Identifying and evaluating layers of vulnerability - a way forward

Decision-making in case of an unintended pregnancy: an overview of what is known about this complex process

Introduction: Unintended pregnancies are a worldwide health issue, faced each year by one in 16 people, and experienced in various ways. In this study we focus on unintended pregnancies that are, at some point, experienced as unwanted because they present the pregnant person with a decision to continue or terminate the pregnancy. The aim of this study is to learn more about the decision-making process, as there is a lack of insights into how people with an unintended pregnancy reach a decision. This is caused by 1) assumptions of rationality in reproductive autonomy and decision-making, 2) the focus on pregnancy outcomes, e.g. decision-certainty and reasons and, 3) the focus on abortion in existing research, excluding 40% of people with an unintended pregnancy who continue the pregnancy. Method: We conducted a narrative literature review to examine what is known about the decision-making process and aim to provide a deeper understanding of how persons with unintended pregnancy come to a decision.Results: Our analysis demonstrates that the decision-making process regarding unintended pregnancy consists of navigating entangled layers, rather than weighing separable elements or factors. The layers that are navigated are both internal and external to the person, in which a 'sense of knowing' is essential in the decision-making process. Conclusion: The layers involved and complexity of the decision-making regarding unintended pregnancy show that a rational decision-making frame is inadequate and a more holistic frame is needed to capture this dynamic and personal experience.

Extreme poverty first: An argument on the equitable distribution of the COVID-19 vaccine in Peru

Effective vaccines for COVID-19 are already available to humankind. In Peru, 86 million doses were administered to cover the demand for 33 million Peruvian people. Hence, vaccination has been prioritized in groups: health personnel, subjects with pre-existing health conditions and those over 65 years of age. However, given the social problems and the public health situation in Peru, this work defends that the priority of vaccination should be focused on the population living in extreme poverty. The method used was an ethical argumentation on the distribution of scarce antiSARS-CoV2 vaccine in Peru. This argument is based on the analysis of the Peruvian population living in extreme poverty, which presents different layers of vulnerability, and that, in the face of an eventual SARS-CoV2 infection, these would be exacerbated one after the other, through a cascade effect. This scenario would give rise to new vulnerabilities to those already existing, causing greater damage. Vaccination efforts on this key population would give them the opportunity to continue to find ways to bring food to their homes, significantly reducing the risk of contagion in their environment and mitigating the devastating effect of the local diseases to which they are already exposed. Four objections related to this argument are raised with their corresponding responses. Priority access to the vaccine would significantly reduce the humanitarian harm to people living in extreme poverty, prevailing the principles of justice and equity.

Autonomy-based bioethics and vulnerability during the COVID-19 pandemic: towards an African relational approach

The COVID-19 pandemic has provoked new interest in the notion of vulnerability and in identifying alternative approaches for responding to vulnerable patients and populations during health emergencies. In this paper, I argue that the autonomy-based approach (the most dominant approach in bioethics) to responding to vulnerability during health emergencies is deficient because it focuses only on the interests, values, and decisions of the individual patient. It overly emphasizes respect for autonomy and not respect for the patient as it does not consider the patient as a social and relational agent. Indeed, relational approaches to autonomy like the feminist and indigenous sub-Saharan African ethical approaches are promising alternatives. In this essay, I use the indigenous African relational approach to autonomy as an example of an alternative method which can be used to respond to vulnerability during a global health emergency like COVID-19.

Conceptual definition for drowning prevention: a Delphi study

BACKGROUND

Expanding support for drowning prevention is evidenced by interlinked Resolutions at the United Nations (2021) and World Health Assembly (2023). While progress has accelerated, a universally agreed definition for drowning prevention remains absent. Here, we aim to develop a conceptual definition of drowning prevention using the Delphi method.

METHODS

First, we conducted a document review to guide our development and consensus-building process. Then, we formed an advisory group and recruited participants with diverse expertise to contribute to Delphi-method surveys. In the first round, participants selected from draft concepts to build a definition and delineate between the terms drowning prevention and water safety. In the second round, we presented a codeveloped definition, and three statements based on first-round findings. We then sought participant feedback where ≥70% support was considered consensus-based agreement.

RESULTS

Participants (n=134) were drawn from community (7.46%), policy (26.87%), research (40.30%) and technical backgrounds (25.37%), and low-income and middle-income countries (38.06%). In the first- round, half (50.74%) disagreed with the proposition that drowning prevention was synonymous to water safety, while 40.30% agreed. The second- round achieved consensus-based agreement (97.27%) for the definition: Drowning prevention is defined as a multidisciplinary approach that reduces drowning risk and builds resilience by implementing evidence-informed measures that address hazards, exposures and vulnerabilities to protect an individual, community or population against fatal and non-fatal drowning.

CONCLUSION

The Delphi method enabled the codevelopment of our conceptual definition for drowning prevention. Agreement on the definition forms the basis for strengthened multisectoral action, and partnerships with health and sustainable development agendas. Defining drowning prevention in terms of vulnerability and exposure might increase focus on social determinants and other upstream factors critical to prevention efforts.

How and why to use 'vulnerability': an interdisciplinary analysis of disease risk, indeterminacy and normality

In recent years, 'vulnerability' has been getting more traction in theoretical, professional and popular spaces as an alternative or complement to the concept of risk. As a group of science and technology studies scholars with different disciplinary orientations yet a shared concern with biomedicine, self and society, we investigate how vulnerability has become a salient and even dominant idiom for discussing disease and disease risk. We argue that this is at least partly due to an inherent indeterminacy in what 'vulnerability' means and does, both within and across different discourses. Through a review of feminist and disability theory, and a discussion of how vulnerability and disease both get recruited into a binary conceptualisation of normal versus abnormal, we argue that vulnerability's indeterminacy is, in fact, its strength, and that it should be used differently than risk. Using COVID-19 management in the UK as an illustration of the current ambivalence and ambiguity in how vulnerability versus risk is applied, we suggest that instead of being codified or quantified, as it has started to be in some biomedical and public health applications, vulnerability and its remedies should be determined in conjunction with affected communities and in ways that are polyvalent, flexible and nuanced. The concept of vulnerability encapsulates an important precept: we must recognise inequality as undesirable while not attempting to 'solve' it in deterministic ways. Rather than becoming fixed into labels, unidirectional causalities or top-down universalising metrics, vulnerability could be used to insist on relational, context-specific understandings of disease and disease risk-in line with contemporary social justice movements that require non-hierarchical and non-universal approaches to problems and solutions.

