Research ethics review during the COVID-19 pandemic: An international study

Research ethics review committees (ERCs) worldwide faced daunting challenges during the COVID-19 pandemic. There was a need to balance rapid turnaround with rigorous evaluation of high-risk research protocols in the context of considerable uncertainty. This study explored the experiences and performance of ERCs during the pandemic. We conducted an anonymous, cross-sectional, global online survey of chairs (or their delegates) of ERCs who were involved in the review of COVID-19-related research protocols after March 2020. The survey ran from October 2022 to February 2023 and consisted of 50 items, with opportunities for descriptive responses to open-ended questions. Two hundred and three participants [130 from high-income countries (HICs) and 73 from low- and middle-income countries (LMICs)] completed our survey. Respondents came from diverse entities and organizations from 48 countries (19 HICs and 29 LMICs) in all World Health Organization regions. Responses show little of the increased global funding for COVID-19 research was allotted to the operation of ERCs. Few ERCs had pre-existing internal policies to address operation during public health emergencies, but almost half used existing guidelines. Most ERCs modified existing procedures or designed and implemented new ones but had not evaluated the success of these changes. Participants overwhelmingly endorsed permanently implementing several of them. Few ERCs added new members but non-member experts were consulted; quorum was generally achieved. Collaboration among ERCs was infrequent, but reviews conducted by external ERCs were recognized and validated. Review volume increased during the pandemic, with COVID-19-related studies being prioritized. Most protocol reviews were reported as taking less than three weeks. One-third of respondents reported external pressure on their ERCs from different stakeholders to approve or reject specific COVID-19-related protocols. ERC members faced significant challenges to keep their committees functioning during the pandemic. Our findings can inform ERC approaches towards future public health emergencies. To our knowledge, this is the first international, COVID-19-related study of its kind.

Community Voices and Whole-Genome Sequencing for Tuberculosis: Storytelling and the Importance of Listening

One of the primary public health functions of a tuberculosis (TB) program is to arrest the spread of infection. Traditionally, TB programs have relied on epidemiological information, gathered through contact tracing, to infer that transmission has occurred between people. The ability of drawing such inferences is extensively context dependent. Where epidemiological information has been strong, such as 2 cases of TB occurring sequentially within a single household, confidence in such inferences is high; conversely, public health authorities have been less certain about the significance of TB cases merely occurring in the same wider social group or geographic area. Many current laboratory tests for TB used globally may be sufficient to confirm a diagnosis and guide appropriate therapy but still be insufficiently precise for distinguishing two strains reliably. In short, drawing inferences regarding a chain of transmissions has always been as much art as science.

Ethics and Health Security in the Australian COVID-19 Context: A Critical Interpretive Literature Review

Background The concept of "health security" is often used to motivate public health responses, yet the ethical values that underpin this concept remain largely unexamined. The recent Australian responses to COVID-19 serve as an important case study by which we can analyse the pre-existing literature to see what ethical values shaped, and continue to shape, Australia's response. Methods We conducted a critical interpretive literature review of academic and grey literatures within key databases, resulting in 2,220 sources. After screening for duplicates and relevance, we analysed ninety-six sources. Results First, risk and uncertainty are a leading focus, with a heavy concentration on risks to life and health. Second, free movement, safety, and security were recurringly emphasized, albeit narrowly focused upon the safety of the population. Third, legitimacy was a recurring theme, and it is here that discussions of "health security" figured highly. Conclusion Discussions of harm from government and associated official bodies fail to adequately distinguish between various senses of harm. Moreover, while the literature often discusses the balancing of rights, the steps involved in the weighing of these rights is rarely adequately explained and defended. We suggest that decision-makers should endeavour to clearly identify and defend the values undergirding their decisions in the public sphere.

Data Sharing During Pandemics: Reciprocity, Solidarity, and Limits to Obligations

South Africa shared with the world the warning of a new strain of SARS-CoV2, Omicron, in November 2021. As a result, many high-income countries (HICs) instituted complete travel bans on persons leaving South Africa and other neighbouring countries. These bans were unnecessary from a scientific standpoint, and they ran counter to the International Health Regulations. In short, South Africa was penalized for sharing data. Data sharing during pandemics is commonly justified by appeals to solidarity. In this paper, we argue that solidarity is, at best, an aspirational ideal to work toward but that it cannot ground an obligation to share data. Instead, low-and-middle income countries (LIMCs) should be guided by the principle of reciprocity, which states that we ought to return good for good received. Reciprocity is necessarily a conditional principle. LMICs, we argue, should only share data during future pandemics on the condition that HICs provide enforceable assurances that the benefits of data sharing will be equitably distributed and that LMICs won't be penalized for sharing information.

To kill or not to kill: A systematic literature review of high-stakes moral decision-making measures and their psychometric properties

Introduction

The present systematic review investigates the psychological tools available for capturing high-stakes decisions involving life-death content and their psychometric properties. Valid measurement of these individual differences will provide crucial information in the personnel selection and training in fields where high-stakes moral issues exist (e.g., military, medicine). To our knowledge, this is the first systematic examination of such instruments.

Methods

Systematic searches of 6 electronic databases were conducted according to the PRISMA guidelines. An appraisal tool evaluated the quality of identified measures. Twenty studies met pre-determined inclusion criteria. Moral decision-making was assessed with either a self-report scale (n = 3) or moral dilemmas (n = 17).

