How should ethics be incorporated into public health policy and practice?

Carl H Coleman^a, Marie-Charlotte Bouësseau^b, Andreas Reis^b, Alexander M Capron^c

The ethical obligations of those who work for health are as old as the health professions themselves; indeed, the commitment to place the interests of clients above all else is one of the hallmarks of professionalism. Ethical prescriptions are found in many cultures, such as the oath and associated writings of Hippocrates in ancient Greece and the writings of the medieval Jewish philosopher Maimonides. Though originating with the professions, ethical duties are of concern to society in general, and their violation – as by the doctors who conducted experiments in the Nazi prison camps – can constitute human rights as well as ethical violations.

In response to the tremendous expansion of the powers of medicine and biomedical science in the 20th century, the new field of bioethics emerged in the 1960s, first in North America and western Europe and eventually around the world. With contributions not only from moral philosophers but also from physicians, nurses and other health professionals, social and natural scientists and lawyers, bioethics has become a field of major concern. Health professionals, health authorities and the public debate the issues raised by organ and tissue transplantation, unequal access to life-saving medicines, new reproductive technologies and vast increases in the numbers and types of clinical trials.

While abundant analysis and official guidelines have been produced on most of the ethical issues in health care and research, until recently the field of public health received relatively little attention among ethicists. Similarly, while ethical questions have always been an implicit part of public health practice, the idea of incorporating a formal process of ethical deliberation into public health policy-making remains relatively new. As the ethics of public health receives greater attention, new paradigms and methods of ethical analysis will have to be developed. In particular, whereas medical ethics has traditionally aimed to protect individual interests in the context of the physician–patient relationship, public health ethics focuses on the design and implementation of measures to monitor and improve the health of broader populations. In addition, public health ethics must look beyond health care per se to consider the structural conditions, and social and economic determinants that promote or inhibit the development of healthy societies.

Incorporating ethical analysis into public health raises many challenging questions. For example, what does ethical analysis add to public health beyond legal or public policy analysis? Is the law itself subject to a process of ongoing ethical scrutiny? When ethicists appeal to “values”, who gets to decide which values are worthy of protection or how these values should be prioritized in cases of conflict? How should ethical analysis address the tension between universal principles and culturally specific values, and find common ground among individuals from diverse cultural backgrounds? Such questions have practical implications for how public health policies are designed, implemented and evaluated. For example, when public health authorities make decisions about allocating limited resources, they will implicitly or explicitly determine which principles and values underlie those decisions. Such decisions also vary according to the processes by which they are made and to what extent the public, nongovernmental and international organizations, and national or regional governments participate in these processes.

A Bulletin theme issue, to be published in August 2008, will provide a forum for examining these and related issues. The goal of this theme issue is to explore how ethical considerations have been and should be incorporated into decision-making about public health issues. The Bulletin encourages the submission of papers covering practical examples that illustrate how ethical questions have been addressed at the domestic and international levels. For example, how have governments or professional associations used ethical analysis to evaluate health-care workers’ obligations during influenza pandemics? What does ethics have to say about the use of financial incentives to increase the supply of organs for transplantation? In general, we seek to publish specific examples of structures and processes that have been used for ethical deliberation, combined with a candid examination of these options’ advantages and drawbacks. Contributions from authors from developing countries are particularly welcome.

It is hoped that the papers in this issue will help national policy-makers reflect on the need to consider ethics in formulating and implementing health policies, while also providing best practices that can be adapted to specific national contexts. The issue will provide a forum for units at WHO headquarters and regional offices that have engaged in ethical analysis of their programmes to share their work. Finally, the empirical basis of the papers will provide much-needed data about global efforts to address ethical issues and the impact these efforts are having on the health of populations.

The deadline for submissions is 11 January 2008. All submissions will go through the Bulletin’s peer review process. ■

Τέλος Εξεταστικής

..................................................όχι άλλη Amelie....!! καλό καλοκαίρι σε όλους..

WORLD'S HIGHEST MOBILE CALL

British man makes history with Mount Everest callA British climber has set a world record by making the first mobile telephone call from the top of Mount Everest.

Rod Baber made the historic call at 5.37 local time (1.37 BST) on Monday 21st May 2007, saying "It's cold, it's fantastic, the Himalayas are everywhere." He also sent a text message from the summit.

The world's highest peak now receives mobile phone coverage thanks to a phone mast installed by China Telecom at the base camp in Rongbuk. Although the phone used to make this first call was not modified in any way, Mr Baber had to carry the battery within his clothes to keep it warm enough to function in the -30º temperatures.