Layered vulnerability and researchers' responsibilities: learning from research involving Kenyan adolescents living with perinatal HIV infection

BACKGROUND

Carefully planned research is critical to developing policies and interventions that counter physical, psychological and social challenges faced by young people living with HIV/AIDS, without increasing burdens. Such studies, however, must navigate a 'vulnerability paradox', since including potentially vulnerable groups also risks unintentionally worsening their situation. Through embedded social science research, linked to a cohort study involving Adolescents Living with HIV/AIDS (ALH) in Kenya, we develop an account of researchers' responsibilities towards young people, incorporating concepts of vulnerability, resilience, and agency as 'interacting layers'.

METHODS

Using a qualitative, iterative approach across three linked data collection phases including interviews, group discussions, observations and a participatory workshop, we explored stakeholders' perspectives on vulnerability and resilience of young people living with HIV/AIDS, in relation to home and community, school, health care and health research participation. A total of 62 policy, provider, research, and community-based stakeholders were involved, including 27 ALH participating in a longitudinal cohort study. Data analysis drew on a Framework Analysis approach; ethical analysis adapts Luna's layered account of vulnerability.

RESULTS

ALH experienced forms of vulnerability and resilience in their daily lives in which socioeconomic context, institutional policies, organisational systems and interpersonal relations were key, interrelated influences. Anticipated and experienced forms of stigma and discrimination in schools, health clinics and communities were linked to actions undermining ART adherence, worsening physical and mental health, and poor educational outcomes, indicating cascading forms of vulnerability, resulting in worsened vulnerabilities. Positive inputs within and across sectors could build resilience, improve outcomes, and support positive research experiences.

CONCLUSIONS

The most serious forms of vulnerability faced by ALH in the cohort study were related to structural, inter-sectoral influences, unrelated to study participation and underscored by constraints to their agency. Vulnerabilities, including cascading forms, were potentially responsive to policy-based and interpersonal actions. Stakeholder engagement supported cohort design and implementation, building privacy, stakeholder understanding, interpersonal relations and ancillary care policies. Structural forms of vulnerability underscore researchers' responsibilities to work within multi-sectoral partnerships to plan and implement studies involving ALH, share findings in a timely way and contribute to policies addressing known causes of vulnerabilities.

Involving older people in the preparedness, response, and recovery phases in humanitarian emergencies: a theoretical framework on ageism, epistemic injustice, and participation

Humanitarian emergencies disproportionally affect older people. Although defining an older person by an age range can help alert us to emerging or changing needs and potential vulnerabilities during humanitarian emergencies, ageing is not necessarily synonymous with increasing vulnerability, and individual variations exist due to the heterogeneity of older people. In general, reduced access to safety, health services, clean water, and appropriate food puts older people at increased risk of poor health outcomes during humanitarian emergencies, including disability, injury, malnutrition, and mental health issues. The theoretical framework presented in this Personal View explains how ageism, further compounded by intersecting oppression, leads to the exclusion of older people from the preparedness, response, and recovery phases of humanitarian emergencies. The exclusion of older people is discriminatory, violates core humanitarian and bioethical principles, and leads to an epistemic injustice. We suggest that humanitarian actors implement participatory approaches with older people in humanitarian contexts. Through these approaches, solutions will be identified by and together with older people, leading to community-driven and context-appropriate ways to include the needs and strengths of older people in the preparedness, response, and recovery phases of humanitarian emergencies.

Reconceiving vulnerabilities in relations of care how to account for and deal with carers' vulnerabilities

While carers' vulnerability has often been neglected in the literature, the recent COVID-19 pandemic brought this issue to the fore. This article explores why it has been so often ignored and how could it be dealt with differently. It does so in the form of a philosophical and conceptual investigation illustrated by various examples and situations, related primarily, but not exclusively, to the COVID period. Criticising a property-based view, and based on examples of carers' vulnerability during the pandemic, our investigation suggests that carers' vulnerability is relationally constructed and played out on multiple interwoven dimensions that may contradict each other. Our examples also suggest that the relational construction of vulnerabilities is socially and organisationally mediated, calling for the development of social and organisational forms of mediation that may help carers deal with their vulnerabilities. Second, and rather counterintuitively with regard to the COVID-period, we question the negative valence usually associated with vulnerability and analyse how this affects ways of dealing with carers' vulnerabilities and the co-creation of care. Finally, following Gilson (2014), we propose an ambivalent, relational conception of vulnerability, considered as 'openness to affectation by' and offer some theoretical and practical implications. Theoretically, this conception also allows us to consider such openness as an ability that may nurture carers' 'response-ability'. It also allows us to develop specific relational ethics for and in care relationships. Practically, this re-conceptualisation may help carers better embrace and process their vulnerabilities, including responses to negative affectations following exposure to carees. It may also facilitate their 'reception' of carees, and help co-create and adapt responses to carees' calls, thus avoiding paternalistic responses.

COVID, Vulnerability, and the Death of Solidarity: "Who Do We Not Save?"

Solidarity between more and less vulnerable groups is fundamental to an effective public health response to a global pandemic. Yet in the case of COVID-19, a focus on deciding who can and who cannot be protected from harm has shaped the pandemic experience and continues to determine the post-pandemic trajectory of life with SARS-CoV-2. In this paper I discuss how this has affected our understanding and acceptance of solidarity.

Ethical issues of involving people with intellectual disabilities in genomic research: a scoping review protocol

Background: Psychiatric genomic research is a growing field of research in Africa that is looking at epigenetics of psychiatric disorders; within which a specific focus is neurodevelopmental disorders including intellectual disability (ID). Conducting this type of research is important to identify etiologies and possible interventions or areas for further research. However, genomic research generally, and psychiatric genomic research, faces many social, ethical, cultural, and legal issues; research involving people with ID is particularly challenging. All research stakeholders - researchers, research review bodies, regulators, patient groups - generally agree that involving people with ID require several considerations, including extra protection. It is also recognized that not involving people with ID in research that is relevant to them means that opportunities to learn on specific issues including lived experiences are missed. In this scoping review, we aim to describe the range of ethical and social-cultural issues concerning involvement of people with intellectual disability in genomic research from existing literature. Methods: This scoping review will be conducted based on the Joanna Briggs Institute guidance for scoping review and reported using the PRISMA-ScR guidelines. Iterative review stages will include systematic search of six databases (Embase, Ovid Global Health, PubMed, Scopus, PsycInfo and Web of Science core collection), screening, charting and synthesis of the data. Forward and backward citation screening will also be done for the articles included in the final review. We will include peer reviewed journal articles, guidance documents and reports. Screening and selection of studies based on the eligibility criteria will be done independently by three reviewers; conflicts will be resolved through discussion with a third reviewer and other experts. Results: The results will be included in the scoping review publication. Conclusions: This scoping review will identify key areas of ethical tensions and possible solutions and inform opportunities for empirical ethics studies.