Results

The findings identified two measures, the Defining Issues Test and the Oxford Utilitarianism Scale as psychometrically sound measures of moral decision-making. However, they are unlikely to be considered "gold standard" measures due to their theoretically specific, but limited, scope. Overall, the findings suggest that research in the area has been scattered. There is a lack of consensus on the definition of moral decision-making, and a lack of cross-validation on how different measures of moral decision-making relate to each other. This presents a gap between theory and empirical measurement in moral decision-making. Further work is needed for a unified conceptualization of moral decision-making to pave the way to both theory development and the development of well-validated measurement tools, and this review provides a critical foundation for both.

Between rules and resistance: moving public health emergency responses beyond fear, racism and greed

In times of a public health emergency, lawyers and ethicists play a key role in ensuring that government responses, such as travel restrictions, are both legally and ethically justified. However, when travel bans were imposed in a broadly discriminatory manner against southern African countries in response to the Omicron SARS-CoV-2 variant in late 2021, considerations of law, ethics or science did not appear to guide politicians' decisions. Rather, these bans appeared to be driven by fear of contagion and electoral blowback, economic motivations and inherently racist assumptions about low-income and middle-income countries (LMICs). With a new pandemic treaty and amendments to the WHO's International Health Regulations (IHR) on the near-term horizon, ethics and international law are at a key inflection point in global health governance. Drawing on examples of bordering practices to contain contagion in the current pandemic and in the distant past, we argue that the current IHR is not adequately constructed for a just and equitable international response to pandemics. Countries impose travel restrictions irrespective of their need or of the health and economic impact of such measures on LMICs. While the strengthening and reform of international laws and norms are worthy pursuits, we remain apprehensive about the transformative potential of such initiatives in the absence of collective political will, and suggest that in the interim, LMICs are justified in seeking strategic opportunities to play the same stark self-interested hardball as powerful states.

Is the Cure Worse than the Disease? The Ethics of Imposing Risk in Public Health

Efforts to improve public health, both in the context of infectious diseases and non-communicable diseases, will often consist of measures that confer risk on some persons to bring about benefits to those same people or others. Still, it is unclear what exactly justifies implementing such measures that impose risk on some people and not others in the context of public health. Herein, we build on existing autonomy-based accounts of ethical risk imposition by arguing that considerations of imposing risk in public health should be centered on a relational autonomy and relational justice approach. Doing so better captures what makes some risk permissible and others not by exploring the importance of power and context in such deliberations. We conclude the paper by applying a relational account of risk imposition in the cases of (a) COVID-19 measures and (b) the regulation of sugar-sweetened beverages to illustrate its explanatory power.

R&D during public health emergencies: the value(s) of trust, governance and collaboration

In January 2021, Dr Tedros Adhanom Ghebreyesus, director–general of the WHO, warned that the world was ‘on the brink of a catastrophic moral failure [that] will be paid with lives and livelihoods in the world’s poorest countries’. We are now past the brink. Many high-income countries have vaccinated their populations (which, in some cases, includes third and even fourth doses) and are loosening public health and social measures, while low-income and middle-income countries are struggling to secure enough supply of vaccines to administer first doses. While injustices abound in the deployment and allocation of COVID-19 vaccines, therapies and diagnostics, an area that has hitherto received inadequate ethical scrutiny concerns the upstream structures and mechanisms that govern and facilitate the research and development (R&D) associated with these novel therapies, vaccines and diagnostics. Much can be learnt by looking to past experiences with the rapid deployment of R&D in the context of public health emergencies. Yet, much of the ‘learning’ from past epidemics and outbreaks has largely focused on technical or technological innovations and overlooked the essential role of important normative developments; namely, the importance of fostering multiple levels of trust, strong and fair governance, and broad research collaborations. In this paper, we argue that normative lessons pertaining to the conduct of R&D during the 2014–2016 Ebola epidemic in West Africa provide important insights for how R&D ought to proceed to combat the current COVID-19 pandemic and future infectious disease threats.

Ethical health security in the age of antimicrobial resistance

OBJECTIVE

Owing to its potential human, social and economic costs, antimicrobial resistance (AMR) is frequently referred to as a threat to health security. Simultaneously, health security and the preservation of antimicrobials are often described as a global public good. However, how the term 'public good' is used in the context of health security, and the values that underpin it, remains ambiguous. Policymaking is never value-free, and a better examination of such values is critical to understanding how issues such as AMR are problematised and how policy decisions are informed.

DESIGN

We used McDougall's version of critical interpretive synthesis to capture the recurring concepts and arguments within public policy, political science and applied ethics literature on AMR. Articles were analysed by identifying recurring ideas and developing themes across the literature.

RESULTS

A total of 77 papers were included in our review. In the context of health security and AMR, the concept of 'public good' appears to be used interchangeably with 'common good', reflecting confusion, but sometimes meaningful differences, regarding how antimicrobials, as a good, are conceived. Main approaches to addressing AMR are statism, globalism and regionalism, which appeal to different values in guiding policymakers. Common justificatory values underpinning preservation of antimicrobials as a public good were prevention of harm, solidarity, justice and rights.

CONCLUSION

The findings suggest that within the literature there is a lack of conceptual clarity as to whether antimicrobials constitute a public good or a common good. Moreover, the way in which antimicrobials are conceived and the approaches through which AMR as a threat to health security is addressed appear to be grounded in values that are often implicit. Being explicit about the values that underpin AMR and health security is not simply an intellectual exercise but has very real policy and programmatic implications.

