violence against women and girls but have to be situated within the broader frame of public health that considers the structural dimensions of such violence. Ultimately, the concerns raised by structural injustice are-alongside key concerns of safety, data privacy, importance of human supportive contact, and so forth-crucial dimensions in the ethical assessment of such apps. However, research on the role and relevance of apps as strategies to address the structural and epistemic dimensions of violence remains scarce. This article aims to provide a foundation for further discussion in this area and could be applicable to other areas in public health policy and practice.

Digital contact tracing and exposure notification: ethical guidance for trustworthy pandemic management.

There is growing interest in contact tracing apps (CT apps) for pandemic management. It is crucial to consider ethical requirements before, while, and after implementing such apps. In this paper, we illustrate the complexity and multiplicity of the ethical considerations by presenting an ethical framework for a responsible design and implementation of CT apps. Using this framework as a starting point, we briefly highlight the interconnection of social and political contexts, available measures of pandemic management, and a multi-layer assessment of CT apps. We will discuss some trade-offs that arise from this perspective. We then suggest that public trust is of major importance for population uptake of contact tracing apps. Hasty, ill-prepared or badly communicated implementations of CT apps will likely undermine public trust, and as such, risk impeding general effectiveness.

Applying a Precautionary Approach to Mobile Contact Tracing for COVID-19: The Value of Reversibility.

The COVID-19 pandemic presents unprecedented challenges to public health decision-making. Specifically, the lack of evidence and the urgency with which a response is called for, raise the ethical challenge of assessing how much (and what kind of) evidence is required for the justification of interventions in response to the various threats we face. Here we discuss the intervention of introducing technology that aims to trace and alert contacts of infected persons-contact tracing (CT) technology. Determining whether such an intervention is proportional is complicated by complex trade-offs and feedback loops. We suggest that the resulting uncertainties necessitate a precautionary approach. On the one hand, precautionary reasons support CT technology as a means to contribute to the prevention of harms caused by alternative interventions, or COVID-19 itself. On the other hand, however, both the extent to which such technology itself present risks of serious harm, as well as its effectiveness, remain unclear. We therefore argue that a precautionary approach should put reversibility of CT technology at the forefront. We outline several practical implications.

Pandemic Surveillance and Racialized Subpopulations: Mitigating Vulnerabilities in COVID-19 Apps.

Debates about effective responses to the COVID-19 pandemic have emphasized the paramount importance of digital tracing technology in suppressing the disease. So far, discussions about the ethics of this technology have focused on privacy concerns, efficacy, and uptake. However, important issues regarding power imbalances and vulnerability also warrant attention. As demonstrated in other forms of digital surveillance, vulnerable subpopulations pay a higher price for surveillance measures. There is reason to worry that some types of COVID-19 technology might lead to the employment of disproportionate profiling, policing, and criminalization of marginalized groups. It is, thus, of crucial importance to interrogate vulnerability in COVID-19 apps and ensure that the development, implementation, and data use of this surveillance technology avoids exacerbating vulnerability and the risk of harm to surveilled subpopulations, while maintaining the benefits of data collection across the whole population. This paper outlines the major challenges and a set of values that should be taken into account when implementing disease surveillance technology in the pandemic response.

[Covid-19: An ad hoc public health ethics consultation]. / Covid-19: Eine Ad hoc Public-Health-Ethikberatung.

In this paper we describe the process and content of our ad hoc public health ethics consultation for a Bavarian health authority in relation to Covid-19.

Mobile applications addressing violence against women: a systematic review.

Introduction: Violence against women is a pressing global health problem that is being met with a new intervention strategy-mobile applications. With this systematic review, we provide an initial analysis and functional categorisation of apps addressing violence against women. Methods: We conducted a systematic online search conforming with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify apps addressing violence against women in five World Bank regions (Europe and Central Asia; North America, Latin America and the Caribbean; Middle East and North Africa; South Asia; and sub-Saharan Africa). Applications with location of initiation in mentioned regions and ≥100 downloads were included. Data on sector, target group(s), year of release, location of initiation and implementation were extracted. By means of a structured qualitative content analysis, applications were then categorised according to their main functions. Results: Of 327 relevant applications, 171 were included into the systematic review and assigned to one of five identified categories of main functions, respectively: emergency, avoidance, education, reporting and evidence building, and supporting apps. The largest proportion (46.78%) consisted of emergency apps, followed by education, reporting and evidence building, supporting and avoidance apps in descending order. With regards to the geographical distribution of app categories, significant (χ2(20)=58.172; p=0.000) differences among the included regions were found. Conclusion: A vast proportion of apps addressing violence against women primarily draw on one-time emergency or avoidance solutions, as opposed to more preventative approaches. Further research is necessary, critically considering questions of data security, personal safety and efficacy of such mobile health interventions.

Clitoral Reconstruction After Female Genital Mutilation/Cutting: A Review of Surgical Techniques and Ethical Debate.