The development in technology has been welcomed by many involved in such extreme outdoor pursuits. The president of Nepal's Mountaineering Association, Ang Tsering Sherpa, said, "It's good news because communications are essential in the mountains where climbers face huge risks. The mobile coverage could help in rescue operations." Mr Baber also expressed his appreciation of having a mobile phone on such expeditions, and spoke of "the added confidence and peace of mind to know that friends, family and even help were just a phone call away."

The call is one of several stunts being carried out in the current Everest climbing season. Last week saw Bear Grylls, a former British soldier, make the first flight over the summit using a powered paraglider. Forthccming high altitude stunts include Wim "Iceman" Hof, a Dutchman who claims to have a special ability to withstand the cold, attempt to reach the top of the peak wearing just shorts, boots, gloves and a cap.

This year 550 people are expected to reach the summit of Mount Everest during the climbing season.

This article differs but finally doctors interests are wider than people believes.

Πράσινο φως στην Ελβετία για το πρώτο εμβόλιο κατά του καρκίνου στον εγκέφαλο

Λονδίνο
Το αμερικανικό εργαστήριο Northwest Biotherapeutics ανακοίνωσε ότι έλαβε άδεια να διαθέσει στην ελβετική αγορά το πρώτο θεραπευτικό εμβόλιο κατά του καρκίνου του εγκεφάλου.

Το εμβόλιο DCVax-Brain, που παρασκευάζεται στις ΗΠΑ, έλαβε το πράσινο φως από το ελβετικό ινστιτούτο δημόσιας υγείας και αναμένεται να είναι διαθέσιμο για τους ασθενείς γύρω στον Σεπτέμβριο.

Η είδηση ανακοινώθηκε από το Χρηματιστήριο του Λονδίνου, όπου είναι καταχωρημένη η εταιρεία.

«Είμαστε πολύ ικανοποιημένοι που είμαστε η πρώτη εταιρεία η οποία εισάγει στην αγορά ένα θεραπευτικό εμβόλιο για τον καρκίνο του εγκεφάλου, για τον οποίο οι πιθανότητες επιβίωσης είναι πολύ μικρές», δήλωσε ο Αλτον Μπόιντον, διευθυντής της αμερικανικής φαρμακοβιομηχανίας.

Το εμβόλιο είναι σχεδιασμένο να αναγκάζει το ανοσοποιητικό σύστημα να αναγνωρίζει τους όγκους και να τους επιτίθεται. Σύμφωνα με τα αποτελέσματα των μέχρι τώρα κλινικών μελετών, αυξάνει από τους 6,9 στους 18,1 μήνες το διάστημα μέχρι την επανεμφάνιση της νόσου και παρατείνει τη μέση διάρκεια επιβίωσης από τους 14,6 στους 33 μήνες.

Η Northwest Biotherapeutics σκοπεύει να υποβάλει προς έγκριση το φάκελο του εμβολίου στις Ηνωμένες Πολιτείες και την Ευρώπη στις αρχές του 2009, ανάλογα με την πρόοδο της φάσης ΙΙ των κλινινών που πραγματοποιούνται σε Αμερικανούς ασθενείς.

Το DCVax-Brain έχει ήδη καταχωρηθεί στην Ευρώπη και στις Ηνωμένες Πολιτείες ως «ορφανό» προϊόν, καθώς προορίζεται για περιορισμένο αριθμό ασθενών. Το καθεστώς θα του εξασφαλίσει για πολλά χρόνια την αποκλειστικότητα στις αγορές όπου έχει λάβει άδεια κυκλοφορίας.

Σύμφωνα με τις δοκιμές που πραγματοποιήθηκαν από την Northwest Biotherapeutics σε ασθενείς που έχουν πρόσφατα διαγνωσθεί,

,με πληροφορίες από ΑΠΕ/Γαλλικό

Have scientists found a way to read your mind?