Predictive Biomathematical Modeling Compared to Objective Sleep During COVID-19 Humanitarian Flights

BACKGROUND: Biomathematical modeling software like the Sleep, Activity, Fatigue, and Task Effectiveness (SAFTE) model and Fatigue Avoidance Scheduling Tool (FAST) help carriers predict fatigue risk for planned rosters. The ability of a biomathematical model to accurately estimate fatigue risk during unprecedented operations, such as COVID-19 humanitarian ultra-long-range flights, is unknown. Azul Cargo Express organized and conducted five separate humanitarian missions to China between May and July 2020. Prior to conducting the missions, a sleep-prediction algorithm (AutoSleep) within SAFTE-FAST was used to predict in-flight sleep duration and pilot effectiveness. Here we compare AutoSleep predictions against pilots' sleep diary and a sleep-tracking actigraphy device (Zulu watch, Institutes for Behavior Resources) from Azul's COVID-19 humanitarian missions.METHODS: Pilots wore Zulu watches throughout the mission period and reported sleep duration for their in-flight rest periods using a sleep diary. Agreement between AutoSleep, diary, and Zulu watch measures was compared using intraclass correlation coefficients (ICC). Goodness-of-fit between predicted effectiveness distribution between scenarios was evaluated using the R² statistic.RESULTS: A total of 20 (N = 20) pilots flying across 5 humanitarian missions provided sleep diary and actigraphy data. ICC and R² values were >0.90, indicating excellent agreement between sleep measures and predicted effectiveness distribution, respectively.DISCUSSION: Biomathematical predictions of in-flight sleep during unprecedented humanitarian missions were in agreement with actual sleep patterns during flights. These findings indicate that biomathematical models may retain accuracy even under extreme circumstances. Pilots may overestimate the amount of sleep that they receive during extreme flight-duty periods, which could constitute a fatigue risk.Devine JK, Garcia CR, Simoes AS, Guelere MR, de Godoy B, Silva DS, Pacheco PC, Choynowski J, Hursh SR. Predictive biomathematical modeling compared to objective sleep during COVID-19 humanitarian flights. Aerosp Med Hum Perform. 2022; 93(1):4-12.

Pilot of a Training Format for Clinicians' Continuing Professional Development: Open House With Rotating Short Segments

INTRODUCTION

Access to continuing professional development offered at lunchtime is limited by hospital scheduling that has staff members taking their lunch breaks at different times. To overcome this barrier, we developed a three-part training format with (1) a focus group segment soliciting participants' opinions on the training's target behavior, (2) a didactic segment introducing tools to support the behavior, and (3) a question-and-answer segment about the session topic. We rotated through these segments, each 15 minutes long, over 3 hours. Participants could join at any segment and experience the full curriculum after 45 minutes.

METHODS

We piloted this training format five times at three hospitals. Our training aimed to encourage clinicians to consistently inform involuntary patients about their Mental Health Act rights. We gauged the effect of the training and participants' opinions of the session using the Continuing Professional Development Reaction questionnaire and a session evaluation, respectively.

RESULTS

Continuing Professional Development-Reaction results (n = 80) showed a detectable increase in clinicians' intent to consistently give involuntary patients rights advice. Participants reported finding the training organized, informative, and valuable.

DISCUSSION

The open house with rotating short segments is a feasible and adaptable training format to engage clinicians in voluntary continuing professional development.

Ethical challenges in the treatment of non-refugee migrants with tuberculosis in Canada

While attention to the ethical issues that migrants face in accessing tuberculosis care has increased in the last few years, most of the attention has focused on challenges that refugees face when emigrating. Less attention has been given to ethical challenges that arise in the context of providing tuberculosis treatment and care to non-refugee migrants in high-income countries (HIC), particularly those that do not face immediate danger or violence. In this paper, we analyze some of the ethical challenges associated with treating migrants with tuberculosis in the Canadian context. In particular, we will discuss (i) inter- and intra-jurisdictional issues that challenge quotidian public health governance structures, and (ii) the ethical imperative for the Canadian government and its provinces to clearly differentiate access to healthcare from a person's immigration status to help overcome power imbalances that may exist between public health workers and their clients. The arguments presented herein could potentially apply to other HIC with some form of universal health coverage.

Advancing TB research using digitized programmatic data

The use of real-world data from national TB care programs has great potential to answer key research questions in TB control and is now opportune due to increasing digital data collection and storage. We summarize an expert stakeholder workshop conducted on this topic in October 2019, with perspectives from academics, national TB program officers, and data managers. We discuss challenges and opportunities in the use of TB programmatic data for research and describe digital data availability in two large, high TB burden countries, Brazil and South Africa. From this, we posit that with a standardized data collection set, improved data management, and greater collaboration, more TB programmatic data can be used for research with measurable public health impact.

Pilot Sleep Behavior across Time during Ultra-Long-Range Flights

Fatigue risk to the pilot has been a deterrent for conducting direct flights longer than 12 h under normal conditions, but such flights were a necessity during the COVID-19 pandemic. Twenty (N = 20) pilots flying across five humanitarian missions between Brazil and China wore a sleep-tracking device (the Zulu watch), which has been validated for the estimation of sleep timing (sleep onset and offset), duration, efficiency, and sleep score (wake, interrupted, light, or deep Sleep) throughout the mission period. Pilots also reported sleep timing, duration, and subjective quality of their in-flight rest periods using a sleep diary. To our knowledge, this is the first report of commercial pilot sleep behavior during ultra-long-range operations under COVID-19 pandemic conditions. Moreover, these analyses provide an estimate of sleep score during in-flight sleep, which has not been reported previously in the literature.

