Close-up image of the asphalt and lane demarcations of a city street.

Public Health Ethics 10(1)

Journal of Bioethical Inquiry, Volume 10, Number 1 (March 2013)
Guest Editors: Stacy M. Carter and Lucie Rychetnik


From Personal Misfortune to Public Liability

Leigh E. Rich and Michael A. Ashby

Letters to the Editor

Bioethics and Its Gatekeepers: Does Institutional Racism Exist in Leading Bioethics Journals?

Subrata Chattopadhyay, Catherine Myser, and Raymond De Vries

Recent Developments

Professional Conduct and Making Decisions for Minors

Bernadette Richards and Cameron Stewart


A Public Health Ethics Approach to Non-Communicable Diseases

Stacy M. Carter and Lucie Rychetnik

What Does Public Health Ethics Tell (or Not Tell) Us About Intervening in Non-Communicable Diseases?

Ross Upshur
Obesity has been described as pandemic and a public health crisis. It has been argued that concerted research efforts are needed to enhance our understanding and develop effective interventions for the complex and multiple dimensions of the health challenges posed by obesity. This would provide a secure evidence base in order to justify clinical interventions and public policy. This paper critically examines these claims through the examination of models of public health and public health ethics. I argue that the concept of an effective public health intervention is unclear and underdeveloped and, as a consequence, normative frameworks reliant on meeting the effectiveness criterion may miss morally salient dimensions of the problems. I conclude by arguing for the need to consider both an ecological model of public health and inclusion of a critical public health ethics perspective for an adequate account of the public health challenges posed by obesity.

Obesity, Public Health, and the Consumption of Animal Products

Jan Deckers
Partly in response to rising rates of obesity, many governments have published healthy eating advice. Focusing on health advice related to the consumption of animal products (APs), I argue that the individualistic paradigm that prevails must be replaced by a radically new approach that emphasizes the duty of all human beings to restrict their negative “Global Health Impacts” (GHIs). If they take human rights seriously, many governments from nations with relatively large negative GHIs—including the Australian example provided here—must develop strategies to reduce their citizens’ negative GHIs. As the negative GHIs associated with the consumption of many APs are excessive, it is my view that many governments ought to adopt a qualified ban on the consumption of APs.

Ethical Considerations Involved in Constructing the Built Environment to Promote Health

Peter Geoffrey Sainsbury
The prevalence of chronic diseases has increased in recent decades. Some forms of the built environment adopted during the 20th century—e.g., urban sprawl, car dependency, and dysfunctional streetscapes—have contributed to this. In this article, I summarise ways in which the built environment influences health and how it can be constructed differently to promote health. I argue that urban planning is inevitably a social and political activity with many ethical dimensions, and I illustrate this with two examples: the construction of a hypothetical new suburb and a current review of planning legislation in Australia. I conclude that (1) constructing the built environment in ways that promote health can be ethically justified, (2) urban planners and public health workers should become more skilled in the application of ethical considerations to practical problems, and (3) the public health workforce needs to become more competent at influencing the activities of other sectors.

Primum Non Nocere: Obesity Stigma and Public Health

Lenny R. Vartanian and Joshua M. Smyth
Several recent anti-obesity campaigns appear to embrace stigmatization of obese individuals as a public health strategy. These approaches seem to be based on the fundamental assumptions that (1) obesity is largely under an individual’s control and (2) stigmatizing obese individuals will motivate them to change their behavior and will also result in successful behavior change. The empirical evidence does not support these assumptions: Although body weight is, to some degree, under individuals’ personal control, there are a range of biopsychosocial barriers that make weight regulation difficult. Furthermore, there is accumulating evidence that stigmatizing obese individuals decreases their motivation to diet, exercise, and lose weight. Public health campaigns should focus on facilitating behavioral change, rather than stigmatizing obese people, and should be grounded in the available empirical evidence. Fundamentally, these campaigns should, first, do no harm.

Original Research

Proposed Changes to New Zealand’s Medicines Legislation in the Medicines Amendment Bill 2011

Jennifer Moore
This article evaluates New Zealand’s Medicines Amendment Bill 2011. This Bill is currently before Parliament and will amend the Medicines Act 1981. On June 20, 2011, the Australian and New Zealand governments announced their decision to proceed with a joint scheme for the regulation of therapeutic products such as medicines, medical devices, and new medical interventions. Eventually, the joint arrangements will be administered by a single regulatory agency: the Australia New Zealand Therapeutic Products Agency. The medicines regulations in Australia and New Zealand will be updated as part of this process. The Medicines Amendment Bill addresses some of the well-recognised deficiencies in the Medicines Act 1981. However, a comprehensive overhaul of the Act is not being undertaken. I argue that repealing and replacing the Medicines Act 1981 would be preferable and advisable, given the number of legal difficulties with the Act and, in particular, where it does not align with equivalent current international law.