Investigating the aftermath of the Türkiye 2023 earthquake: exploring post-disaster uncertainty among Syrian migrants using social network analysis with public health approach

Objectives

On February 6th, 2023, a doublet earthquake struck Türkiye, impacting more than 15 million people including migrants, and resulting in over 50,000 deaths. The Syrian migrants experience multiple uncertainties in their daily lives which are further compounded by multifaceted challenges of the post-disaster environment. Social media was used intensively and with impunity in this environment and thereby provides a window into the explicit and implicit dynamics of daily life after a disaster. We aimed to explore how a post-disaster environment potentially generates new uncertainties or exacerbating pre-existing ones for migrants through social media analysis with an indirect perspective, in the context of 2023-Earthquake in Türkiye and Syrian migrants.

Methods

Social network analysis was used to analyze Twitter-data with the hashtags 'Syrian' and 'earthquake' during a 10-day period beginning on March 22nd, 2023. We calculated network metrics, including degree-values and betweenness-centrality and clustered the network to understand groups. We analyzed a combination of 27 tweets with summative content analysis using a text analysis tool, to identify the most frequently used words. We identified the main points of each tweet and assessed these as possible contributors to post-disaster uncertainty among migrants by using inductive reasoning.

Results

There were 1918 Twitter users, 274 tweets, 124 replies and 1726 mentions. Discussions about Syrian migrants and earthquakes were established across various groups (ngroups(edges > 15) = 16). Certain users had a greater influence on the overall network. The nine most frequently used words were included under uncertainty-related category (nmost_frequently_used_words = 20); 'aid, vote, house, citizen, Afghan, illegal, children, border, and leave'. Nine main points were identified as possible post-disaster uncertainties among migrants.

Conclusion

The post-disaster environment has the potential to exacerbate existing uncertainties, such as being an undocumented migrant, concerns about deportation and housing, being or having a child, inequality of rights between being a citizen and non-citizen, being in minority within minority, political climate of the host nation and access to education or to generate new ones such equitable distribution of aid, which can lead to poor health outcomes. Recognizing the possible post-disaster uncertainties among migrants and addressing probable underlying factors might help to build more resilient and healthy communities.

Situational vulnerability within mental healthcare - a qualitative analysis of ethical challenges during the COVID-19 pandemic

BACKGROUND

Mental healthcare users and patients were described as a particularly vulnerable group in the debate on the burdens of the COVID-19 pandemic. Just what this means and what normative conclusions can be derived from it depend to a large extent on the underlying concept of vulnerability. While a traditional understanding locates vulnerability in the characteristics of social groups, a situational and dynamic approach considers how social structures produce vulnerable social positions. The situation of users and patients in different psychosocial settings during the COVID-19 pandemic has not yet been comprehensively considered and ethically analyzed under the aspect of situational vulnerability.

METHODS

We present the results of a retrospective qualitative analysis of a survey of ethical challenges in different mental healthcare facilities of a large regional mental healthcare provider in Germany. We evaluate them ethically using a dynamic and situational understanding of vulnerability.

RESULTS

Difficulties in implementing infection prevention measures, restrictions of mental health services in favor of infection prevention, social isolation, negative health effects on mental healthcare users and patients, and challenges in implementing regulations on state and provider levels within the local specificities emerged across different mental healthcare settings as ethically salient topics.

CONCLUSIONS

Applying a situational and dynamic understanding of vulnerability allows the identification of specific factors and conditions that have contributed to an increased context-dependent vulnerability for mental healthcare users and patients. These factors and conditions should be considered on the level of state and local regulations to reduce and address vulnerability.

Sociocultural and moral narratives influencing the decision to vaccinate among rheumatic disease patients: a qualitative study

INTRODUCTION/OBJECTIVES

Vaccination is a process that involves individual, social, and ethical aspects, beyond public governance of vaccines or vaccination as a public health concern. The aim of this study is to describe the sociocultural and moral narratives that influence the decision to vaccinate in general and to vaccinate against COVID-19 specifically, among patients at the rheumatology units of two hospitals.

METHODS

Qualitative study involving individual semi-structured interviews following an interview guide. We conducted a thematic analysis using the ATLAS.ti software, with further triangulation to verify concordance and aid in the interpretation of the data from a medical anthropology framework and using a narrative ethics approach to gain insight into the participants' underlying moral values.

RESULTS

We interviewed 37 patients in total, along with 3 rheumatologists. Five core themes emerged from the analysis to understand the decision to vaccinate: (1) information about vaccines and disease, (2) perceived risk-benefit of vaccination, (3) the physician-patient relationship, (4) governance of vaccination programs, (5) attitudes towards vaccines. Individual and family experiences with vaccination are diverse depending on the type of vaccine. The COVID-19 vaccine, as a new medical technology, is met with more controversy leading to hesitancy.

CONCLUSIONS

The decision to vaccinate among Mexican rheumatic disease patients can sometimes involve doubt and distrust, especially for those with a lupus diagnosis, but ultimately there is acceptance in most cases. Though patients make and value autonomous decisions, there is a collective process involving sociocultural and ethical aspects. Key points • The complexity of vaccine decision-making is better identified through a narrative, qualitative approach like the one used in this study, as opposed to solely quantitative approaches • Sociocultural and moral perspectives of vaccination shape decision-making and, therefore, highlight the importance of including patients in the development of effective clinical practice guidelines as well as ethically justified public policy • Sociohistorical context and personal experiences of immunization influence vaccine decision-making much more than access to biomedical information about vaccines, showing that approaches based on the information deficit model are inadequate to fight vaccine hesitancy.

Gender inequity and COVID-19 vaccination policies for pregnant women in the Americas

The region of the Americas has been the epicenter of the COVID-19 pandemic’s worst outcome in terms of number of deaths due to COVID-19. SARS-CoV-2 infection during pregnancy and the postpartum period has been found to be associated with increased risk of mortality and severe disease. Several Latin American and Caribbean countries have disproportionally high maternal mortality rates due to COVID-19. Although this region achieved relatively high vaccination rates among the general adult population, there were differing restrictions regarding the vaccination of those who were pregnant. In a pandemic, policies reflect political priorities in responses to the threats posed to populations and play an important role in promoting gender equity. This paper reports the results of an ethical analysis of 45 national COVID-19 vaccination public policies from seven countries – Argentina, Brazil, Canada, Colombia, Mexico, Peru, and United States. The analysis drew on reproductive justice and feminist bioethics frameworks, paying close attention to whether and how gender and social and economic inequities were addressed. It found that exclusionary approaches in immunization policies which restricted access to vaccination during pregnancy were often justified on the basis of a lack of evidence about the effects of immunization of pregnant persons, and on the grounds of medical expertise, to the detriment of women’s autonomy and agency. As such these policies reiterate patriarchal moral understandings of women, pregnancy and motherhood. In practice, they counter human rights gender equity and equality principles, and became lethal, particularly to racialized women in Latin America. During an emerging lethal disease, policies and policy development must consider the intersection of oppressive structures to protect and guarantee rights of women, girls, and pregnant persons.