Medium and large-sized mammals of a private protected wetland in the Cerrado-Amazon biological corridor, Brazil

Brazil is the world's richest country in biodiversity, including mammal species. In the Brazilian Cerrado biome, mammalian diversity is vast, with about 251 species, 32 of them are endemic and 22 listed as threatened species. In this work, we investigated species diversity of medium- and large-sized mammals in the private protected area RPPN Pontal do Jaburu (RPPN-PJ) and its surroundings, which is a flooded area located in an important biological corridor in the Cerrado-Amazon ecotone zone, a priority area for biodiversity conservation in Brazil. We used camera-trapping, active search (night and day), and track survey during dry season (Apr - Aug 2016). We recorded 29 mammal species, being the Carnivora order the most representative with 11 species. Regarding threat status, 35.7% of the recorded species were listed as threatened in Brazil and 32.1% worldwide. We highlight the high relative frequency of threatened species records such as Tapirus terrestris, Panthera onca, Blastocerus dichotomus, Pteronura brasiliensis, Priodontes maximus, and other, as well as the presence of the newly described aquatic mammal species Inia araguaiaensis. We stress the importance of RPPN-PJ and its surroundings for mammal conservation, which include complex habitats (wetlands) located in an important ecotone zone.

Ethics Guidance for Environmental Scientists Engaged in Surveillance of Wastewater for SARS-CoV-2

The COVID-19 pandemic has given rise to rapid and widespread international pursuit of wastewater surveillance for genetic signals of SARS-CoV-2, the virus causing the pandemic. Environmental scientists and engineers familiar with the techniques required for this endeavor have responded. Many of the environmental scientists engaged in these investigations have not necessarily had experience with the ethical obligations associated with generating and handling human health data. The Canadian Water Network facilitated adoption of these surveillance methods by creating a national coalition, which included a public health advisory group that recognized a need for ethics guidance for the wastewater approach to public health surveillance. This Policy Analysis addresses that need and is based on a review of relevant ethics literature tightly focused on ethics applicable to public health surveillance. That review revealed that classical health bioethics governing clinical practice and general public health ethics guidance did not adequately address key issues in wastewater surveillance. The 2017 World Health Organization guidelines, directly based on a systematic literature review, specifically addressed ethical issues in public health surveillance. The application of relevant ethical guidance to wastewater surveillance is analyzed and summarized for environmental scientists.

Ethics and human rights considerations regarding involuntary isolation of people with TB

Involuntary isolation of people with tuberculosis is rarely medically required, ethically permitted or justified on the ground of human rights law. The rare circumstances that do call for involuntary isolation must only occur once a number of conditions are met. These include just procedural protections and ensuring that all other options have been exhausted before resorting to involuntary isolation. This article is intended to outline for healthcare workers, policy makers and advocates the ethical reasoning behind isolation and involuntary isolation, as well as describing the requisite human rights laws that impinge on the topic. Finally, we present a list of conditions that must be met to justify involuntary isolation on the grounds of both ethics and human rights.

A qualitative study of clinicians' perspectives on independent rights advice for involuntary psychiatric patients in British Columbia, Canada

BACKGROUND

In British Columbia (BC), Canada, clinicians are responsible for giving involuntary psychiatric patients rights information upon admission. Yet an investigation by the BC Office of the Ombudsperson found that clinicians are not always fulfilling this responsibility. The Ombudsperson recommended that the provincial government fund an independent body to give rights advice to patients.

METHODS

To understand how clinicians feel about this recommendation, focus groups of clinicians who may give psychiatric patients rights information (n = 81) were conducted in Vancouver, BC, to probe their attitudes toward independent rights advisors. The focus group transcripts were thematically analyzed.

RESULTS

Most clinicians believe that giving rights information is within their scope of practice, although some acknowledge that it poses a conflict of interest when the patient wishes to challenge the treatment team's decisions. Participants' chief concerns about an independent rights-advice service were that (a) patients may experience a delay in receiving their rights information, (b) integrating rights advisors into the workflow would complicate an already chaotic admission process, and (c) more patients would be counselled to challenge their hospitalization, leading to an increased administrative workload for clinical staff. However, many participants believed that independent rights advisors would be a positive addition to the admission process, both allowing clinicians to focus on treatment and serving as a source of rights-related information.

CONCLUSIONS

Participants were generally amenable to an independent rights-advice service, suggesting that the introduction of rights advisors need not result in an adversarial relationship between treatment team and patient, as opponents of the proposal fear. Clearly distinguishing between basic rights information and in-depth rights advice could address several of the clinicians' concerns about the role that independent rights advisors would play in the involuntary admission process. Clinicians' and other stakeholders' concerns should be considered as the province develops its rights-advice service.

Regional support in the health regions of Rio de Janeiro state: a strategy for strengthening SUS

Brazil is one of the few countries in the world with more than 200 million inhabitants that has a universal public health system. In its 30 years of existence, the Unified Health System (SUS) has brought many advances to the Brazilian society. However, it still faces challenges to ensure health services in quantity and quality to the entire population. Federal, state and municipal government levels share the responsibility for its management and financing. In this governance scheme, it is the Municipal Health Secretariats (MHS) of the 5,596 Brazilian municipalities that are primarily responsible for providing and managing health services. Given the importance of this responsibility, Councils of Municipal Health Departments (COSEMS) and the National Council of Municipal Health Departments (CONASEMS) were created in 1986. Their role is to promote the articulation and negotiation of their interests with the federal and state levels. In Rio de Janeiro, a team of specialized professionals has been providing support for COSEMS-RJ since 2012. The team carries out activities in the nine regions of the state, which has 92 municipalities and more than 16 million inhabitants, the 3rd largest population in Brazil. Its activities are maintained by CONASEMS, the Ministry of Health and the State University of Rio de Janeiro (UERJ). The objetive of this report is to present the experience of the expert team of COSEMS RJ as a strategy for strengthening regional governance and intergovernmental relations. Providing specialized technical support for MHS has improved local management of SUS and has allowed for the establishment of regionalized health care networks in Rio de Janeiro.