Trouble in the Gap: A Bioethical and Sociological Analysis of Informed Consent for High-Risk Medical Procedures

Christopher F. C. Jordens, Kathleen Montgomery, and Rowena Forsyth
Concerns are frequently raised about the extent to which formal consent procedures actually lead to “informed” consent. As part of a study of consent to high-risk medical procedures, we analyzed in-depth interviews with 16 health care professionals working in bone-marrow transplantation in Sydney, Australia. We find that these professionals recognize and act on their responsibility to inform and educate patients and that they expect patients to reciprocate these efforts by demonstrably engaging in the education process. This expectation is largely implicit, however, and when it is not met, this can give rise to trouble that can have adverse consequences for patients, physicians, and relationships within the clinic. We revisit the concept of the sick role to formalize this new role expectation, and we argue that “informed” consent is a process that is usually incomplete, despite trappings and assumptions that help to create the illusion of completeness.

Should There Be a Female Age Limit on Public Funding for Assisted Reproductive Technology?

Drew Carter, Amber M. Watt, Annette Braunack-Mayer, Adam G. Elshaug, John R. Moss, and Janet E. Hiller
Should there be a female age limit on public funding for assisted reproductive technology (ART)? The question bears significant economic and sociopolitical implications and has been contentious in many countries. We conceptualise the question as one of justice in resource allocation, using three much-debated substantive principles of justice—the capacity to benefit, personal responsibility, and need—to structure and then explore a complex of arguments. Capacity-to-benefit arguments are not decisive: There are no clear cost-effectiveness grounds to restrict funding to those older women who still bear some capacity to benefit from ART. Personal responsibility arguments are challenged by structural determinants of delayed motherhood. Nor are need arguments decisive: They can speak either for or against a female age limit, depending on the conception of need used. We demonstrate how these principles can differ not only in content but also in the relative importance they are accorded by governments. Wide variation in ART public funding policy might be better understood in this light. We conclude with some inter-country comparison. New Zealand and Swedish policies are uncommonly transparent and thus demonstrate particularly well how the arguments we explore have been put into practice.

Challenges in End-of-Life Decisions in the Intensive Care Unit: An Ethical Perspective

Hanne Irene Jensen, Jette Ammentorp, Helle Johannessen, and Helle Ørding
When making end-of-life decisions in intensive care units (ICUs), different staff groups have different roles in the decision-making process and may not always assess the situation in the same way. The aim of this study was to examine the challenges Danish nurses, intensivists, and primary physicians experience with end-of-life decisions in ICUs and how these challenges affect the decision-making process. Interviews with nurses, intensivists, and primary physicians were conducted, and data is discussed from an ethical perspective. All three groups found that the main challenges were associated with interdisciplinary collaboration and future perspectives for the patient. Most of these challenges were connected with ethical issues. The challenges included different assessments of treatment potential, changes and postponements of withholding and withdrawing therapy orders, how and when to identify patients’ wishes, and suffering caused by the treatment. To improve end-of-life decision-making in the ICU, these challenges need to be addressed by interdisciplinary teams.

Stability Over Time in the Preferences of Older Persons for Life-Sustaining Treatment

Ines M. Barrio-Cantalejo, Pablo Simón-Lorda, Adoración Molina-Ruiz, Fátima Herrera-Ramos, Encarnación Martínez-Cruz, Rosa Maria Bailon-Gómez, Antonio López-Rico, and Patricia Peinado Gorlat
Objective: To measure the stability of life-sustaining treatment preferences amongst older people and analyse the factors that influence stability. Design: Longitudinal cohort study. Setting: Primary care centres, Granada (Spain). Eighty-five persons age 65 years or older. Participants filled out a questionnaire with six contexts of illness (LSPQ-e). They had to decide whether or not to receive treatment. Participants completed the questionnaire at baseline and 18 months later. Results: 86 percent of the patients did not change preferences. Sex, age, marital status, hospitalisation, and self-perception of health and pain did not affect preferences. Morbidity and the death of a relative did. Conclusion: Stability of preferences of older persons in relation to end-of-life decisions seems to be more probable than instability. Some factors, such as the death of a relative or the increase in morbidity, can change preferences. These findings have implications for advance directives (ADs) and advance care planning.


Strings Attached: Untangling the Ethics of Incentives

Maude Laliberté

And If We All Lived Together? [Et si on vivait tous ensemble?]

Katrina A. Bramstedt

Portrait of Spain: Masterpieces From the Prado

Katrina A. Bramstedt

Case Studies

Return-to-Play Confusion: Considerations for Sport-Related Concussion

Amanda Clacy, Rachael Sharman, and Geoff Lovell

In That Case: Moral Distress in Uninsured Health Care

Anita Nivens and Janet Buelow