Do genomic passports leave us more vulnerable or less vulnerable? Perspectives from an online citizen engagement

Since genomics is becoming commonplace in healthcare for the diagnosis, treatment, and prevention, the prospect of generating a genomic passport for all citizens is gaining traction. While this would have many advantages, it raises ethical issues requiring societal debate alongside academic reflection. Hence, Sciensano-the Belgian scientific Institute of Public Health-organised an online citizen engagement on genomic information usage, including a question on a genomic passport for all. The inductive thematic analysis of participants' contributions highlighted vulnerability as a fundamental concern, while this has not received sufficient attention so far in genomics. Participants expressed their vulnerability in two ways. First, the genomic passport would inform them about their ontological vulnerability. By revealing their constitutional weaknesses (predisposition to diseases), it reminds them that everyone is unavoidably and perennially at risk of being harmed. Second, the misuse of the genomic passport can add situational vulnerabilities (e.g., discrimination causing psychological and economic harm). Moreover, the fundamental uncertainty in genomics-how will such sensitive information be used, and how will the science evolve?-exacerbates these vulnerabilities. This article ends with recommendations to alleviate these vulnerabilities in genomics now and in the future in which the genomic passport may become a reality.

[Evaluation of COVID-19 vaccination programs in South America]

National vaccination programs against SARS-CoV2 in South America played an important role in the timely response to the COVID-19 pandemic, however, was an ethical approach capable of guaranteeing greater benefit to the population through vaccination being applied? To answer this question, my aim was to analyze the national vaccination programs of Argentina, Brazil, Chile, and Peru to identify the extent to which they aligned with the utilitarianism and prioritarianism oriented ethical approaches when assigning the vaccine against COVID-19. I start from the hypothesis that all the selected countries propose vaccination policies with possible prioritarian and/or utilitarian ethical approaches, however, those that align with prioritarianism manage to better adhere to the moral duties of social justice. To demonstrate my hypothesis, I have integrated the socio-economic information, analyzed the coverage strategies of each country and tried to frame them with the proposed ethical approaches, to finally present arguments for and against these approaches. I conclude that, unlike utilitarianism, the application of prioritarianism to the vaccine allocation schemes of the four countries analyzed allowed prioritizing the vaccine in those who are worse off in terms of social justice, and that, unequivocally, includes the severely ill.

Protecting the Vulnerable and Including the Under-Represented: IRB Practices and Attitudes

Since their inception, Institutional Review Boards (IRBs) have been charged with protecting the vulnerable in research. More recently, attention has turned to whether IRBs also have a role to play in ensuring representative study samples and promoting the inclusion of historically under-represented groups. These two aims-protecting the vulnerable and including the under-represented-can pull in different directions, given the potential for overlap between the vulnerable and the under-represented. We conducted a pilot, online national survey of IRB Chairs to gauge attitudes and practices with regard to protecting the vulnerable and including the under-represented in research. We found that IRBs extend the concept of vulnerability to different groups across various contexts, are confident that they effectively protect vulnerable individuals in research, and believe that IRBs have a role to play in ensuring representative samples and the inclusion of under-represented groups.

The concept of vulnerability in aged care: a systematic review of argument-based ethics literature

BACKGROUND

Vulnerability is a key concept in traditional and contemporary bioethics. In the philosophical literature, vulnerability is understood not only to be an ontological condition of humanity, but also to be a consequence of contingent factors. Within bioethics debates, vulnerable populations are defined in relation to compromised capacity to consent, increased susceptibility to harm, and/or exploitation. Although vulnerability has historically been associated with older adults, to date, no comprehensive or systematic work exists on the meaning of their vulnerability. To fill this gap, we analysed the literature on aged care for the meaning, foundations, and uses of vulnerability as an ethical concept.

METHODS

Using PRISMA guidelines, we conducted a systematic review of argument-based ethics literature in four major databases: PubMed, Embase®, Web of Science™, and Philosopher's Index. These covered biomedical, philosophy, bioethical, and anthropological literature. Titles, abstracts, and full texts of identified papers were screened for relevance. The snowball technique and citation tracking were used to identify relevant publications. Data analysis and synthesis followed the preparatory steps of the coding process detailed in the QUAGOL methodology.

RESULTS

Thirty-eight publications met our criteria and were included. Publication dates ranged from 1984 to 2020, with 17 publications appearing between 2015 and 2020. Publications originated from all five major continents, as indicated by the affiliation of the first author. Our analyses revealed that the concept of vulnerability could be distinguished in terms of basic human and situational vulnerability. Six dimensions of older adults' vulnerability were identified: physical; psychological; relational/interpersonal; moral; sociocultural, political, and economic; and existential/spiritual. This analysis suggested three ways to relate to older adults' vulnerability: understanding older adults' vulnerability, taking care of vulnerable older adults, and intervening through socio-political-economic measures.

CONCLUSIONS

The way in which vulnerability was conceptualised in the included publications overlaps with distinctions used within contemporary bioethics literature. Dimensions of aged care vulnerability map onto defining features of humans, giving weight to the claim that vulnerability represents an inherent characteristic of humans. Vulnerability is mostly a value-laden concept, endowed with positive and negative connotations. Most publications focused on and promoted aged care, strengthening the idea that care is a defining practice of being human.

Barriers to Equitable Public Participation in Health-System Priority Setting Within the Context of Decentralization: The Case of Vulnerable Women in a Ugandan District

BACKGROUND

Decentralization of healthcare decision-making in Uganda led to the promotion of public participation. To facilitate this, participatory structures have been developed at sub-national levels. However, the degree to which the participation structures have contributed to improving the participation of vulnerable populations, specifically vulnerable women, remains unclear. We aim to understand whether and how vulnerable women participate in health-system priority setting; identify any barriers to vulnerable women's participation; and to establish how the barriers to vulnerable women's participation can be addressed.

METHODS

We used a qualitative description study design involving interviews with district decision-makers (n=12), sub-county leaders (n=10), and vulnerable women (n=35) living in Tororo District, Uganda. Data was collected between May and June 2017. The analysis was conducting using an editing analysis style.

RESULTS

The vulnerable women expressed interest in participating in priority setting, believing they would make valuable contributions. However, both decision-makers and vulnerable women reported that vulnerable women did not consistently participate in decision-making, despite participatory structures that were instituted through decentralization. There are financial (transportation and lack of incentives), biomedical (illness/disability and menstruation), knowledge-based (lack of knowledge and/or information about participation), motivational (perceived disinterest, lack of feedback, and competing needs), socio-cultural (lack of decision-making power), and structural (hunger and poverty) barriers which hamper vulnerable women's participation.