Many of who saw the movie "Minority Report" experienced two distinct reactions: first, "Please, this is pure science fiction" and then, "There but for the grace of God..." Really, how many of us have not fantasized at least once about what we would do if we ever came upon that guy who stole our car? And maybe on a trip to Best Buy, you imagined for a second what it would be like to just pick up that 60-inch DLP out-of-the-box set, hoist it on your back and walk out of the store. Would you get tackled by a salesperson?
But these are just passing thoughts, even the stuff of jokes. They're not actually plans, right? The distinction between the two is just a part of the ethical debate surrounding a study published in the journal Current Biology in February 2007, which reports the findings of an experiment on reading people's intentions. The study, led by John-Dylan Haynes of the Max Planck Institute for Human Cognitive Brain Sciences in Germany, shows that through brain scans and corresponding computer software designed to correlate specific brain activity with specific thoughts, researchers are able to read people's intentions with great accuracy.
The study used functional MRI (fMRI) to monitor subjects' brain activity while they formed and held an intention. The researchers told each subject that they were about to see a set of two numbers, and they should decide beforehand what they wanted to do with those numbers -- either add them or subtract them. There was a several-second delay during which the subjects were supposed to focus on this intention. By clearly separating the intentions from the numbers themselves and the subsequent mathematical action, the researchers sought to isolate the brain activity association with the intended action ("I'm going to add it" or "I'm going to subtract it") from any brain stimulation resulting from the numbers and the calculations.
The brain scans were one part of the study; the other part went on behind the scenes. The researchers had to decide which types of brain activity would indicate which intention in order to establish a computer algorithm that would read the fMRI results. The software incorporates a high degree of complexity. Brain patterns are not necessarily localized; sometimes, in order to fully grasp what's happening, you need to be able to interpret patterns from different parts of the brain simultaneously. Technological innovation plays a large part in what appears to be a successful attempt to read people's minds.
Using a combination of the brain scans and the computer software, researchers were able to "guess" whether the subject intended to add or subtract the upcoming numbers with 70 percent accuracy -- not a bad success rate for mind reading. Activity patterns in the middle of the prefrontal cortex were different depending on whether the subject intended to add or intended to subtract. The researchers essentially looked around the brain and decided, based on all of the activity they were seeing and especially the patterns of stimulation in the prefrontal cortex, whether the brain was preparing to add or subtract.
The study also proved some fascinating hypotheses set forth in other experiments that will no doubt lead to some very speedy progress in the area of mind reading via brain scan:
Freely chosen intentions are stored in the prefrontal cortex.
Intentions based on external orders are stored in a different part of the brain than those based on internal choice. Intentions based on "following orders" live on the surface of the brain, not deep in the gray matter.
When intentions are acted upon, the neural activity moves to a slightly different part of the brain, meaning the brain essentially "copies" the intention and transfers it in order to convert it into action. The next step in the research is to build on these results to create a sort of mind-reading database of intentions. If scientists can accurately pinpoint the brain activity signaling particular intentions -- such as violent or criminal intentions, the intention to lie, or the intention to read or speak a specific word or move a limb in a certain way, the uses of this process are endless. This is where the ethical debate comes in.
Advances in mind reading can lead to better brain-activated wheelchairs, computers and artificial limbs. A person without the use of his hands could think, "I plan to go to check my e-mail," and a computer could open up that person's inbox. But on the darker side, while the current state of the art is very rudimentary, mind-reading technology could ultimately be used to stop a crime before it's even committed, with the government implanting everyone with chips that alert the authorities if a person's brain stores the intention to break the law. But what if that intention is just a passing thought? Some scientists fear this new technology will be put to use before all the kinks are ironed out, and many have called on the scientific community to hold an international discussion on the ethical implications of mind reading.

Sources
"Revealing Secret Intentions in the Brain." Press Release. Max Planck Society. Feb. 8, 2007.http://www.mpg.de/english/illustrationsDocumentation/documentation/pressReleases/2007/pressRelease20070206/index.html
Sample, Ian. "The brain scan that can read people's intentions." GuardianUnlimited. Feb. 9, 2007.http://www.guardian.co.uk/science/story/0,,2009217,00.html

DNA REVEALS DISEASE

Analysis of the DNA of 17,000 volunteers found genetic variations between people suffering from depression, Crohn’s disease, coronary heart disease, hypertension, rheumatoid arthritis and certain types of diabetes.The team of 200 scientists from the Wellcome Trust used ‘gene chips’ (tagged sequences of DNA) to identify the genetic differences across the entire genome. Many of the genes identified were found in parts of the genome not previously associated with disease. Future screening may be able to test for combinations of genes to discover the potential risk of disease.

Do girls really talk more than guys?

Psychologists are dispelling the myth that women are more talkative than men. Six years of in depth research shows little difference between the daily word counts of the sexes. Admittedly women do come out on top, but only by a small margin.

Researchers at the University of Arizona recorded the conversations of 400 US and Mexican students using an EAR, an electronically activated recorder, triggered when study participants started to speak. On average, women spoke 16,215 words a day, while men spoke 15,669.

The findings, published in the journal Science, challenge recent claims made by a renowned neuropsychiatrist that women use nearly three times as many words as men every day. In the bestseller The Female Brain, Louann Brizendine famously quoted a figure of 20,000, versus 7000 for men, however these numbers have been widely disputed.

SECOND SKIN

Skin tissue grown in the lab has been used to heal patients’ wounds in tests. Scientists from the British biotechnology company Intercytex Group Plc developed the artificial skin, ‘ICX-SKN’, which is able to integrate successfully into surrounding tissue.

