The growing number of zoonotic diseases in the last few decades, caused by increasing human-nature interactions and the devastating impacts of global climate change on health, has compelled global stakeholders to start considering the need for a paradigm shift in global public health governance. In this paper, I show that although the One Health approach is one of the most recent global responses to the growing human-environmental health crises, indigenous people around the world have some of the earliest and enduring examples of the idea of One Health. I demonstrate this by examining the indigenous African notion of health as one of such examples. It is a wholistic and interconnected outlook, where health is perceived as moral, spiritual, ecologic and cosmic harmony. When the health of part of this integrated universe is threatened, the entire universe is in peril. According to this African conception of health, no individual can be considered healthy if a member of the community is sick. There is solidarity not only between created beings, but also between the natural and the supernatural world. I show that some ideas from the African relational view of health may contribute insights to the global conversation on One Health.
Paternalistic actions interfere with the autonomy of an agent, so they can only be justified by strong moral considerations. Yet how seriously an action infringes on autonomy depends on how it affects autonomy. Autonomous actions require at least three independent elements: agents must act with an understanding of the risks of their actions, without the coercive influence of others and in accord with their most important values. Each of these elements exists along a spectrum, and by mapping measures in the resulting three-dimensional space, we get a better understanding of what is at stake in any debate about them, and we can understand when paternalistic measures might be justified and when they are not.
Humanitarian needs are increasing globally, while resources available to humanitarian organizations are stagnating. Consequently, humanitarian actors increasingly face difficult decisions about when and how to end interventions. Poorly planned project closures can generate ethical harms for affected communities, local partners, staff, and institutions. Despite growing recognition of the importance of 'responsible exit', the evidence base remains fragmented and conceptually underdeveloped. We conducted a scoping review following Joanna Briggs Institute methodology to examine the literature on exit strategies of international non-governmental humanitarian organizations. Bibliographic and gray literature sources were searched without date restrictions. Data were extracted and thematically analyzed to map existing evidence; describe core concepts, theories, and frameworks related to 'responsible exit'; and identify key knowledge gaps. Fifty-seven documents published between 1999 and 2022 were included, the majority of which were gray literature. The review revealed substantial variability in terminology and approaches to exit strategies. Exit decision-making was found to be ethically complex and shaped by organizational mandates, contextual constraints, global funding dynamics, and decision-makers. Poorly managed exits were associated with negative outcomes, including service disruption, dependency, erosion of trust, and harm to organizational legitimacy. Responsible exit was characterized by three core capacities: foresight, attentiveness, and responsiveness, supported by the guiding principles of inclusive participation and transparency. Responsible exit should be understood as an ethically grounded, continuous process spanning the entire project cycle. Strengthening ethical guidance and empirical evidence, particularly by incorporating perspectives of affected populations and local partners, is essential to improve accountability and practice in humanitarian project closure.
Livingston and Boyd have rightly suggested that 'conceptual clarity regarding "stigma" is lagging behind the burgeoning body of research regarding its effects'. This observation still seems valid. In this paper, we argue that existing definitions of stigma, most prominently that of Link and Phelan, rely on multiple overlapping criteria, potentially contributing to ambiguity and measurement difficulties. We analyze Link and Phelan's definition and thereby indirectly other later definitions that build on the same components. We show that three of five constitutive components are redundant. We therefore propose that stigma consists of only the components that has shown non-redundant in our analysis-negative labeling maintained by power asymmetry. On that basis we outline 13 analytical dimensions of the phenomena of stigma to demonstrate that this stripped-down account can capture its' complexity without the redundancies found in previous accounts. In closing, we discuss the implications of our proposal for efforts aimed at reducing stigma.
This paper examines the experiences of teachers in Australia during the COVID-19 pandemic from a care ethics perspective. While pandemic preparedness plans prioritised continuity of services and infection control, they failed to anticipate the relational and moral labour required of frontline workers in non-clinical roles. Paradoxically, otherwise prudent and precautionary responses to the risks posed by the pandemic established new barriers to care and human connection and exacerbated existing ones. Drawing on 32 qualitative interviews with teachers, we analyse how they engaged in improvised, context-specific practices of care. We distinguish between care initiated by workers and care requested of them, highlighting asymmetries. We argue that the pandemic exposed and intensified structurally patterned inequities in the distribution and valuation of care work and that existing accounts of care ethics do not sufficiently explain community care performed by teachers. The paper calls for pandemic planners to explicitly anticipate the needs that public health restrictions create and acknowledge and centre care as a communal good. This is because when care is invisible, it is not planned for, acknowledged or supported. Ignoring it exposes persistent institutional failures to recognise and sustain the everyday labour that holds society together in times of crisis.