CONCLUSION

The identified barriers hinder vulnerable women's participation in health-system priority setting. Some of the barriers could be addressed through the existing decentralization participatory structures. Respondents made both short-term, feasible recommendations and more systemic, ideational recommendations to improve vulnerable women's participation. Integrating the vulnerable women's creative and feasible ideas to enhance their participation in health-system decision-making should be prioritized.

"Who am I to say?" Dutch care providers' evaluation of psychosocial vulnerability in pregnant women

Maternity care increasingly focuses on evaluating psychosocial vulnerability during pregnancy. Research and nationwide (public health) programs, both in the USA and Europe, led to the development of new protocols and screening instruments for care providers to systematically screen for psychosocial vulnerability in pregnant women. However, standardised screening for vulnerability is complex since it requires discussion of sensitive issues. Women may fear stigmatisation and may have limited trust in their care providers or the health system. Our study contributes to the growing field of client-facing risk work by exploring care providers' interpretations and evaluation of psychosocial vulnerability in pregnant women. Drawing on semi-structured interviews with Dutch maternity care providers, we explore how they conceptualise risk and vulnerability and identify 'vulnerable pregnant women' in their practices. We find that care providers conceptualise 'vulnerability' as primarily based on risk, which contributes to an imbalanced focus on individual mothers, rather than on both parents and the social context. Our findings highlight care providers' concerns around 'care avoidance', seen as a risk factor affecting 'vulnerability' during pregnancy and as a possible consequence of risk screening. The care providers we interviewed employ "in between-strategies" based on intuition, emotion, and trust to skillfully attend to the risk that comes with risk work, in terms of its potential impact on relationships of trust and open communication. We conclude that 'vulnerability' should be understood as a multi-layered, situated and relational concept rather than simply as an epidemiological category. Since a trusting relationship between pregnant women and care providers is crucial for the evaluation of vulnerability, we reflect critically on the risk of standardised perinatal psychosocial risk evaluations. Policy should recognise providers' "in between-strategies" to embed epidemiological understandings of risk in the context of everyday risk work.

Vulnerability in practice: Peeling back the layers, avoiding triggers, and preventing cascading effects

The concept of vulnerability is widely used in bioethics, particularly in research ethics and public health ethics. The traditional approach construes vulnerability as inherent in individuals or the groups to which they belong and views vulnerability as requiring special protections. Florencia Luna and other bioethicists continue to challenge traditional ways of conceptualizing and applying the term. Luna began proposing a layered approach to this concept and recently extended this proposal to offer two new concepts to analyze the concept of vulnerability, namely understanding external conditions that trigger vulnerability and layers of vulnerability with cascading effects. Luna's conception of vulnerability is useful, which we demonstrate by applying her layered view and the new analyses in multiple contexts. We begin by outlining Luna's view and we use vignettes from healthcare involving transgender patients, the care of patients in psychiatric contexts, and research involving prisoners to illustrate how each part of Luna's concept elucidates important moral issues.

Vulnerability and the Ethics of Human Germline Genome Editing

The concept of vulnerability has played an important role in theoretical bioethics as well as in numerous authoritative guidelines on research ethics. The concept helps to identify situations in which research participants and other individuals may be at a heightened risk of experiencing harm. However, existing guidance documents on the ethics of human germline gene editing largely fail to make any reference to considerations of vulnerability. In this article, we discuss this oversight and we highlight the role that vulnerability can play in ethical debates about human heritable genome editing. Future guidance documents on germline gene editing should pay attention to considerations of vulnerability and reference these appropriately.

Does Venue of HIV Testing and Results Disclosure in the Context of a Research Study Affect Adolescent Health and Behavior? Results from a Study in Western Kenya

Ethical concerns about risks to minor adolescents participating in HIV prevention research is a barrier to their inclusion. One concern is whether HIV testing and results disclosure venue affects the health and behavior of adolescent participants. We assessed for differential effects on quality of life (QOL), depressive symptoms, and sexual behavior due to (1) testing venue (home or health facility) and (2) test result (HIV-positive, HIV-negative, indeterminate). We collected data at three timepoints (baseline, 2-month follow-up, 12-month follow-up) from 113 Kenyan adolescents aged 15-19 (51% female). We analyzed the data using linear mixed effects models for the QOL and depressive symptoms outcomes and a logistic model for the sexual behavior outcome. Results showed a small mental health benefit for adolescents tested for HIV at a health facility compared with home. There was little evidence that testing venue influenced sexual behavior or that test results moderated the effects of HIV testing across all outcomes. The decision to conduct HIV testing at home or a health facility may not be very consequential for adolescents' health and behavior. Findings underscore the need to critically examine assumptions about adolescent vulnerability to better promote responsible conduct of HIV prevention research with youth in sub-Saharan Africa.

Aproximaciones al concepto de vulnerabilidad desde la bioética: una revisión integradora

Para dar cuenta de la revisión integradora de literatura sobre el concepto de vulnerabilidad desde la bioética se analizó un corpus de 60 artículos publicados en español, inglés y portugués. Esto permitió identificar las tendencias temáticas: riesgo, susceptibilidad, autonomía y cultura en personas y comunidades; la aproximación metodológica ha sido mayormente desde un enfoque cualitativo; las disciplinas que más abordaron el concepto pertenecen a las ciencias humanas y sociales; los autores recomiendan realizar estudios del concepto desde la perspectiva de las personas y que los comités de ética revisen el consentimiento informado y las guías de información de acuerdo con estos resultados. Las categorías dan paso al concepto de vulnerabilidades, que en la bioética debe ser analizado más allá del principialismo.

Conscientious Objection to Providing Gender Health Care in Pediatric Training: Balancing the Vulnerability of Transgender Youth and the Vulnerability of Pediatric Residents

Within pediatric graduate medical education, the care of transgender youth presents opportunities for deepening learners' understanding of equity, access, the role of the physician as an advocate, and health disparities caused by stigma and minority stress. However, when a pediatric resident objects to providing health care to this uniquely vulnerable population owing to their personal beliefs and values, how should pediatrician-educators respond? Important reasons to respect healthcare professionals' conscience have been described in the scholarly literature; however, equally important concerns have also been raised about the extent to which conscientious objection should be permitted in a pluralistic society, particularly given power differentials that favor healthcare professionals and grants them a monopoly over certain services. In the context of medical education, however, residents are in a unique position: they are simultaneously learners and employees, and although privileged relative to their patients, they are also vulnerable in relation to the hierarchy of healthcare and of institutions. We must find a compassionate balance between nurturing the evolving conscience of students and trainees and protecting the health and well-being of our most vulnerable patients. Educators have an obligation to foster empathy, mitigate bias, and mentor their learners, regardless of beliefs, but in some cases, they may recognize that there are limits: patients' welfare ultimately takes precedence and trainees should be guided toward alternative career paths. We explore the limits of conscientious objection in medical training and propose a framework for pediatrician-educators to support learners and patients in challenging circumstances.