ICX-SKN is a matrix of skin cells called fibroblasts, which are the same cells responsible for creating collagen in natural skin. The fibroblasts are taken from donors and encouraged to grow in the lab. As they grow, they build a mesh-like framework – just as they would in real skin. Within a month of treatment, ICX-SKN melds with the patient’s own skin.

This new breakthrough could mean an end to painful skin grafts, currently the best available option for those suffering serious wounds such as burns. The next step is to test the synthetic skin on larger wounds. The researchers eventually hope to create an off-the-shelf product.

At a glance: Occupied Palestinian Territory

Recent violence in Gaza leaves many young people shaken

© UNICEF/HQ07-0772/El Baba

With his school bag over his shoulder, a boy walks cautiously through a scene of recent intra-Palestinian fighting in Gaza.

By Amy Bennett

NEW YORK, USA, 19 June 2007 – The recent intra-Palestinian violence in the Gaza Strip left many young people traumatized and unable to carry out their daily activities. Last week’s clashes between Hamas and Fatah killed more than 110 people and injured another 500.

Families cowered in their homes, unable to venture out, many without electricity and water. Young people were left with nothing to do but wait and hope, disappointed over the cancellation of summer plans and the uncertainty that is now a part of their lives.

“Last week, life wasn’t going that well,” recalled Julie, 17, one of several Palestinian youths who spoke to UNICEF Radio about their ordeal. “They were continuously shooting for five days,” she continued. “The situation was really bad. Nobody was able to get out of the house, not even able to get near a window.”

© UNICEF/2007/El Baba

A girl tries to climb up to help her brother above the doorway of their home in the Rafah refugee camp, southern Gaza.

‘Fighting in the streets’

Bombs did extensive damage to the electricity network in Gaza, and many people lost power in their homes. The outage also interrupted sewage and water-supply services.

Fear was most deeply felt by civilians near the areas where fighting was most intense.

“The last week was awful. It was a nightmare,” said Chris, 13. “There was conflict near our house, and everywhere we heard the clashes. We couldn’t leave our house.

“We went in the bathroom and we stayed there for the whole day. When it was time to sleep, we slept on the ground, because we were afraid of bullets coming into our house,” he noted.

“It was a mess,” reported Mustafa, another teenager. “It was all masked men fighting in the streets. They just threw the bombs and many, many houses here got attacked for nothing. Many civilians died, just walking in the streets or while they were in their homes.”

© UNICEF/HQ07-0775/El Baba

Palestinian children fly a kite next to a destroyed house in Rafah.

Final exams disrupted for many

Mustafa and other students who were taking their Tawjihi exams (secondary-school matriculation finals) amidst the crisis were under considerable stress. Some did not do as well as they had hoped, while others missed the tests entirely. Still, some 24,000 students sat their exams each day.

“It was really hard for me to concentrate on my studies with all this shooting and fighting on the other side,” said Yaffa, 18.

Added Mustafa: “I had to miss one of my exams. We didn’t leave our home for a few days.”

Despite these challenges, both Mustafa and Yaffa hope their test scores will help them get into the universities they choose.

Relief aid from UNICEF

In the aftermath of last week’s violence, UNICEF is planning to ship much-needed vaccines to Gaza. Hospitals there have been hard hit; they still lack vascular surgery kits, blood units, X-ray films, sutures, lab supplies and orthopaedic casts. Many essential drugs are running out.

© UNICEF/HQ07-0776/El Baba

A boy plays with friends in the Gaza refugee camp in the northern Gaza Strip.

UNICEF is also planning to provide 50,000 litres of diesel fuel through its partner, the Coastal Municipalities Water Utility, while the provision of fuel through regular channels is restored.

And psychosocial counselling teams have resumed their work in Gaza through a partnership between UNICEF and local non-governmental organizations. The teams are currently screening children in the most affected areas to identify those who require the most attention.

Living with fear and uncertainty

In the meantime, young people like Julie, Chris, Mustafa and Yaffa must live with the trauma they have endured, and face an uncertain future.

“We are afraid that electricity and water will stop,” said Chris. “We are afraid that there is no money, and no food that will enter Gaza because all the borders with countries that support Gaza are closed. Last summer, the same thing happened.

“I am afraid to go out, and so are my friends in Gaza, because we are afraid that the conflicts will resume,” he explained.

“Every time I hope that they will get everything fixed,” lamented Julie, “they turn back to fighting, again and again, over and over. They never stop.”