Key messages

The project improves the participation of municipal managers and teams in regional spaces. It strengthens their capacity for intergovernamental decision-making and regionalization of the health system. The project qualifies the municipal management for fundraising, knowledge building, policy implementing and monitoring, as well as participatory planning.

Social distancing, social justice, and risk during the COVID-19 pandemic

Social distancing is an important and necessary measure to help arrest the spread of SARS-CoV-2 during the COVID-19 pandemic. However, it does place persons who are socially or politically marginalized, including those who are of lower socio-economic status, at risk of further harms. In other words, marginalized or disadvantaged persons are at risk of both contracting SARS-CoV-2 and the risk of harms that may come about because of the social distancing measures themselves. Finally, a third layer of risk faced by marginalized persons would be the overuse of utility (i.e., maximize the benefit of resource x) as the primary ethics principle upon which to make allocation decisions, since oftentimes it is resource-intensive to help those in positions of social marginality. This three-fold risk of harm to which marginalized persons are subjected runs counter to the very notion of social justice that underpins public health. Social distancing in a socially just manner requires dialoguing with affected populations and providing social supports to marginalized persons, regardless of the associated costs.

Developing and Implementing new TB Technologies: Key Informants' Perspectives on the Ethical Challenges

OBJECTIVE

To identify the ethical challenges associated with the development and implementation of new tuberculosis (TB) drugs and diagnostics.

METHODS

Twenty-three semi-structured qualitative interviews conducted between December 2015 and September 2016 with programme administrators, healthcare workers, advocates, policymakers, and funders based in the Americas, Europe, and Africa. Interviews were analysed using thematic analysis.

RESULTS

Divergent interests and responsibilities, coupled with power imbalances, are a primary source of ethical challenges; the uncertain risk profiles of new drugs present an additional one. Although this challenge can be partially mitigated through stringent pharmacovigilance, respondents highlighted that high-burden countries tend to lack the resources to facilitate safe implementation. Increased advocacy and community engagement are considered an ethical imperative for future TB development and implementation.

CONCLUSIONS

This project helps identify some of the ethical challenges of new TB technologies. It demonstrates that investigating ethical challenges through qualitative research is one way to apprehend the difficulty of implementing new TB technologies. Addressing this difficulty will require that those in positions of power reconsider their interests in relation to disempowered communities.

POLICY IMPLICATIONS

Efforts to build consensus regarding what values should underpin the global governance of TB research, prevention, and care are essential to facilitate the ethical implementation of new TB technologies.

Systems thinking and ethics in public health: a necessary and mutually beneficial partnership

Systems thinking has emerged as a means of conceptualizing and addressing complex public health problems, thereby challenging more commonplace understanding of problems and corresponding solutions as straightforward explanations of cause and effect. Systems thinking tries to address the complexity of problems through qualitative and quantitative modeling based on a variety of systems theories, each with their own assumptions and, more importantly, implicit and unexamined values. To date, however, there has been little engagement between systems scientists and those working in bioethics and public health ethics. The goal of this paper is to begin to consider what it might mean to combine systems thinking with public health ethics to solve public health challenges. We argue that there is a role for ethics in systems thinking in public health as a means of elucidating implicit assumptions and facilitating ethics debate and dialogue with key stakeholders.

Attending to scalar ethical issues in emerging approaches to environmental health research and practice

Accelerated changes to the planet have created novel spaces to re-imagine the boundaries and foci of environmental health research. Climate change, mass species extinction, ocean acidification, biogeochemical disturbance, and other emergent environmental issues have precipitated new population health perspectives, including, but not limited to, one health, ecohealth, and planetary health. These perspectives, while nuanced, all attempt to reconcile broad global challenges with localized health impacts by attending to the reciprocal relationships between the health of ecosystems, animals, and humans. While such innovation is to be encouraged, we argue that a more comprehensive engagement with the ethics of these emerging fields of inquiry will add value in terms of the significance and impact of associated interventions. In this contribution, we highlight how the concept of spatial and temporal scale can be usefully deployed to shed light on a variety of ethical issues common to emerging environmental health perspectives, and that the potential of scalar analysis implicit to van Potter's conceptualization of bioethics has yet to be fully appreciated. Specifically, we identify how scale interacts with key ethical issues that require consideration and clarification by one health, ecohealth, and planetary health researchers and practitioners to enhance the effectiveness of research and practice, including justice and governance.

Trust and the ethical challenges in the use of whole genome sequencing for tuberculosis surveillance: a qualitative study of stakeholder perspectives

BACKGROUND

Emerging genomic technologies promise more efficient infectious disease control. Whole genome sequencing (WGS) is increasingly being used in tuberculosis (TB) diagnosis, surveillance, and epidemiology. However, while the use of WGS by public health agencies may raise ethical, legal, and socio-political concerns, these challenges are poorly understood.

METHOD

Between November 2017 and April 2018, we conducted semi-structured interviews with 22 key stakeholders across the fields of governance and policy, public health, and laboratory sciences representing the major jurisdictions currently using WGS in national TB programs. Thematic analysis of the interviews was conducted using NVivo 11.

RESULTS

Respondents identified several ethical and practical challenges associated with WGS in TB care and surveillance, all related to issues of trust, including: 1) the power of public health; 2) data sharing and profits derived from surveillance efforts; and 3) concerns regarding who has access to, and can benefit from, the technology. Additional challenges included: the potential utility that WGS adds to a public health program, the risks associated with linking necessary epidemiological metadata to the genomic data, and challenges associated with jurisdictional capacity to implement the technology.