Cancer rehabilitation and palliative care for socially vulnerable patients in Denmark: an exploration of practices and conceptualisations

Background:

Despite a tax-funded, needs-based organisation of the Danish health system, social inequality in cancer rehabilitation and palliative care (PC) has been noted repeatedly. Little is known about how best to improve access and participation in cancer rehabilitation and PC for socio-economically disadvantaged and socially vulnerable patients.

Aim:

To gather, synthesise and describe practice-orientated development studies presented in Danish-language publications and examine the underpinning conceptualisations of social inequality and vulnerability; explore related views of stakeholders working in the field.

Methods:

The study comprised a narrative review of Danish-language literature on practice-orientated development studies which address social inequality and vulnerability in cancer rehabilitation and PC and an online stakeholder consultation workshop with Danish professionals and academics working in the field.

Results:

Two themes characterise the included publications (n = 8): types of interventions; conceptualisations of social inequality and vulnerability; three themes were identified in the workshop data: focus and type of interventions; organisation of cancer care; and vulnerability of the healthcare system. The publications and the workshop participants (n = 12) favoured approaches which provide additional individualised resources throughout the cancer trajectory for this patient group. The terms social inequality and social vulnerability are largely used interchangeably, and associated with low income and no or little education yet qualified with multiple descriptors, which reflect the diverse socio-economic situations professionals encounter in cancer patients and their psychosocial needs.

Conclusion:

Addressing social inequality and vulnerability in cancer rehabilitation and PC in Denmark entails practical and conceptual challenges. Of importance is individualised support and the integration of rehabilitation and PC into standardised care pathways. To conceive of social vulnerability as a layered, dynamic, relational and contextual concept reflects current practice in identifying the diversity of cancer patients who may benefit from additional support in accessing and participating in rehabilitation and PC.

Conceptualizing Vulnerability for Health Effects of the COVID-19 Pandemic and the Associated Measures in Utrecht and Zeist: A Concept Map

The COVID-19 pandemic and the associated measures have impacted the health of many. Not all population groups are equally vulnerable to such health effects, possibly increasing health inequalities. We performed a group concept mapping procedure to define a common, context-specific understanding of what makes people vulnerable to health effects of the pandemic and the measures. We organized a two-step, blended brainstorming session with locally involved community members, using the brainstorm focus prompt 'What I think makes people vulnerable for the COVID-19 pandemic and the measures is…'. We asked participants to generate as many statements as possible. Participants then individually structured (sorted and ranked) these statements. The structuring data was analysed using the groupwisdom^TM software and then interpreted by the researchers to generate the concept map. Ninety-eight statements were generated by 19 participants. Sixteen participants completed both structuring tasks. The final concept map consisted of 12 clusters of vulnerability factors, indicating a broad conceptualization of vulnerability during the pandemic. It is being used as a basis for future research and local supportive interventions. Concept mapping is an effective method to arrive at a vulnerability assessment in a community in a short time and, moreover, a method that promotes community engagement.

Ethical implications of COVID-19: vulnerabilities in a global perspective

The COVID-19 pandemic has highlighted a number of ethical issues that typically have not been addressed openly in public debate. The argument 'protect the vulnerable' has been a mantra to motivate all sorts of measures, many of them not scientifically motivated. In this article, the concept of 'vulnerability' is analyzed, and a model is suggested to distinguish layers of vulnerability that may or may not result in poor outcomes, depending on how many layers are present and how they interact. Ethical aspects also need to be considered at the global level, where the issue of vaccine distribution illustrates that stronger obligations and responsibilities need to be taken to fulfil wishes and declarations on the fair distribution of resources.

Beyond trust: Amplifying unheard voices on concerns about harm resulting from health data-sharing

Background:

The point of care in many health systems is increasingly a point of health data generation, data which may be shared and used in a variety of ways by a range of different actors.

Aim:

We set out to gather data about the perspectives on health data-sharing of people living in North East England who have been underrepresented within other public engagement activities and who are marginalized in society.

Methods:

Multi-site ethnographic fieldwork was carried out in the Teesside region of England over a 6-month period in 2019 as part of a large-scale health data innovation program called Connected Health Cities. Organizations working with marginalized groups were contacted to recruit staff, volunteers, and beneficiaries for participation in qualitative research. The data gathered were analyzed thematically and vignettes constructed to illustrate findings.

Results:

Previous encounters with health and social care professionals and the broader socio-political contexts of people’s lives shape the perspectives of people from marginalized groups about sharing of data from their health records. While many would welcome improved care, the risks to people with socially produced vulnerabilities must be appreciated by those advocating systems that share data for personalized medicine or other forms of data-driven care.

Conclusion:

Forms of innovation in medicine which rely on greater data-sharing may present risks to groups and individuals with existing vulnerabilities, and advocates of these innovations should address the lack of trustworthiness of those receiving data before asking that people trust new systems to provide health benefits.

Quality of life in Brazilian elderly: an analysis of healthy aging from the perspective of Potter's global bioethics

INTRODUCTION

Quality of Life (QOL) is essential for healthy aging and through the WHOQOL-Old, it is possible to analyze factors that increase vulnerability and reduce QOL. Aligned with healthy aging is Potter's global bioethics proposing expanded ethics and social justice.

OBJECTIVE

To analyze the QOL of Brazilian elderly from the perspective of Potteŕs global bioethics.

METHOD

Analytical observational research with a quantitative approach composed of 280 Brazilian, aged 60 or over, of both gender, volunteers, who answered the WHOQOL-Old online.

RESULT

Global score of 77.9%, with the mean ± standard deviation: Functioning of the senses 86% (17.22 ± 2.80); Autonomy 78.5% (15.7 ± 2.60); Past, present, and future activities 77.3% (15.46 ± 2.34); Social participation 74.9% (14.99 ± 2.62); Death and dying 71.6% (14.33 ± 3.88) and Intimacy 79.1% (15.82 ± 2.82).

CONCLUSION

Elderly perceived their QOL positively. In the quest to promote healthy aging, it is necessary to broaden the vision for social justice proposed by Potteŕs global bioethics.

COVID-19: opportunities for public health ethics?

Public health ethics is the discipline that ensures that public health professionals and policy makers explain what they do, and why. During the COVID-19 pandemic, ethical deliberations often did not feature explicitly in public health decisions, thus reducing transparency and consistency in decision-making processes, and resulting in loss of trust by the general public. A public health ethics framework based on principles would add to transparency and consistency in public health decision-making. A framework of seven principles is presented and illustrated by applying them to vital COVID-19 ethical questions. Next the question of COVID-19 vaccination shows how the principles work in conjunction. In conclusion, embedding explicit ethical analysis in public health work is necessary to be trustworthy and regain trust. Preparedness for future challenges implies making the public health community more 'ethically literate'.

