<p> The US wields the most powerful military in the history of the world, and deploys military personnel throughout the globe to fight, kill and die in atoned conflict. US veterans number around 22.5 million or about 14% of the US population. Some veterans, troubled by violence, enroll in the Veterans Health Administration (VHA) and receive care from mental health providers who have developed, through their particular framework, the medical constructs of post-traumatic stress disorder (PTSD) and moral injury (MI) to diagnose and/or "treat" these veterans as "patients." The PTSD construct casts veterans as "patients with a disorder," minimizes legitimate moral pain, and enables the US public to avoid the work of reckoning with harmful consequences of US military action for which they hold ultimate responsibility. MI, a more recent and fluid construct, occurs at the intersection of religion and violence and thus invites the contribution of chaplains. A focused MI group for combat veterans within the VHA co-facilitated by a chaplain and psychologist provides veterans the opportunity for <i>frame breaking</i> and <i> reframing</i> and holds the possibility of systemic change in a response grounded not in individual therapy or treatment but rather in shared spiritual and moral community. A public ceremony with ritual and spiritual discipline creates sanctuary for veterans to provide <i>adaptive leadership</i>, as they transform themselves from patient to prophet, bearing witness to unsanitized and inglorious truths while the US public listens and wrestles with issues of culpability, obligation, and moral responsibility. The outcome is post-traumatic growth and spiritual development&mdash;indicated by greater moral engagement, awareness, forgiveness, and compassion. Such adaptive change may lead to increased resistance to militarism and greater reverence for all life on this fragile earth.</p><p>

no / This comment on Professor Fotaki's Editorial agrees with her arguments that training health professionals in more compassionate, caring and ethically sound care will have little value unless the system in which they work changes. It argues that for system change to occur, senior management, government members and civil servants themselves need training so that they learn to understand the effects that their policies have on health professionals. It argues that these people are complicit in the delivery of unethical care, because they impose requirements that contradict health professionals' desire to deliver compassionate and ethical forms of care.

Background and aim: Lung cancer is the leading cause of cancer incidence and mortality in Canada. Population-based screening programs using low dose computed tomography are being more widely used. Screening reduces lung cancer mortality. It also introduces potential ethical issues that need to be elucidated to inform the ethical, equitable, and effective implementation of screening programs. This aim of this research was to begin developing an understanding of what the ethical issues are and how they are being, and should be, approached in health policy. Methods: Using empirical ethics inquiry, this research produced descriptive evidence via three independent studies: a systematic literature review and mixed methods integrative synthesis of public perspectives on screening benefits and harms, and two qualitative description studies about public and key informants’ ethical and social values on ethical issues in screening. Results: The major finding of this research was the preponderance of ethical issues located within health and social systems and structures, including equity of screening access, stigma against people who currently smoke commercial tobacco, commercialization of tobacco, and the need for increased investment in primary prevention of lung cancer. These ethical issues reflect the social, economic, and political determinants of lung cancer and the means available to reduce the burden of lung cancer in Canada, including but not limited to screening. In health policy, there was a lack of ethical frameworks or principles currently being used to address these ethical issues and the sometimes-conflicting perspectives found between the public and key informants. Discussion: Future empirical and normative research is needed to understand ethical and social values related to screening by populations with high lung cancer incidence and mortality, and to integrate empirical evidence with appropriate ethical theories to make recommendations for ethical, equitable, and effective population-based LDCT lung cancer screening policy in Canada. / Thesis / Candidate in Philosophy / Lung cancer is the top cause of cancer in Canada. An estimated 30,000 people were diagnosed with lung cancer and 20,700 people died from lung cancer in 2022. Screening is being more widely used to find and treat lung cancer in earlier stages. There are some ethical questions to consider, like how to ensure that screening programs are fair and effective. This research focused on understanding what the ethical issues are and how they could be solved in health policy. Perspectives on ethical issues were collected and analyzed from the public and lung cancer screening leaders. The two major ethical issues were fair access to screening and stigma against people who currently smoke commercial tobacco. There was a lack of ethical guidance to address these issues in health policy. Ethical concepts about justice and individual choice, and ethics research with key communities, may help navigate ethical issues in health policy.

