An Ecostructural Lens for Health Ethics.

In this commentary, I describe an ecostructural approach to health ethics, which is grounded in a conception of people as ecological subjects and privileges place in supporting health and health justice. This approach sees people as dwelling in health ecosystems that can support or undermine health, and it situates us in social norms and processes, with a particular concern for structural health injustice. In patient care, an ecostructural approach can be operationalized by attending to conditions in the sites where birthing, healing, and dying take place and by critiquing their economic structures. For public health, relationships between people, animals, land, the built environment, and climate demand attention, as do racist norms and economic processes that thwart health justice. For global health, an ecostructural approach might envision a revolution in governance that challenges nationalism, in which health systems treat citizens while depending on human resources supplied through structures that sustain health injustice.

A Global Ecological Ethic for Human Health Resources.

COVID 19 has highlighted with lethal force the need to re-imagine and re-design the provisioning of human resources for health, starting from the reality of our radical interdependence and concern for global health and justice. Starting from the structured health injustice suffered by migrant workers during the pandemic and its impact on the health of others in both destination and source countries, I argue here for re-structuring the system for educating and distributing care workers around what I call a global ecological ethic. Rather than rely on a system that privileges nationalism, that is unjust, and that sustains and even worsens injustice, including health injustice, and that has profound consequences for global health, a global ecological ethic would have us see health as interdependent and aim at "ethical place-making" across health ecosystems to enable people everywhere to have the capability to be healthy.

Displacement and solidarity: An ethic of place-making.

Drawing on a conception of people as 'ecological subjects', creatures situated in specific social relations, locations, and material environments, I want to emphasize the importance of place and place-making for basing, demonstrating, and forging future solidarity. Solidarity, as I will define it here, involves reaching out through moral imagination and responsive action across social and/or geographic distance and asymmetry to assist other people who are vulnerable, and to advance justice. Contained in the practice of solidarity are two core 'enacted commitments', first, to engaging our moral imaginations and recognizing others in need and, second, to responsive action. Recognizing the suffering of displacement and responding through place-making should follow from even the most simplistic understanding of people as 'implaced'. Recognition, furthermore, that places are created and sustained, transformed, or neglected in ways that foster or perpetuate inequities, including health inequities, generates responsibilities concerning place-making. Place-based interventions, on either count, should be principal and, indeed, prioritized ways of showing solidarity for the vulnerable and promoting justice. Where solidaristic relations do not prevail, place-making can catalyze and nurture them, and over time advance justice. On the moral landscapes of bioethics, the terrain where care and health are or should be at the center of attention, an ethic of place and place-making for those who have been displaced - patients, the elderly, urban populations, and asylum-seekers, for instance - expresses and has rich potential for nurturing bonds of solidarity.

Familiar ethical issues amplified: how members of research ethics committees describe ethical distinctions between disaster and non-disaster research.

BACKGROUND: The conduct of research in settings affected by disasters such as hurricanes, floods and earthquakes is challenging, particularly when infrastructures and resources were already limited pre-disaster. However, since post-disaster research is essential to the improvement of the humanitarian response, it is important that adequate research ethics oversight be available. METHODS: We aim to answer the following questions: 1) what do research ethics committee (REC) members who have reviewed research protocols to be conducted following disasters in low- and middle-income countries (LMICs) perceive as the key ethical concerns associated with disaster research?, and 2) in what ways do REC members understand these concerns to be distinct from those arising in research conducted in non-crisis situations? This qualitative study was developed using interpretative description methodology; 15 interviews were conducted with REC members. RESULTS: Four key ethical issues were identified as presenting distinctive considerations for disaster research to be implemented in LMICs, and were described by participants as familiar research ethics issues that were amplified in these contexts. First, REC members viewed disaster research as having strong social value due to its potential for improving disaster response, but also as requiring a higher level of justification compared to other research settings. Second, they identified vulnerability as an overarching concern for disaster research ethics, and a feature that required careful and critical appraisal when assessing protocols. They noted that research participants' vulnerabilities frequently change in the aftermath of a disaster and often in unpredictable ways. Third, they identified concerns related to promoting and maintaining safety, confidentiality and data security in insecure or austere environments. Lastly, though REC members endorsed the need and usefulness of community engagement, they noted that there are significant challenges in a disaster setting over and above those typically encountered in global health research to achieve meaningful community engagement. CONCLUSION: Disaster research presents distinctive ethical considerations that require attention to ensure that participants are protected. As RECs review disaster research protocols, they should address these concerns and consider how justification, vulnerability, security and confidentially, and community engagement are shaped by the realities of conducting research in a disaster.

Defining Ethical Placemaking for Place-Based Interventions.

As place-based interventions expand and evolve, deeper reflection on the meaning of ethical placemaking is essential. I offer a summary account of ethical placemaking, which I propose and define as an ethical ideal and practice for health and for health justice, understood as the capability to be healthy. I point to selected wide-ranging examples-an urban pathway, two long-term care settings, innovations in refugee health services, and a McDonald's restaurant-to help illustrate these ideas.

Ethics of emergent information and communication technology applications in humanitarian medical assistance.