Vulnerability, Disability, and Public Health Crises

This article suggests that those individuals typically acknowledged as vulnerable during public health crises, such as pandemics, are often-times doubly so. I suggest that individuals can be vulnerable in a person-affecting way (in a way that suggests they are at greater risk to their physical person) as well as in a personhood-affecting way (in a manner that results in individuals being at risk of having their personhood or status as valuable members of a society challenged). I suggest that the former notion of vulnerability coincides with many existing accounts of vulnerability and that subsequently, many of the more standard arguments for moral and justice-based obligations to minimize such vulnerability, hold. I also suggest that the latter notion of vulnerability adds another layer of vulnerability to those that we typically view to be at risk. I argue that personhood-vulnerability constitutes a novel interpretation of vulnerability than expands our ideas of the kinds of harm that emerge during public health crises.

"It's all about delivery": researchers and health professionals' views on the moral challenges of accessing neurobiological information in the context of psychosis

Background

The convergence of neuroscience, genomics, and data science holds promise to unveil the neurobiology of psychosis and to produce new ways of preventing, diagnosing, and treating psychotic illness. Yet, moral challenges arise in neurobiological research and in the clinical translation of research findings. This article investigates the views of relevant actors in mental health on the moral challenges of accessing neurobiological information in the context of psychosis.

Methods

Semi-structured individual interviews with two groups: researchers employed in the National Health Service (NHS) or a university in England (n = 14), and mental health professionals employed in NHS mental health services (n = 14). This article compares results in the two groups (total n = 28).

Results

This article presents findings around three conceptual areas: (1) research ethics as mostly unproblematic, (2) psychosis, neurobiological information, and mental health care, and (3) identity, relationships, and the future. These areas are drawn from the themes and topics that emerged in the interviews across the two groups of participants. Researchers and health professionals provided similar accounts of the moral challenges of accessing—which includes acquisition, communication, and use of—neurobiological information in the context of psychosis. Acquiring neurobiological information was perceived as mostly unproblematic, provided ethical safeguards are put in place. Conversely, participants argued that substantive moral challenges arise from how neurobiological information is delivered—that is, communicated and used—in research and in clinical care. Neurobiological information was seen as a powerful tool in the process through which individuals define their identity and establish personal and clinical goals. The pervasiveness of this narrative tool may influence researchers and health professionals’ perception of ethical principles and moral obligations.

Conclusions

This study suggests that the moral challenges that arise from accessing neurobiological information in the context of psychosis go beyond traditional research and clinical ethics concerns. Reflecting on how accessing neurobiological information can influence individual self-narratives will be vital to ensure the ethical translation of neuroscience and genomics into mental health.

Trial registration

The study did not involve a health care intervention on human participants. It was retrospectively registered on 11 July 2018, registration number: researchregistry4255.

The vulnerabilities of lives: Zika, women and children in Alagoas State, Brazil

Until 2015, Zika was mostly unknown in Brazil and in the world. Since then, the Zika virus has been found to be vertically transmitted and to cause congenital Zika syndrome (CZS). This study aims to describe and analyze the vulnerabilities of the women and children most affected by the Zika epidemic in Brazil. Alagoas has the lowest Human Development Index in Brazil and one of the highest rates of adolescent pregnancy. Between December 2016 and March 2017, interviews were conducted with 54 women with children affected by Zika. The interviews had two components: a narrative-oriented conversation and a semi-structured questionnaire. This comprehensive mixed methods case study represented 45% of the confirmed CZS cases and 20% of the cases under investigation in the state at that time. The women are predominantly Afro-Brazilian; most experienced their first pregnancy during adolescence, and had little education. Many were not covered by social protection programs and were not receiving adequate health care. The rights and needs of these women and children are impacted by a systemic lack of access to services and medications. There is inadequate transportation to services that many families depend on. Discrimination against their children with disabilities is a new and complex concept in their lives. The Zika epidemic has compounded rights violations in their lives and worsened their social and economic layers of vulnerability. There is an urgent need for a robust public response to guarantee the rights of these women and children and to implement mechanisms to prevent and eliminate their vulnerabilities.

A Taxonomy of Ethical, Legal and Social Implications of Wearable Robots: An Expert Perspective

Wearable robots and exoskeletons are relatively new technologies designed for assisting and augmenting human motor functions. Due to their different possible design applications and their intimate connection to the human body, they come with specific ethical, legal, and social issues (ELS), which have not been much explored in the recent ELS literature. This paper draws on expert consultations and a literature review to provide a taxonomy of the most important ethical, legal, and social issues of wearable robots. These issues are categorized in (1) wearable robots and the self, (2) wearable robots and the other, and (3) wearable robots in society.

Proposal for the elaboration of a triage guideline in the context of the COVID-19 pandemic

This document offers a proposal for the elaboration of a triage guideline in the context of the COVID-19 pandemic. This proposal includes recommendations on the procedural norms and substantive norms that should govern the allocation and reallocation of therapeutic resources in conditions of extreme scarcity.

Psychosis, vulnerability, and the moral significance of biomedical innovation in psychiatry. Why ethicists should join efforts

The study of the neuroscience and genomics of mental illness are increasingly intertwined. This is mostly due to the translation of medical technologies into psychiatry and to technological convergence. This article focuses on psychosis. I argue that the convergence of neuroscience and genomics in the context of psychosis is morally problematic, and that ethics scholarship should go beyond the identification of a number of ethical, legal, and social issues. My argument is composed of two strands. First, I argue that we should respond to technological convergence by developing an integrated, patient-centred approach focused on the assessment of individual vulnerabilities. Responding to technological convergence requires that we (i) integrate insights from several areas of ethics, (ii) translate bioethical principles into the mental health context, and (iii) proactively try to anticipate future ethical concerns. Second, I argue that a nuanced understanding of the concept of vulnerability might help us to accomplish this task. I borrow Florencia Luna's notion of 'layers of vulnerability' to show how potential harms or wrongs to individuals who experience psychosis can be conceptualised as stemming from different sources, or layers, of vulnerability. I argue that a layered notion of vulnerability might serve as a common ground to achieve the ethical integration needed to ensure that biomedical innovation can truly benefit, and not harm, individuals who suffer from psychosis.

Why have Non-communicable Diseases been Left Behind?