Thesis (DPhil (Philosophy))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: This dissertation has two quite separate and rather different starting points. The first centres on the significant renaissance of virtue ethics as a moral theory that has occurred in the last 50 years. The second starting point is embedded in the recent discourse about the need for an ethical framework for public-health policymaking. (Up until now the ethical theories of deontology, manifested as either a ‘principlebased’ or ‘human-rights’ approach, and utilitarianism, have provided the theoretical background to this discourse.) When these two starting points fuse, the question arising – can character or virtue ethics contribute positively to the moral debates surrounding many vexing public-health issues? – seeks an answer. Broadly speaking, the ethics of public-health policymaking deals with ethical issues that occur within the macro-environment and that arise out of relationships between entities other than individuals, for example, states, regions, institutions, etcetera, and the policies in terms of which these interactions are regulated. Public health ethics ‘seeks to find a balance between the notions of ‘common good’ or ‘public interest’ and individual autonomy. I plan to investigate whether a virtue-based ethics, -which is concerned with a notion of human flourishing that is not primarily atomistic but intricately linked to the mutual well being of others and to notions of what the ‘good life for man’ means within the context of a shared history and connectedness with fellow human beings,- could contribute positively to current ‘public health ethics’ discourse. I believe that an exploration of the ethical basis of public health decision-making, focusing particularly on virtue ethics, but also examining other approaches like utilitarianism, principlebased approaches and the human-rights approach, will make a positive and original contribution to this area of philosophical discourse. Chapter one is an introduction which provides the rationale and motivation for the dissertation and briefly introduces the layout of each subsequent chapter. Chapter two is a concept analysis of ‘public health’ and justifies why I argue that the concept of public health is contingent, and ought to be contingent on an inextricably linked, and context appropriate concept of social justice. In this chapter I clarify the scope of the concept of public health used for this dissertation. Chapter three is an in-depth literature review of virtue ethics and similarly the next chapter is a literature review of the current status of public health ethics. Chapter five is entitled “Virtue Ethics, Social Justice and Public health”. My overall aim in this dissertation is to consider if virtue ethics as a moral theory can contribute positively to the practice of public health and thus by inference to an underlying concept of social justice. This receives in-depth consideration in this chapter. In chapter six I explore virtue theory in relation to public health from various other perspectives. In particular I return to MacIntyre to consider his concept of a ‘practice’1 which I apply specifically to the domain of public health, exploring the concepts of “extrinsic goods” and “intrinsic goods”, and how they translate to the practice of public health. Chapter VII is entitled “Theory and Practice: Critical Perspectives”. In this chapter I explore the challenges of adapting philosophical theory to actual context. I focus particularly on the problems of public health policy within a Southern African context. I conclude this dissertation by conceding that while virtue ethics can indeed make a positive contribution in some respects, its applicability is largely limited to public health problems that pertain to specific localised contexts. It has very limited applicability as an ethical theory or framework for trans-global public health issues, and public health issues influenced by global politics and economics. / AFRIKAANSE OPSOMMING: Hierdie verhandeling het twee heeltemal afsonderlike en taamlik uiteenlopende uitgangspunte. Die eerste handel oor die beduidende oplewing in deugde-etiek as 'n morele teorie oor die afgelope 50 jaar. Die tweede uitgangspunt is veranker in die onlangse diskoers oor die behoefte aan 'n etiese raamwerk vir die bepaling van openbaregesondheidsbeleid. (Tot dusver het die etiese teoriee van deontologie, hetsy in die vorm van . 