What does it take to make a wrong decision? A qualitative study from Pakistan's health sector.

Background: Pakistan's health system over the past three decades has experienced social, economic, geopolitical instability, and notwithstanding man-made and natural catastrophes. Since 2001, the health system in Pakistan has undergone three phases of organizational and management reforms and does not have a unified national health policy since then. The aim of this research was to assess the factors behind the decision-making by policy planners in the health system of Pakistan. Methods: An exploratory qualitative study based on grounded theory was designed where in-depth interviews conducted with 20 representatives of the political constituencies, civil bureaucracy, health planners and managers, research and educational institutions, NGOs providing technical support in the health sector, development partners and media. Results: There leading reason cited was the dearth of leadership in health sector, which is compounded by a range of factors such as "institutional monopoly", "contextual deterrents", "power for turf"; "inadequate knowledge", and "design faults". Such factors were perceived to have a serious effect on the competencies, roles and responsibilities, use of knowledge for decision making. The behavioral aspects of decision makers include the "mindset," and "conflicting interests". Conclusions: The multitude of factors and complexities within the health sector of Pakistan continue to widen the vacuum in the leadership echelons. Hence, there is a high probability of taking wrong decisions not based on evidence, and resulting in a grossly under-performing health system.

Towards a paradigm shift in environmental health decision-making: a case study of oxybenzone.

BACKGROUND: Technological advancements make lives safer and more convenient. Unfortunately, many of these advances come with costs to susceptible individuals and public health, the environment, and other species and ecosystems. Synthetic chemicals in consumer products represent a quintessential example of the complexity of both the benefits and burdens of modern living. How we navigate this complexity is a matter of a society's values and corresponding principles. OBJECTIVES: We aimed to develop a series of ethical principles to guide decision-making within the landscape of environmental health, and then apply these principles to a specific environmental chemical, oxybenzone. Oxybenzone is a widely used ultraviolet (UV) filter added to personal care products and other consumer goods to prevent UV damage, but potentially poses harm to humans, wildlife, and ecosystems. It provides an excellent example of a chemical that is widely used for the alleged purpose of protecting human health and product safety, but with costs to human health and the environment that are often ignored by stakeholders. DISCUSSION: We propose six ethical principles to guide environmental health decision-making: principles of sustainability, beneficence, non-maleficence, justice, community, and precautionary substitution. We apply these principles to the case of oxybenzone to demonstrate the complex but imperative decision-making required if we are to address the limits of the biosphere's regenerative rates. We conclude that both ethical and practical considerations should be included in decisions about the commercial, pervasive application of synthetic compounds and that the current flawed practice of cost-benefit analysis be recognized for what it is: a technocratic approach to support corporate interests.

Ethics Guidelines in Environmental Epidemiology: Their Development and Challenges We Face.

PURPOSE OF REVIEW: This review integrates historical developments and key events in bringing ethics into epidemiology in general and into environmental epidemiology in particular. The goal is to provide context for and discern among the various approaches and motivations that drive the need for ethical conduct in support of the public interest. RECENT FINDINGS: The need for ethics guidelines in epidemiology is different from developments in other biomedical-related fields by virtue of its focus on populations rather than on individuals. The need for ethics guidelines in environmental epidemiology as a subspecialty of epidemiology stems from the larger scale of its mission than that of epidemiology per se. Ethics guidelines in the field of environmental epidemiology have been established. They articulate not only the profession's core values and mission, but more specifically, they address the environmental epidemiologist's obligations to the participants in research, to colleagues, and to employers. They are the product of consensus, scholarship, and diligent stewardship over several decades. The next challenge is ensuring their value and impact. The forces that support professional and institutional success, and the power of special interests, are the major threats to achieving the goals of ethical conduct and research for the public good. In environmental epidemiology, these threats have global implications.

A dimensão bioética dos conflitos de interesses na relação entre médico e indústria farmacêutica / The bioethics dimension of the conflicting interests in the relation between physicians and pharmaceutical industry

JUSTIFICATIVA E OBJETIVOS: No relacionamento entre a indústria farmacêutica e a classe médica podem ocorrer situações de conflitos de interesses. Esse relacionamento, iniciado nas primeiras décadas do século passado, tem aumentado em frequência e intensidade, levando a situações que podem interferir na graduação, na educação continuada, nas publicações científicas e na própria prática médica; pode comprometer a independência do trabalho médico e colocar em risco o prestígio da profissão. Os médicos e a indústria têm em comum o interesse pelos avanços dos conhecimentos médicos. Entretanto, o interesse primário do médico é promover o melhor interesse de seu paciente, enquanto o da indústria é o seu próprio desenvolvimento.CONTEÚDO: Discutem-se, à luz da Bioética, os conflitos de interesses no relacionamento entre a classe médica e a indústria farmacêutica, assim como as normatizações éticas e legais brasileiras.CONCLUSÃO: No relacionamento entre a classe médica e a indústria farmacêutica, os únicos e exclusivos compromissos do médico são para com o seu paciente e a ciência.(AU)

BACKGROUND AND OBJECTIVES: The relation between the pharmaceutical industry and the medical class may generate conflicting situations of interests. This relation initiated in the first decade of the last century has enhanced in frequency and intensity, leading to situations that may interfere in the graduation, in continuous education, some scientific publications and even the medical practice. This situation may interfere in the independence of the medical performance and put at risk the prestige of the profession. Doctors and industry have in common the interest for the advances of medical knowledge. However, the primary interest of the doctor is to promote the best interest for their patients while the industry interest is its own development.CONTENTS: The conflicting interests in the relation between the medical class and the pharmaceutical industry are discussed according to Bioethics, as well as ethical and legal Brazilian legislation.CONCLUSION: In the relation between the medical class and pharmaceutical industry, the only and exclusive doctor commitments are related to the patient and science.(AU)