New applications of information and communication technology (ICT) are shaping the way we understand and provide humanitarian medical assistance in situations of disaster, disease outbreak or conflict. Each new crisis appears to be accompanied by advancements in humanitarian technology, leading to significant improvements in the humanitarian aid sector. However, ICTs raise ethical questions that warrant attention. Focusing on the context of humanitarian medical assistance, we review key domains of ICT innovation. We then discuss ethical challenges and uncertainties associated with the development and application of new ICTs in humanitarian medical assistance, including avoiding harm, ensuring privacy and security, responding to inequalities, demonstrating respect, protecting relationships, and addressing expectations. In doing so, we emphasize the centrality of ethics in humanitarian ICT design, application and evaluation.

The Challenge of Timely, Responsive and Rigorous Ethics Review of Disaster Research: Views of Research Ethics Committee Members.

BACKGROUND: Research conducted following natural disasters such as earthquakes, floods or hurricanes is crucial for improving relief interventions. Such research, however, poses ethical, methodological and logistical challenges for researchers. Oversight of disaster research also poses challenges for research ethics committees (RECs), in part due to the rapid turnaround needed to initiate research after a disaster. Currently, there is limited knowledge available about how RECs respond to and appraise disaster research. To address this knowledge gap, we investigated the experiences of REC members who had reviewed disaster research conducted in low- or middle-income countries. METHODS: We used interpretive description methodology and conducted in-depth interviews with 15 respondents. Respondents were chairs, members, advisors, or coordinators from 13 RECs, including RECs affiliated with universities, governments, international organizations, a for-profit REC, and an ad hoc committee established during a disaster. Interviews were analyzed inductively using constant comparative techniques. RESULTS: Through this process, three elements were identified as characterizing effective and high-quality review: timeliness, responsiveness and rigorousness. To ensure timeliness, many RECs rely on adaptations of review procedures for urgent protocols. Respondents emphasized that responsive review requires awareness of and sensitivity to the particularities of disaster settings and disaster research. Rigorous review was linked with providing careful assessment of ethical considerations related to the research, as well as ensuring independence of the review process. CONCLUSION: Both the frequency of disasters and the conduct of disaster research are on the rise. Ensuring effective and high quality review of disaster research is crucial, yet challenges, including time pressures for urgent protocols, exist for achieving this goal. Adapting standard REC procedures may be necessary. However, steps should be taken to ensure that ethics review of disaster research remains diligent and thorough.

Real-time Responsiveness for Ethics Oversight During Disaster Research.

Disaster research has grown in scope and frequency. Research in the wake of disasters and during humanitarian crises--particularly in resource-poor settings--is likely to raise profound and unique ethical challenges for local communities, crisis responders, researchers, and research ethics committees (RECs). Given the ethical challenges, many have questioned how best to provide research ethics review and oversight. We contribute to the conversation concerning how best to ensure appropriate ethical oversight in disaster research and argue that ethical disaster research requires of researchers and RECs a particular sort of ongoing, critical engagement which may not be warranted in less exceptional research. We present two cases that typify the concerns disaster researchers and RECs may confront, and elaborate upon what this ongoing engagement might look like--how it might be conceptualized and utilized--using the concept of real-time responsiveness (RTR). The central aim of RTR, understood here as both an ethical ideal and practice, is to lessen the potential for research conducted in the wake of disasters to create, perpetuate, or exacerbate vulnerabilities and contribute to injustices suffered by disaster-affected populations. Well cultivated and deployed, we believe that RTR may enhance the moral capacities of researchers and REC members, and RECs as institutions where moral agency is nurtured and sustained.

Global solidarity, migration and global health inequity.

The grounds for global solidarity have been theorized and conceptualized in recent years, and many have argued that we need a global concept of solidarity. But the question remains: what can motivate efforts of the international community and nation-states? Our focus is the grounding of solidarity with respect to global inequities in health. We explore what considerations could motivate acts of global solidarity in the specific context of health migration, and sketch briefly what form this kind of solidarity could take. First, we argue that the only plausible conceptualization of persons highlights their interdependence. We draw upon a conception of persons as 'ecological subjects' and from there illustrate what such a conception implies with the example of nurses migrating from low and middle-income countries to more affluent ones. Next, we address potential critics who might counter any such understanding of current international politics with a reference to real-politik and the insights of realist international political theory. We argue that national governments--while not always or even often motivated by moral reasons alone--may nevertheless be motivated to acts of global solidarity by prudential arguments. Solidarity then need not be, as many argue, a function of charitable inclination, or emergent from an acknowledgment of injustice suffered, but may in fact serve national and transnational interests. We conclude on a positive note: global solidarity may be conceptualized to helpfully address global health inequity, to the extent that personal and transnational interdependence are enough to motivate national governments into action.

Dealing with the long-term social implications of research.

Biomedical and behavioral research may affect strongly held social values and thereby create significant controversy over whether such research should be permitted in the first place. Institutional review boards (IRBs) responsible for protecting the rights and welfare of participants in research are sometimes faced with review of protocols that have significant implications for social policy and the potential for negative social consequences. Although IRB members often raise concerns about potential long-term social implications in protocol review, federal regulations strongly discourage IRBs from considering them in their decisions. Yet IRBs often do consider the social implications of research protocols and sometimes create significant delays in initiating or even prevent such research. The social implications of research are important topics for public scrutiny and professional discussion. This article examines the reasons that the federal regulations preclude IRBs from assessing the social risks of research, and examines alternative approaches that have been used with varying success by national advisory groups to provide such guidance. The article concludes with recommendations for characteristics of a national advisory group that could successfully fulfill this need, including sustainability, independence, diverse and relevant expertise, and public transparency.