Humanitarian aid workers face several ethical challenges. They work in resource-limited settings, navigate power imbalances and face obstacles responding to populations affected by crisis. The Covid-19 pandemic added additional layers of challenge in places such as camps for refugees and internally displaced persons. However, the impact of the pandemic in these settings was varied, and in many cases, less than anticipated, raising questions about calibration of Covid-19 prevention and response to local realities. We conducted an exploratory qualitative descriptive study to better understand humanitarian aid workers' experiences in temporary displacement camps in the context of the Covid-19 pandemic. We interviewed 10 humanitarian aid workers with pandemic experience working in the Middle East, Africa, Asia and Europe, among others. Participants described ethical challenges, including implementing proportionate Covid-19 prevention strategies while mitigating harms of this response; navigating an environment with misinformation; responding to expectations of external authorities; fulfilling aid worker obligations amidst a global pandemic; questioning power imbalances within the humanitarian aid organizational hierarchy. Further understanding these ethical challenges may help orient training and policy to support responses to the needs of displaced populations in future public health emergencies, as well as better support humanitarian aid workers in these situations.
This Case for Discussion examines legislative constraints as occupational health hazards that induce moral distress among healthcare professionals (including physicians, nurses, and midwives). Traditionally framed as clinical ethics issues, moral distress emerges as a population-level public health concern when regulatory barriers systematically conflict with clinical judgment. Drawing on empirical evidence from abortion restrictions and European contexts (Italy, France, Spain), the case highlights psychological harms, burnout, and systemic consequences like defensive medicine and workforce emigration. Key normative questions address occupational risk classification, stress assessment tools, prospective legislative impact evaluations, occupational medicine roles, professional associations' advocacy, and institutional obligations balancing conscientious objection with service provision. The analysis reframes moral distress through a public health ethics lens, advocating expanded risk frameworks, organizational support, and policy interventions to protect healthcare workers while advancing population health goals.
Information provided to women invited to participate in mammography screening is crucial in supporting informed consent. Expert recommendations remain divided, and the ethical framing of autonomy, especially in shared decision-making, often fails to reflect the realities of clinical practice. This study examines how public-facing documents communicate screening information and explores whether relational autonomy offers a more ethically coherent approach. A document analysis was conducted using the READ method. Documents published between 1999 and 2023, from Quebec, Ontario or Canada, containing the keywords 'breast cancer screening' and 'screening mammography' were included and assessed using a 16-category grid. Fifty-one documents were included (Qc: 16, On: 10, Can: 25) and 11 were excluded. 10 per cent included women from the public, but the majority of contributing experts were women (57 per cent). 96 per cent of documents were considered inaccessible based on the Flesch-Kincaid Grade Level score. Benefits were mentioned more often than risks (90 per cent vs 37 per cent) and 16 per cent confused diagnosis and screening. Women under 50 were overrepresented (37 per cent) and racialized women underrepresented (58 per cent). This analysis reveals biases in how screening information is designed and communicated. Relational autonomy offers a more inclusive framework for evaluating and improving screening communication.
How ought scarce health research resources be allocated, where health research spans basic, translational, clinical, health systems and public health research? In this article, I first outline a previously suggested answer to this question: the 'fair-share principle' stipulates that total health research funding ought to be allocated in direct proportion with suffering caused by each disease. Second, I highlight a variety of problems the fair-share principle faces. Like other resource allocation frameworks, the principle needs to address the aggregation and distribution of harms and consider cost-effectiveness. Moreover, to make resource allocation recommendations, the principle has to be used in conjunction with real-world estimates of 'suffering', usually provided by the Global Burden of Disease Study. These estimates are disease-centric and only take 'proximal' causes of health loss into account. Applying the principle based on such estimates disregards 'distal' causes, including social determinants of health, thus skewing resource allocation towards biomedical research and away from public health research. Since public health research aims at improving population health while reducing health inequalities, the principle leads to inequitable priority-setting. The fair-share principle can only become equitable when due consideration is also given to 'distal' causes that are amenable to public health research and interventions.
The global spread of highly pathogenic avian influenza (H5N1) clade 2.3.4.4b has evolved into a multispecies panzootic that disrupts conventional boundaries between human, animal and environmental health systems. Using Brazil's response as an illustrative case, this article argues that prevailing containment strategies-particularly mass culling-remain ethically insufficient and practically misaligned with the ecological complexity of H5N1 transmission. To clarify the normative foundations of an alternative approach, we introduce a theoretical framework grounded in zoonoethics and global ecological bioethics, emphasizing multispecies justice, relational vulnerability, intercultural and community engagement and co-responsibility. We then apply this framework to evaluate the limitations of reactive biosecurity paradigms and to outline multispecies-sensitive One Health governance guidelines. The analysis demonstrates that effective and legitimate panzootic response requires moving beyond biomedical and anthropocentric models toward anticipatory, inclusive and ethically grounded governance capable of addressing structural drivers such as biodiversity loss, land-use change and the erosion of Indigenous territorial protections. We conclude by discussing how the H5N1 panzootic represents a 'perfect storm' that demands not only improved preparedness, but a reconceptualization of One Health as an ethical and political project of multispecies cohabitation in an era of planetary instability.