'beginselgegronde' of 'menseregte'-benadering, en utilitarisme as teoretiese grondslag vir hierdie diskoers gedien.) Wanneer hierdie twee uitgangspunte egter byeenkom, ontstaan die vraag: Kan karakter- of deugdeetiek 'n positiewe bydrae tot die morele debatte oor talle netelige openbaregesondheidskwessies lewer? Oor die algemeen handel etiek in die bepaling van openbaregesondheidsbeleid oor etiese kwessies in die makro-omgewing wat ontstaan vanuit die wisselwerking tussen entiteite anders as individue, soos state, streke en instellings, en die beleid wat hierdie wisselwerking reguleer. Openbaregesondheidsetiek is daarop uit om 'n balans te vind tussen die konsepte 'algemene welsyn' of 'openbare belang', en individuele outonomie. Hierdie ondersoek beoog om vas te stel of 'n deugdegegronde etiek 'n wat gemoeid is met 'n konsep van menslike welstand wat nie grootliks atomisties is nie, maar ten nouste verband hou met die onderlinge welstand van ander, en 'n begrip van 'die goeie lewe' in die konteks van 'n gedeelde geskiedenis en verbondenheid met ander mense 'n positief tot die huidige diskoers oor 'openbaregesondheidsetiek' kan bydra. Die navorser argumenteer dat 'n ondersoek van die etiese grondslag van besluitneming oor openbare gesondheid, met 'n bepaalde klem op deugde-etiek, dog ook 'n nuwe bydrae tot ander benaderings soos 'n utilitaristiese benadering, beginselgegronde benaderings en die menseregtebenadering, 'n positiewe en oorspronklike bydrae tot hierdie filosofiese diskoers (kan) lewer. Hoofstuk 1 bied 'n inleiding wat die beweegrede en motivering vir die verhandeling uiteensit, en verduidelik kortliks die uitleg van elke daaropvolgende hoofstuk. Hoofstuk 2 is 'n konseptuele ontleding van 'openbare gesondheid', en ondersteun die navorser se betoog dat die konsep van openbare gesondheid afhanklik is en afhanklik behoort te wees van . kontekstoepaslike begrip van sosiale geregtigheid wat onlosmaaklik daarmee verbind is. In hierdie hoofstuk word die betekenis en omvang van die begrip 'openbare gesondheid' soos dit in hierdie verhandeling gebruik word, ook verduidelik. Hoofstuk 3 bevat 'n omvattende literatuuroorsig van deugde-etiek, terwyl die daaropvolgende hoofstuk eweneens 'n literatuuroorsig van die huidige stand van openbaregesondheidsetiek behels. Hoofstuk 5 is getiteld 'Deugde-etiek, sosiale geregtigheid en openbare gesondheid'. Die oorkoepelende doelwit van hierdie verhandeling is om daaroor te besin of deugde-etiek as 'n morele teorie positief tot die praktyk van openbare gesondheid, en dus ook tot 'n onderliggende konsep van maatskaplike geregtigheid, kan bydra. Dit word omvattend in hierdie hoofstuk bespreek. In hoofstuk 6 ondersoek die navorser deugde-teorie met betrekking tot openbare gesondheid uit verskeie ander oogpunte. Die studie konsentreer in besonder op MacIntyre se konsep van . 'praktyk',2 wat bepaald op die gebied van openbare gesondheid toegepas word om so die begrippe 'ekstrinsieke goedere' en 'intrinsieke goedere', en hoe dit in die praktyk van openbare gesondheid omgesit word, te bestudeer. Hoofstuk 7, getiteld 'Teorie en praktyk: Kritiese perspektiewe', bevat . ondersoek van die uitdagings om filosofiese teorie by die werklike konteks aan te pas. Die navorser konsentreer veral op die probleme van openbaregesondheidsbeleid in Suider-Afrikaanse verband. Die verhandeling sluit af deur toe te gee dat, hoewel deugde-etiek inderdaad in sommige opsigte 'n positiewe bydrae kan lewer, die toepaslikheid daarvan grootliks tot openbaregesondheidsprobleme in bepaalde gelokaliseerde kontekste beperk is. Dit het 'n uiters beperkte nut as 'n etiek-teorie of raamwerk vir globale openbaregesondheidskwessies, en openbaregesondheidskwessies wat deur die wereldpolitiek en -ekonomie geraak word.