INTRODUCTION: Clitoral reconstruction (CR) is a controversial surgical procedure performed for women who have undergone medically unnecessary, often ritualistic genital cutting involving the clitoris. Such cutting is known by several terms; we will use female genital mutilation/cutting (FGM/C). Treatments offered to women affected by complications of FGM/C include defibulation (releasing the scar of infibulation to allow penetrative intercourse, urinary flow, physiological delivery, and menstruation) and CR to decrease pain, improve sexual response, and create a pre-FGM/C genital appearance. AIM: In this study, our aim is to summarize the medical literature regarding CR techniques and outcomes, and stimulate ethical discussion surrounding potential adverse impacts on women who undergo the procedure. METHODS: A broad literature review was carried out to search any previous peer-reviewed publications regarding the techniques and ethical considerations for CR. MAIN OUTCOME MEASURE: The main outcome measure includes benefits, risks, and ethical analysis of CR. RESULTS: While we discuss the limited evidence regarding the risks and efficacy of CR, we did not find any peer-reviewed reports focused on ethical implications to date. CLINICAL IMPLICATIONS: CR can be indicated as a treatment for pain and potential improvement of associated sexual dysfunction when these have not responded to more conservative measures. Women must be appropriately informed about the risks of CR and the lack of strong evidence regarding potential benefits. They must be educated about their genital anatomy and disabused of any myths surrounding female sexual function as well as assessed and treated in accordance with the current scientific evidence and best clinical practices. STRENGTH & LIMITATIONS: This is the first formal ethical discussion surrounding CR. This is not a systematic review, and the ethical discussion of CR has only just begun. CONCLUSION: We present a preliminary ethical analysis of the procedure and its potential impact on women with FGM/C. Sharif Mohamed F, Wild V, Earp BD, et al. Clitoral Reconstruction After Female Genital Mutilation/Cutting: A Review of Surgical Techniques and Ethical Debate. J Sex Med 2020;17:531-542.

Do attitudes and behavior of health care professionals exacerbate health care disparities among immigrant and ethnic minority groups? An integrative literature review.

OBJECTIVES: Recent investigations of ethnicity related disparities in health care have focused on the contribution of providers' implicit biases. A significant effect on health care outcomes is suggested, but the results are mixed. The purpose of this integrative literature review is to provide an overview and synthesize the current empirical research on the potential influence of health care professionals' attitudes and behaviors towards ethnic minority patients on health care disparities. DESIGN: Integrative literature review. DATA SOURCES: Four internet-based literature indexes - MedLine, PsychInfo, Sociological Abstracts and Web of Science - were searched for articles published between 1982 and 2012 discussing health care professionals' attitudes or behaviors towards ethnic minority patients. REVIEW METHODS: Thematic analysis was used to synthesize the relevant findings. RESULTS: We found 47 studies from 12 countries. Six potential barriers to health care for ethnic minorities were identified that may be related to health care professionals' attitudes or behaviors: Biases, stereotypes and prejudices; Language and communication barriers; Cultural misunderstandings; Gate-keeping; Statistical discrimination; Specific challenges of delivering care to undocumented migrants. CONCLUSIONS: Data on health care professionals' attitudes or behaviors are both limited and inconsistent. We thus provide reflections on methods, conceptualization, interpretation and the importance of the geographical or socio-political settings of potential studies. More empirical data is needed, especially on health care professionals' attitudes or behaviors towards (irregular) migrant patients.

Health incentive research and social justice: does the risk of long term harms to systematically disadvantaged groups bear consideration?

The ethics of health incentive research-a form of public health research-are not well developed, and concerns of justice have been least examined. In this paper, we explore what potential long term harms in relation to justice may occur as a result of such research and whether they should be considered as part of its ethical evaluation. 'Long term harms' are defined as harms that contribute to existing systematic patterns of disadvantage for groups. Their effects are experienced on a long term basis, persisting even once an incentive research project ends. We will first establish that three categories of such harms potentially arise as a result of health incentive interventions. We then argue that the risk of these harms also constitutes a morally relevant consideration for health incentive research and suggest who may be responsible for assessing and mitigating these risks. We propose that responsibility should be assigned on the basis of who initiates health incentive research projects. Finally, we briefly describe possible strategies to prevent or mitigate the risk of long term harms to members of disadvantaged groups, which can be employed during the design, conduct and dissemination of research projects.

Migrants' Health in Iran from the Perspective of Social Justice: a Systematic Literature Review.

This paper presents a systematic literature review of studies that shed light on the health of migrants in Iran from the perspective of social justice. A systematic search was conducted in PubMed and Iranian databases, including IranMedex, Magiran, and SID, in June 2012. All studies that were published until June 2012 describing the health status of migrants - including refugees - in Iran were included. The search results were categorisoyed according to an adapted version of the six dimensions of well-being in Madison Powers' and Ruth Faden's theory of social justice in health. They consisted of access to health care, health, respect, self-determination and attachment, personal security, and social determinants of health. The majority of papers mentioned issues related to infectious diseases (100 papers, 60.2%). Only a few papers mentioned socioeconomic status and access to health services, education, and work. Infectious diseases and high population growth among migrants and the problematic image of migrants as "threat" to the Iranian population's health appear to be the most prominent results in our search. It is imperative to combat the high numbers of infectious diseases among migrants in Iran while simultaneously making efforts to change the public image of migrants as a health and social service threat to Iran. Data concerning social and ethical issues of migrants' health in Iran is scarce, and thus, future research is necessary using other methods and sources.