Non-communicable diseases are no longer largely limited to high-income countries and the elderly. The burden of non-communicable diseases is rising across all country income categories, in part because these diseases have been relatively overlooked on the global health agenda. Historically, communicable diseases have been prioritized in many countries as they were perceived to constitute the greatest disease burden, especially among vulnerable and poor populations, and strategies for prevention and treatment, which had been successful in high-income settings, were considered feasible and often affordable in low-income settings. This prioritization has reduced the communicable diseases burden globally but has left non-communicable diseases largely neglected. A new approach is urgently needed to tackle non-communicable diseases. Based on an analysis of potential features which may have underlain the different approaches to non-communicable diseases and communicable diseases until now, including acuity of disease, potential for control or cure, cost, infectiousness, blaming of individuals and logistical barriers, little ethical or rational justification can be found to support continued neglect of non-communicable diseases. Justice demands access to quality and affordable care for all. An equitable approach to non-communicable diseases is therefore strongly mandated on medical, ethical, economic, and public health grounds. Funding must not however be diverted away from communicable diseases, which continue to require attention-but concomitantly, funding for non-communicable diseases must be increased. International and multi-sectoral action is required to accelerate progress towards true universal health coverage and towards achievement of all of the sustainable development goals, such that prevention and access to care for non-communicable disease can become a global reality.

The Concept of Vulnerability in Mental Health Research: A Mixed Methods Study on Researcher Perspectives

The concept of vulnerability plays a central role in research ethics in signaling that certain research participants warrant more careful consideration because their risk of harm is heightened due to their participation in research. Despite scholarly debates, the descriptive and normative meanings ascribed to the concept have remained disengaged from the perspective of users of the concept and those concerned by its use. In this study, we report a survey- and interview-based investigation of mental health researcher perspectives on vulnerability. We found that autonomy-based understandings of vulnerability were predominant but that other understandings coexisted, reflecting considerable pluralism. A wide range of challenges were associated with this concept, and further training was recommended by researchers.

Program implementation gaps and ethical issues in the prevention of HIV infection among infants, children, and adolescents in sub-Saharan Africa

Strategies for HIV prevention among infants, children, and adolescents have evolved significantly over the past 20 years. These include the global scale-up of simplified multidrug HIV regimens for pregnant women, leading to impressive reductions in new child HIV infections. However, significant gaps remain, especially in high HIV-burden sub-Saharan African countries. For example, many pregnant women living with HIV (WLHIV) are unable to access and sustain HIV testing and treatment partly due to low agency and harmful gender norms. Among pregnant WLHIV, adolescent girls face an additional layer of societal and health-system barriers in accessing care for themselves and their exposed infants. Legal and structural barriers limit access to HIV prevention-related sexual and reproductive health services among high-risk adolescents, including girls and young men who have sex with men. Key ethical issues underlying HIV prevention gaps for infants, children, and adolescents prevail. This narrative review explores these issues and highlights counter-measures for programming and policy, including gender empowerment, improving access to and appropriateness of critical health services, rights-based policy and legislation, closing research gaps, and considering the values and preferences of young people for HIV prevention and treatment services.

Vulnerability identified in clinical practice: a qualitative analysis

BACKGROUND

Although it is the moral duty of physicians to protect vulnerable patients, there are no data on how vulnerability is perceived in clinical practice. This study explores how physicians classify someone as "vulnerable".

METHOD

Thirty-three physicians were initially questioned about resource allocation problems in their work. The results of these interviews were examined with qualitative study software to identify characteristics associated with vulnerability in patients. Data were conceptualized, classified and cross-linked to highlight the major determinants of vulnerability. The findings revealed the principal factors that make patients vulnerable in clinical practice, according to our definition of vulnerability: the likelihood of having one's interests unjustly considered.

RESULTS

Vulnerability can arise as a result of a mismatch between the characteristics of patients and physicians, the healthcare system, the treatment, or the communication between physicians and patients. Vulnerability appears as a gap between a patient's needs and the means intended to meet them. Vulnerability can further be the result of doing too little or too much for patients. This result suggests that structures provided by healthcare systems are not as differentiated as they should be to cover all situations. Our initial definition of vulnerability was illustrated and supported by our results, showing that it encompasses all factors involved, not solely personal characteristics, indicating the need for a more pragmatic approach for use in clinical practice.

CONCLUSION

Vulnerability is not due to a single factor but appears under certain circumstances when there is a discrepancy between a patient's interests and the care provided, despite existing compensation systems.

Teaching Vulnerability in Research: A Study of Approaches Utilized by a Sample of Research Ethics Training Programs

This article reports the outcomes of qualitative research on the teaching of "vulnerability in research" undertaken with principal investigators of international bioethics training programs funded by the Fogarty International Center of the National Institutes of Health (NIH) of the United States. To properly contextualize this research, we begin with an overview of the various ways in which vulnerability has been conceptualized both by writers and by ethical guidance from low-, middle-, and high-income countries. We conclude with some preliminary suggestions for best practice and recommendations for further research. To the best of our knowledge, this is the first time research of this kind has been carried out.

Ethical challenges in global health-related stigma research

BACKGROUND

It is critically important to conduct research on stigmatized conditions, to include marginalized groups that experience stigma, and to develop interventions to reduce stigma. However, such research is ethically challenging. Though superficial reference is frequently made to these widely acknowledged challenges, few publications have focused on ethical issues in research on stigmatized groups or conditions. In fact, a brief literature review found only two such publications.

MAIN TEXT

At a recent Science of Stigma Reduction workshop comprising 60 stigma researchers from the USA and low and middle-income countries, the need for more robust and critical discussion of the ethics of the research was highlighted. In this paper we describe, illustrate through cases, and critically examine key ethical challenges that are more likely to arise because a research study focuses on health-related stigma or involves stigmatized groups or conditions. We examine the ethics of this research from two perspectives. First, through the lens of overprotection, where we discuss how the perception of stigma can impede ethical research, disrespect research participants, and narrow the research questions. Second, through the lens of research risks, where we consider how research with stigmatized populations can unintentionally result in harms. Research-related harms to participants include potential breaches of confidentiality and the exacerbation of stigma. Potential harms also extend to third parties, including families and populations who may be affected by the dissemination of research results.

CONCLUSIONS

Research with stigmatized populations and on stigmatized conditions should not be impeded by unnecessary or inappropriate protective measures. Nevertheless, it may entail different and greater risks than other health research. Investigators and research ethics committees must be particularly attentive to these risks and how to manage them.

Identifying and evaluating layers of vulnerability - a way forward

“Vulnerability” is a key concept for research ethics and public health ethics. This term can be discussed from either a conceptual or a practical perspective. I previously proposed the metaphor of layers to understand how this concept functions from the conceptual perspective in human research. In this paper I will clarify how my analysis includes other definitions of vulnerability. Then, I will take the practical‐ethical perspective, rejecting the usefulness of taxonomies to analyze vulnerabilities. My proposal specifies two steps and provides a procedural guide to help rank layers. I introduce the notion of cascade vulnerability and outline the dispositional nature of layers of vulnerability to underscore the importance of identifying their stimulus condition. In addition, I identify three kinds of obligations and some strategies to implement them.

This strategy outlines the normative force of harmful layers of vulnerability. It offers concrete guidance. It contributes substantial content to the practical sphere but it does not simplify or idealize research subjects, research context or public health challenges.