CONCLUSIONS

Successful implementation of WGS is dependent on fostering relationships of trust between those working with genomics technology and those directly impacted by it, including clinicians. Building trust (a) between the public and the public health agencies and (b) within public health agencies themselves is critical due to the inherent complexity of WGS and its implementation for communicable disease control purposes.

A failure in solidarity: Ethical challenges in the development and implementation of new tuberculosis technologies

Prominent tuberculosis (TB) actors are invoking solidarity to motivate and justify collective action to address TB, including through intensified development and implementation (D&I) of technologies such as drugs and diagnostics. We characterize the ethical challenges associated with D&I of new TB technologies by drawing on stakeholder perspectives from 23 key informant interviews and we articulate the ethical implications of solidarity for TB technology D&I. The fundamental ethical issue facing TB technological D&I is a failure within and beyond the TB community to stand in solidarity with persons with TB in addressing the complex sociopolitical contexts of technological D&I. The failure in solidarity relates to two further ethical challenges raised by respondents: skewed power dynamics that hinder D&I and uncertainties around weighing risks and benefits associated with new technologies. Respondents identified advocacy and participatory research practices as necessary to address such challenges and to motivate sustained collective action to accelerate toward TB elimination. We present the first empirical examination of bioethical accounts of solidarity in public and global health. Our study suggests that solidarity allows us better to understand and address the ethical challenges that arrest the D&I of new TB technologies. Solidarity lends credence to policies and practices that address the relational nature of illness and health through collective action.

Provider perspectives on liberty and harm in the treatment of persons with tuberculosis and mental illness

<sec id="st1"> <title>OBJECTIVES</title> To examine how frontline health care workers (HCWs) and decision-makers working in tuberculosis (TB) care and mental health care conceptualise liberty, harm and the harm principle-which are often invoked in health care legislation to justify liberty restrictions-in the treatment and care of persons with TB and severe and persistent mental illness (SPMI). </sec> <sec id="st2"> <title>DESIGN</title> Qualitative study of 20 semi-structured interviews with HCWs and decision-makers working in public or mental health from three public health units and two psychiatric hospitals in the Greater Toronto Area in Ontario, Canada. Interviews were evaluated using thematic analysis. </sec> <sec id="st3"> <title>RESULTS</title> Three themes were identified: 1) the contextual nature of liberty restrictions; 2) the concept of liberty as a matter of degree; and 3) the challenges of balancing the treatment and care goals of TB and mental health for persons with both TB and SPMI. </sec> <sec id="st4"> <title>CONCLUSION</title> Harm is understood by HCWs caring for persons with TB and/or SPMI in a context-dependent manner. This is compounded in the case of persons with both TB and SPMI. Liberty restrictions to advance public health goals entail reciprocal obligations from society, including social protections and additional resources, to ease the effects and range of liberty restrictions. Attention is required to ensure that treatment and care for SPMI does not impede that of TB and vice versa. </sec>.

Sensing the Plant Surface Prior to Feeding and Oviposition: Differences in External Ultrastructure and Function Among Tarsi of Heliconius erato

Adult foretarsi of Heliconius erato Linnaeus (Lepidoptera, Nymphalidae) are reduced in size and are not used for walking. Foretarsi of the female have specialized sensilla that are presumably used to identify the host plant, by drumming. The mid- and hind tarsi also bear sensilla in both sexes, but these have not been described in detail, nor has their chemosensory function been determined. We described and compared the tarsi of H. erato under light and scanning electron microscopy. Behavioral experiments showed that differences in the shape, number, and size of sensilla were related to feeding and oviposition behaviors. Two types of sensillum (chaeticum and trichodeum) were found in similar numbers and size on the mid- and hind tarsi of both sexes. Sensilla on the female foretarsi act in host-plant site selection, strongly affecting oviposition rates when isolated. Male foretarsi lack sensilla, which may have been selected against due to the absence of function and thus lost. Sensilla on the mid- and hind tarsi are involved in sugar detection in both sexes, responding to an effective dose of sucrose (ED₅₀) near 0.01 M, and therefore might be used to identify food resources when the butterflies settle on flowers.

Ethics of health research with prisoners in Canada

BACKGROUND

Despite the growing recognition for the need to improve the health of prisoners in Canada and the need for health research, there has been little discussion of the ethical issues with regards to health research with prisoners in Canada. The purpose of this paper is to encourage a national conversation about what it means to conduct ethically sound health research with prisoners given the current realities of the Canadian system. Lessons from the Canadian system could presumably apply in other jurisdictions.

MAIN TEXT

Any discussion regarding research ethics with Canadian prisoners must begin by first taking into account the disproportionate number of Indigenous prisoners (e.g., 22-25% of prisoners are Indigenous, while representing approximately 3% of the general Canadian population) and the high proportion of prisoners suffering from mental illnesses (e.g., 45% of males and 69% of female inmates required mental health interventions while in custody). The main ethical challenges that researchers must navigate are (a) the power imbalances between them, the correctional services staff, and the prisoners, and the effects this has on obtaining voluntary consent to research; and (b), the various challenges associated to protecting the privacy and confidentiality of study participants who are prisoners. In order to solve these challenges, a first step would be to develop clear and transparent processes for ethical health research, which ought to be informed by multiple stakeholders, including prisoners, the correctional services staff, and researchers themselves.