Άρωμα... τοξίνης !!! Tοξικά αποδεικνύονται 36 γνωστά αρώματα, σύμφωνα με την Greenpeace.

Τα αρώματα που φοράμε μάς εκθέτουν σε χημικές ουσίες που μπορούν να διεισδύσουν στο σώμα, δεν διασπώνται εύκολα και πιθανόν να έχουν ανεπιθύμητες επιπτώσεις στην υγεία μας.

H οργάνωση Greenpeace έδωσε χθες στη δημοσιότητα μια έρευνα, στο πλαίσιο της οποίας 36 γνωστά αρώματα ελέγχθηκαν από ένα ολλανδικό εργαστήριο (ΤΝΟ) για δύο δυνάμει επικίνδυνες ομάδες χημικών ουσιών: τους φθαλικούς εστέρες και τα συνθετικά musk (μόσχος, ένα πολύ σημαντικό συστατικό της αρωματοποιίας, που στη φυσική μορφή του λαμβάνεται από αδένες ζώων). H τρέχουσα νομοθεσία δεν ορίζει ανώτατα επίπεδα για καμιά από τις ουσίες αυτές, οι οποίες περιέχονται σε καλλυντικά και πολλά άλλα προϊόντα.
«Την ημέρα του Αγίου Βαλεντίνου θέλουμε να δείξουμε την αγάπη μας, όχι να εκθέσουμε τον σύντροφό μας σε επικίνδυνα χημικά» δήλωσε η Ελέν Περιβιέ της Greenpeace International. «Το άρωμα πρέπει να προσφέρει απόλαυση όταν το δωρίζεις και όταν το φοράς, όχι να είναι πηγή συσσώρευσης χημικών ουσιών στο σώμα μας».

Οι χημικές ουσίες

Σχεδόν όλα τα αρώματα που δοκιμάστηκαν στο πλαίσιο της έρευνας με τίτλο «Eau de toxine» (όπως λέμε eau de cologne ή eau de parfum), περιείχαν φθαλικούς εστέρες και συνθετικά musk. Και καθώς η ύπαρξη των χημικών αυτών ουσιών σπάνια αναφέρεται στις συσκευασίες, οι καταναλωτές δεν μπορούν να επιλέξουν να τις αποφύγουν, επισημαίνει η Greenpeace.
Πολύ υψηλά επίπεδα διαιθυλικού φθαλικού εστέρα (DEP) εντοπίστηκαν στο γυναικείο Eternity του Κάλβιν Κλάιν και στο ανδρικό Le Male του Ζαν-Πολ Γκοτιέ. H χημική αυτή ουσία, προειδοποιεί η Greenpeace, διεισδύει άμεσα στο δέρμα και εξαπλώνεται στον οργανισμό. Μέσα στον οργανισμό μετατρέπεται σε μονοαιθυλικό φθαλικό εστέρα (ΜΕΡ), που πιθανολογείται ότι επηρεάζει το DNA του σπέρματος και συμβάλλει στον περιορισμό της λειτουργίας των πνευμόνων στους άνδρες. Αντίθετα, το Vanderbilt της Γκλόρια Βάντερμπιλτ δεν περιείχε ανιχνεύσιμη ποσότητα οποιουδήποτε από τους φθαλικούς εστέρες για τους οποίους ελέγχθηκε.
Όσον αφορά τα συνθετικά musk, υψηλά επίπεδα εντοπίστηκαν στο Le Baiser Du Dragon του οίκου Cartier και στο White Musk της εταιρείας The Body Shop. Τα συνθετικά musk συγκεντρώνονται σε ζωντανούς ιστούς. Επηρεάζουν πιθανώς τα ορμονικά συστήματα επικοινωνίας των ψαριών, των αμφίβιων και των θηλαστικών και επιτείνουν τις επιπτώσεις από την έκθεση σε άλλες τοξικές χημικές ουσίες.

Οι συζητήσεις

Τα αποτελέσματα της έρευνας έκαναν την Greenpeace ν' αρχίσει επαφές με τους παρασκευαστές αρωμάτων για να συζητήσει μαζί τους τη σταδιακή μείωση της χρήσης επικίνδυνων χημικών ουσιών στα αρώματα. H οικολογική οργάνωση τάσσεται κατηγορηματικά υπέρ της προτεινόμενης κανονιστικής ρύθμισης της E.E. για τα χημικά (REACH), που ζητεί από τη βιομηχανία να εξαλείψει σταδιακά τις προβληματικές χημικές ουσίες και να τις αντικαταστήσει με ασφαλέστερες εναλλακτικές. Αλλά η πρόταση έχει δεχθεί πυρά από τη χημική βιομηχανία και την αμερικανική κυβέρνηση.