This dissertation explores tensions between individual freedom and institutional authority. Chapter one examines public perceptions of the legitimacy of "new frontier" public health measures. I present results from a national survey of 1,817 adults concerning the acceptability of public health interventions for noncommunicable diseases. We found that support for these interventions is high overall; strongly associated with race and political orientation; and tied to perceptions of democratic representation in policy making. There was much support for strategies that enable people to exercise healthful choices, but considerably less for more coercive measures. These findings suggest that the least coercive path will be the smoothest. Additionally, the findings underscore the need for policy makers to involve the public in decision making, understand the public's values, and communicate how policy decisions reflect this understanding.

Introduction: Forty years ago the life saving and life prolonging therapy of dialysis was rationed. It was extremely unlikely that people aged over 50 years would be offered treatment. Today, those aged over 65 years are becoming the fastest growing group of patients on dialysis. Changing population demographics and referral patterns, the opening up of eligibility for dialysis to high risk individuals, refinement and developments in dialysis technology and its ‘success’ in keeping more patients alive for longer periods, along with rising public expectation, are just some of the reasons behind this change in the age profile of those being currently treated for kidney failure. Older people are likely to have multiple co-morbidities and decreased functional status that may complicate their decision-making about dialysis and limit their treatment options. / Enhancing choice and involvement in treatment decision-making to the patient’s satisfaction is a central theme of health care ethics. Current national and international ethical guidelines about the initiation of dialysis recommend shared or joint decision-making and discuss patient ‘benefit’ and patient ‘need’. This project sought to determine how these recommendations, and other ethical issues related to informed consent, possible withdrawal of treatment and quality of life, were embodied in the personal experiences of a group of older people facing dialysis decisions. / Aim: The general aim of this research was to follow the dialysis decision-making process over time amongst a group of people aged 65 years and older. More specifically, this research sought to explore with the participants the following issues: what factors impacted on their dialysis decision-making; how they understood both what was happening to them and the goals of treatment; their preferences for information seeking; how they perceived any future decision-making; how or whether the commencement and experience of dialysis influenced their decision-making; and once treatment had been initiated, how they felt about their initial decisions. / Method: A predominantly longitudinal qualitative study was undertaken. Meetings were conducted prior to the potential initiation of dialysis with 21 participants. These meetings involved a semi-structured interview and the administration of three questionnaires focusing on preferences for decision-making, information seeking and quality of life. Data was also collected from the participants’ health records. For those participants who commenced dialysis a further two meetings were undertaken one month and then six months after treatment was instigated. The qualitative data was analysed thematically using concepts that had either been pre-determined and explored within the interviews or, had emerged from the participants’ stories. / Findings: Findings from this study include: participants not feeling that they had a choice about dialysis; a mismatch between theoretical expectations of informed consent and shared decision-making and the ‘actor centred experiential’ model of decision-making adopted by participants; a need to re-evaluate the balance and relationships between physiological measures of effectiveness emphasised by health professionals, and psychosocial and functional markers valued by participants; and treatment goals not being individually negotiated. / Conclusion: An interest in remaining alive was the driving force behind why participants chose to have dialysis. Other factors impacting on decisions about dialysis were multi-faceted and were based on priorities other than what health professionals consider important. Shared decision-making, as described in the literature, is not unproblematic. However, health professionals need to accept the underlying premises on which shared decision-making is based so that they can find out what expectations patients have of treatment, beyond that of saving life. Such expectations need to be discussed with patients and the various treatment options need to be negotiated in an attempt to achieve patients’ goals. Patients should be encouraged however to be involved in decision-making to the extent to which they desire.

The 2003 Severe Acute Respiratory Syndrome (SARS) outbreak in Canada highlights a broad range in ethical challenges, particularly in priority setting. Presently, a leading theory in ethical priority setting is Daniels’ and Sabin’s Accountability for Reasonableness (A4R), which enhances fair and legitimate procedural decision making in typical healthcare settings. A4R attempts to mitigate conflicting interests and facilitate fairness in deliberations over priority setting issues. Whether this framework may be applied to public health emergencies has yet to be examined. This qualitative study describes the outbreak through the lens of A4R and explores the applicability of A4R in atypical or emergent circumstances. Findings from 25 structured key informant interviews of public health officials suggest refinements to the framework may be required for emergency events. The presence of such a framework may minimize collateral damage during and after a response. The lessons may guide future preparedness efforts such as pandemic planning.

The 2003 Severe Acute Respiratory Syndrome (SARS) outbreak in Canada highlights a broad range in ethical challenges, particularly in priority setting. Presently, a leading theory in ethical priority setting is Daniels’ and Sabin’s Accountability for Reasonableness (A4R), which enhances fair and legitimate procedural decision making in typical healthcare settings. A4R attempts to mitigate conflicting interests and facilitate fairness in deliberations over priority setting issues. Whether this framework may be applied to public health emergencies has yet to be examined. This qualitative study describes the outbreak through the lens of A4R and explores the applicability of A4R in atypical or emergent circumstances. Findings from 25 structured key informant interviews of public health officials suggest refinements to the framework may be required for emergency events. The presence of such a framework may minimize collateral damage during and after a response. The lessons may guide future preparedness efforts such as pandemic planning.