CONCLUSION

Stakeholder and community engagement ought to occur in Canada with regards to ethical health research with prisoners that should also include consultation with various parties, including prisoners, correctional services staff, and researchers. It is important that national and provincial research ethics organizations examine the sufficiency of existing research ethics guidance and, where there are gaps, to develop guidelines and help craft policy.

Unpacking the financial costs of "bariatric tourism" gone wrong: Who holds responsibility for costs to the Canadian health care system?

SUMMARY

Canadians are motivated to travel abroad for bariatric surgery owing to wait times for care and restrictions on access at home for various reasons. While such surgery abroad is typically paid for privately, if "bariatric tourists" experience complications or have other essential medical needs upon their return to Canada, these costs are borne by the publicly funded health system. In this commentary, we discuss why assigning responsibility for the costs of complications stemming from bariatric tourism is complicated and contextual.

Animal Study Registries: Results from a Stakeholder Analysis on Potential Strengths, Weaknesses, Facilitators, and Barriers

Publication bias in animal research, its extent, its predictors, and its potential countermeasures are increasingly discussed. Recent reports and conferences highlight the potential strengths of animal study registries (ASRs) in this regard. Others have warned that prospective registration of animal studies could diminish creativity, add administrative burdens, and complicate intellectual property issues in translational research. A literature review and 21 international key-informant interviews were conducted and thematically analyzed to develop a comprehensive matrix of main- and subcategories for potential ASR-related strengths, weaknesses, facilitators, and barriers (SWFBs). We identified 130 potential SWFBs. All stakeholder groups agreed that ASRs could in various ways improve the quality and refinement of animal studies while allowing their number to be reduced, as well as supporting meta-research on animal studies. However, all stakeholder groups also highlighted the potential for theft of ideas, higher administrative burdens, and reduced creativity and serendipity in animal studies. Much more detailed reasoning was captured in the interviews than is currently found in the literature, providing a comprehensive account of the issues and arguments around ASRs. All stakeholder groups highlighted compelling potential strengths of ASRs. Although substantial weaknesses and implementation barriers were highlighted as well, different governance measures might help to minimize or even eliminate their impact. Such measures might include confidentiality time frames for accessing prospectively registered protocols, harmonized reporting requirements across ASRs, ethics reviews, lab notebooks, and journal submissions. The comprehensive information gathered in this study could help to guide a more evidence-based debate and to design pilot tests for ASRs.

The manifold contributions over the last years on “publication bias” and “reproducibility crisis” in animal research initiated a debate on whether and how prospective animal study registries (ASRs) should be established in analogy to clinical trial registries. All recent debate, however, followed rather broad lines of argumentation and concluded that future decision-making on the issue of ASRs depends strongly on better knowledge about relevant characteristics of ASRs and about conflicting stakeholder interests. More qualitative but systematically developed evidence in this regard is needed. The primary objective of this study, therefore, was to present a systematically derived spectrum of all relevant strengths, weaknesses, facilitators and barriers (SWFBs) for ASRs. A systematic literature review and 21 key-informant interviews with experts from preclinical and clinical research, industry, and regulatory bodies were conducted to fulfill this objective. Our investigations resulted in a comprehensive and structured account of 130 issues and arguments around ASRs. Future debate and decision-making on ASRs might be heavily influenced by arguments and reasoning from individual experts and thus result in “eminence-based” policy making that relies on expert opinion. This study’s comprehensive spectrum of arguments and issues around ASR, developed through systematic and transparent methods, helps to balance the ongoing debate and thus facilitate a more evidence-based policy making.

Reciprocity and Ethical Tuberculosis Treatment and Control

This paper explores the notion of reciprocity in the context of active pulmonary and laryngeal tuberculosis (TB) treatment and related control policies and practices. We seek to do three things: First, we sketch the background to contemporary global TB care and suggest that poverty is a key feature when considering the treatment of TB patients. We use two examples from TB care to explore the role of reciprocity: isolation and the use of novel TB drugs. Second, we explore alternative means of justifying the use of reciprocity through appeal to different moral and political theoretical traditions (i.e., virtue ethics, deontology, and consequentialism). We suggest that each theory can be used to provide reasons to take reciprocity seriously as an independent moral concept, despite any other differences. Third, we explore general meanings and uses of the concept of reciprocity, with the primary intention of demonstrating that it cannot be simply reduced to other more frequently invoked moral concepts such as beneficence or justice. We argue that reciprocity can function as a mid-level principle in public health, and generally, captures a core social obligation arising once an individual or group is burdened as a result of acting for the benefit of others (even if they derive a benefit themselves). We conclude that while more needs to be explored in relation to the theoretical justification and application of reciprocity, sufficient arguments can be made for it to be taken more seriously as a key principle within public health ethics and bioethics more generally.

Ethics for pandemics beyond influenza: Ebola, drug-resistant tuberculosis, and anticipating future ethical challenges in pandemic preparedness and response

The unprecedented outbreak of Ebola virus disease (EVD) in West Africa has raised several novel ethical issues for global outbreak preparedness. It has also illustrated that familiar ethical issues in infectious disease management endure despite considerable efforts to understand and mitigate such issues in the wake of past outbreaks. To improve future global outbreak preparedness and response, we must examine these shortcomings and reflect upon the current state of ethical preparedness. To this end, we focus our efforts in this article on the examination of one substantial area: ethical guidance in pandemic plans. We argue that, due in part to their focus on considerations arising specifically in relation to pandemics of influenza origin, pandemic plans and their existing ethical guidance are ill-equipped to anticipate and facilitate the navigation of unique ethical challenges that may arise in other infectious disease pandemics. We proceed by outlining three reasons why this is so, and situate our analysis in the context of the EVD outbreak and the threat posed by drug-resistant tuberculosis: (1) different infectious diseases have distinct characteristics that challenge anticipated or existing modes of pandemic prevention, preparedness, response, and recovery, (2) clear, transparent, context-specific ethical reasoning and justification within current influenza pandemic plans are lacking, and (3) current plans neglect the context of how other significant pandemics may manifest. We conclude the article with several options for reflecting upon and ultimately addressing ethical issues that may emerge with different infectious disease pandemics.