Relational ethics gained increased attention as a guiding approach for public health during the COVID-19 pandemic. Highlighting the social features of viral transmission, such as shared risk, relational ethics emphasizes the importance of collective responses rooted in values of community solidarity, mutual obligation and equity. However, many discussions of relational ethics have remained largely normative rather than empirical in character. In this paper, we report a study of relational ethics in the context of a COVID-19 asymptomatic testing programme implemented at a UK university during the pandemic. Exploring how staff and students considered the exceptional ethical demands and dilemmas of the pandemic, we show that respondents discussed participation in the asymptomatic testing programme in relational terms. In particular, they emphasised the mutual dependencies of communal living, the risks of community transmission, expectations for institutional care and distributed responsibility to care for those most vulnerable to severe disease. Our empirical findings advance normative discussions of relational ethics by demonstrating the relevance of institutional context and social change, offering insights for future public health interventions premised on relational values.
This paper examines Kieran Oberman's original application of a particular conception of freedom as non-interference to justify lockdowns during a pandemic. Oberman claims that lockdowns can be justified exclusively on the basis of the value of freedom. He also suggests that people who protested against lockdowns by demanding freedom did not fully grasp the value to which they appealed. This paper argues that the conception of freedom as non-interference Oberman employs is not useful as a guide to make public health policy decisions. This is because it unnecessarily multiplies the freedoms that need to be considered, and unhelpfully reinterprets easily understood harms such as severe illness and death in terms of loss of freedom. This paper argues that this conception of freedom also leads to counterintuitive assessments. Finally, the paper proposes three ways of thinking about freedom that seem better to capture the sense of loss of freedom during the pandemic and the corresponding political demands expressed in protests.
In healthcare priority setting, the concept of severity often plays an important role, to voice the aspect of need. It has been observed that severity is an under-theorized concept. The recent pandemic raised a number of practical but also theoretical issues; one such aspect is how to handle severity in heterogeneous patient groups, e.g. when we have to vaccinate a large group, but only a fraction of them is at the risk of suffering severe disease. The aim of this article is to explore, what we call such heterogeneous severity. In the article, we explore three approaches, the trump, the average and the additive approach and find that all of these alternatives are wanting given the rationale for taking severity into account. Instead, we examine a double threshold and a stepwise trump approach, and find that they both have a better match with the rationale for taking severity into account when having to consider budget constraints. However, neither of these will provide input to acceptable cost-effectiveness threshold, and therefore will have to be combined with a weighted additive approach. Comparing the double threshold and stepwise trump approach, we find the latter advantageous in avoiding problematic threshold effects.
While the South Korean government's IT-based strategies during the Coronavirus Disease 2019 (COVID-19) pandemic were highly effective, they also highlighted pressing ethical concerns regarding information disclosure and governance. This article emphasizes the critical role of personal information disclosure regulations as a transparency measure requiring a systematic approach. Using Schauer's values of transparency (i.e. regulation, efficiency, epistemology and democracy), we analyze key amendments to the Infectious Disease Control and Prevention Act and related policies, tracing their evolution from the Middle East Respiratory Syndrome outbreak in 2015 to the COVID-19 pandemic in 2021. Significant improvements were identified in information management procedures, including pre- and post-disclosure actions and government-led information administration. However, the absence of standardized procedures for determining disclosure specifications raises concerns about democratic safeguards. To respond effectively to future infectious diseases, efforts should prioritize balancing transparency with ethical and procedural standards to ensure the accountable handling of disclosed information.
We present a case on the rollout of two malaria vaccines, RTS,S and R21. We examine the implementation of the World Health Organization's framework for the ethical allocation of these vaccines, questioning its founding principles of greatest need, maximizing health impact, equity and fair benefit. We highlight the inequitable distribution of the vaccines, and question the basis for prioritized countries with low vaccine dropout rates. In addition, we examine the disconnect between vaccine availability and uptake, as well as the financial challenges associated with implementing the rollout, arguing that without adequate funding and support for delivery, the potential benefits of these vaccines will be undermined, leaving the rollout to be another missed opportunity in the long fight against malaria.
According to the Public Goods Account, proposed by Jonny Anomaly, public health activities should only be concerned with the provision of health-related public goods. In this paper, I argue that the Public Goods Account cannot serve as an adequate account of public health activity. The main reason is that its central concept, that of health-related public goods, is itself implausible. I offer two potential understandings of health-related public goods and argue that, on both understandings, the provision of health-related public goods is neither necessary nor sufficient for a public health activity. First, on both understandings, there are plausible examples of public health activities that do not produce health-related public goods. And second, there are examples of non-public health activities that produce health-related public goods.