Ce mémoire de maîtrise tente de répondre à la question suivante : quelle est la valeur de l’autonomie dans le domaine de la recherche biomédicale, et plus particulièrement dans le contexte des biobanques? Pour éclairer cette question, nous étudierons le concept d’autonomie dans deux domaines d’éthique appliquée : l’éthique de la recherche et l’éthique de la santé publique. Depuis la deuxième moitié du XXe siècle, le respect de l’autonomie individuelle est un principe programmatique de l’éthique de la recherche. Or, sa conceptualisation a été accusée d’être trop individualiste pour répondre aux enjeux qui caractérisent la recherche en santé d’aujourd’hui. En éthique de la santé publique, au contraire, l’autonomie individuelle prend une place moins prépondérante et fait droit à des dimensions sociopolitiques de l’autonomie qui ont été négligées par le domaine de l’éthique de la recherche. Ces dimensions mettent en lumière le rôle des institutions dans la promotion de l’autonomie tout comme l’importance pour les individus d’avoir la possibilité de participer à l’élaboration des politiques de santé qui les concernent pour réaliser leur autonomie. Le cas de la recherche en contexte de biobanques sera l’occasion d’appliquer ces différentes conceptualisations de l’autonomie à un domaine de recherche en pleine expansion qui se situe au carrefour de l’éthique de la recherche et de l’éthique de la santé publique. / This master's thesis attempts to answer the following question: what is the value of autonomy in biomedical research, and more particularly in the context of biobanks? To answer this question, we will study the concept of autonomy in two areas of applied ethics: research ethics and public health ethics. Since the second half of the 20th century, respect for individual autonomy has been a programmatic principle of research ethics. However, many authors consider this conceptualization to be too individualistic to respond to the challenges that characterize health research today. In public health ethics, on the contrary, individual autonomy takes a less preponderant role and acknowledges some socio-political dimensions of autonomy that have been neglected by the field of research ethics. These dimensions highlight the role of institutions in promoting autonomy as well as the need for individuals to have the opportunity to participate in the development of health policies in order to achieve their autonomy. Finally, the case study of biobanks will provide an opportunity to apply these different conceptualizations of autonomy to a rapidly expanding field of research located at the crossroads between research ethics and public health.

Mini-thesis submitted in partial fulfilment of the requirements for the degree Master of Technology: Public Management in the Faculty of Business at the Cape Peninsula University of Technology 2014 / Maternity service in South Africa faces particular problems in the provision of care to birthing mothers. Violence and abuse have been reported and maternity death rates are high, being related to inadequate provision of care (Myburgh, 2007:29). Ethical conduct plays a significant role in service delivery in Midwife Obstetrics Units (MOU) in general. This is of particular importance since every patient, especially pregnant women, should to be handled with the utmost care, respect and dignity. The research problem emanates from nurses’ behaviour towards patients in MOU labour wards, where women continue to be victims of abuse. Ironically, it is regrettable that they are abused by those who are supposed to be their advocates. The objectives of the study were to assess if nurses in MOU labour wards conduct themselves ethically when dealing with patients, to determine the perceptions of patients towards nurses during child birth stages, as well as to examine factors in maternity wards that may influence a nurse’s performance when dealing with patients. The study adopted the quantitative research method to answer the research question and data interpretation was based on statistical analysis. This method was deemed to be the most effective for collection of a large quantity of data and numerical (quantifiable) data is considered objective. A Likert-type questionnaire comprising closed-ended questions was the measurement instrument. This was considered to least inconvenience nurses and postnatal patients to whom these questionnaires were administered. Answer choices were graded from 1 to 4, being strongly agree, agree, disagree and strongly disagree. The population comprised nurses and postnatal patients in MOUs in the Western Cape, South Africa. Consecutive sampling was conducted in two selected MOUs, being Michael Mapongwana (MM) and Gugulethu (GG), with 311 questionnaires being distributed to both nurses and postnatal Patients in these two facilities. The findings indicated that the ethical conduct of nurses in both MM and GG maternity wards was relatively good. However, some survey findings revealed some unsatisfactory gaps that exist in what both hospitals currently offer to patients in the areas of individual patient care, communication and baby security certainty. Furthermore, the findings indicated that a significant number of patients who chose to make use of MM and GG hospitals, are satisfied with the standard of service received during their stay. However, there were some discrepancies in terms of senior management service where excellence in the monitoring role emerged as being lacking. There is a need for improvement in the current levels of ethical conduct of nurses in both the MM and GG labour wards. These needs for improvement relate to working conditions, especially linked to the human resource (HR) function, leadership and management functions, and improved monitoring and control mechanisms.