Disadvantaging the disadvantaged: When public health policies and practices negatively affect marginalized populations

Public health is intimately related to social justice, which is why practice and research in the field seek to improve the social determinants of health. Despite the best intentions of those working in public health, however, some policies and practices inadvertently further disadvantage pre-existing marginalized populations. In this paper, we provide a diagnosis of possible reasons why this phenomenon might occur. We posit that the challenges associated with further marginalizing certain populations stem from a) not acknowledging the normative aspects of apparently objective data, b) a misunderstanding and an uncritical alignment of public health goals with the ethics theory of utilitarianism, and c) assuming that those working in public health might be able to fully understand the experiences of marginalized populations. It is our view that the trend of public consultation with marginalized persons, the explicit teaching of ethics and philosophy of science in graduate departments of public health, and the increased use of health equity impact assessments might help protect against public health policies and practices that disadvantage marginalized populations.

Endothelial analysis in patients having corneal intrastromal surgery with Cornealring for correction of Keratoconus

PURPOSE

Evaluate corneal endothelium by means of specular microscopy exam in patients with Keratoconus, before and after Cornealring® corneal intrastromal ring surgery.

METHODS

One hundred and two eyes of 67 patients, aged between 12 and 45, with the average age of 27.31 ± 8.15 years, 30 females and 37 males, were selected to be submitted to the implant of Cornealring® corneal ring segments in pre- and post-surgery (six months after the procedure) in the External Diseases and Cornea Ward of the Instituto Panamericano da Visão.

RESULTS

Of the 102 eyes treated, only those that received two rings of equal thickness up to 250 µ showed statistical significance between the initial and final mean number of endothelial cells (P = 0.008), a decrease of 10.1% in the mean coefficient of variation (P = 0.003), and a 9.75% decrease in initial and final hexagonal cell counts. The other eyes receiving rings of other thicknesses showed no statistically significant differences between the mean initial and final SM examinations.

CONCLUSION

A longer segment is necessary for the confirmation or not of the alterations found in this study, particularly regarding the thickness of the ring used, because with the new technologies and the improvement in the result of deep lamellar transplantation, the decrease in the cell count might represent a problem in the indication of this procedure following thick corneal ring implants.

Gymnotus capanema, a new species of electric knife fish (Gymnotiformes, Gymnotidae) from eastern Amazonia, with comments on an unusual karyotype

Gymnotus capanema n. sp. is described on the basis of cytogenetic, morphometric, meristic and osteological data from nine specimens (one male and eight females) from the municipality of Capanema, Pará, in the eastern Amazon of Brazil. Later, three additional specimens were found in museums and regarded as nontypes (not cytogenetically analysed). Gymnotus capanema, which occurs in sympatry with Gymnotus cf. carapo cytotype 2n = 42 (30m/sm + 12st/a) exhibits a novel karyotype for the genus, with 2n = 34 (20m/sm + 14st/a). Gymnotus capanema can be unambiguously diagnosed from all congeners on the basis of a combination of characters from external anatomy, pigmentation and osteology. The constitutive heterochromatin, rich in adenine-thymine (A-T) base pairs [4',6 diamidino-2-phenylindole dihydrochloride (DAPI) positive], occurs in the centromeric region of all of the chromosomes, and in the pericentromeric and the entire short arm of some chromosomes. The nucleolar organizing region (NOR), stained by silver nitrate, chromomycin A(3) (CMA(3)) and 18S ribosomal (r)DNA fluorescence in situ hybridization (FISH), occurs in the short arm of pair 15. FISH, with telomeric probes did not show interstitial telomeric sequences (ITS), despite the reduced 2n in comparison to the karyotypes of other species of Gymnotus. The karyotype of G. capanema, with a reduced 2n, is strikingly different from all other previously studied congeners.

Priority setting of ICU resources in an influenza pandemic: a qualitative study of the Canadian public's perspectives

BACKGROUND

Pandemic influenza may exacerbate existing scarcity of life-saving medical resources. As a result, decision-makers may be faced with making tough choices about who will receive care and who will have to wait or go without. Although previous studies have explored ethical issues in priority setting from the perspective of clinicians and policymakers, there has been little investigation into how the public views priority setting during a pandemic influenza, in particular related to intensive care resources.

METHODS

To bridge this gap, we conducted three public town hall meetings across Canada to explore Canadian's perspectives on this ethical challenge. Town hall discussions group discussions were digitally recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Six interrelated themes emerged from the town hall discussions related to: ethical and empirical starting points for deliberation; criteria for setting priorities; pre-crisis planning; in-crisis decision-making; the need for public deliberation and input; and participants' deliberative struggle with the ethical issues.

CONCLUSIONS

Our findings underscore the importance of public consultation in pandemic planning for sustaining public trust in a public health emergency. Participants appreciated the empirical and ethical uncertainty of decision-making in an influenza pandemic and demonstrated nuanced ethical reasoning about priority setting of intensive care resources in an influenza pandemic. Policymakers may benefit from a better understanding the public's empirical and ethical 'starting points' in developing effective pandemic plans.