Hospice and palliation in the English-speaking Caribbean.

This article presents empirical data on the limited availability of hospice and palliative care to the 6 million people of the English-speaking Caribbean. Ten of the 13 nations therein responded to a survey and reported employing a total of 6 hospice or palliative specialists, and having a total of 15 related facilities. The evolving socioeconomic and cultural context in these nations bears on the availability of such care, and on the willingness to report, assess, and prioritize pain, and to prescribe opiates for pain. Socioeconomics and culture also impinge on what medications and modalities of care are routinely available for pain or other conditions and can challenge professionalism, empathy, and responsiveness to patients' unrelieved pain. Although all respondents report having a protocol for pain management, hospice, or end-of-life care, their annual medical use of opiates is well below the global mean. The International Narcotics Control Board (INCB), which monitors such use, encourages Caribbean and other low- and middle-income countries to increase their use of opiates to treat pain, and to overcome both unfounded fears of addiction and overly restrictive interpretation of related laws and regulations. Contextual considerations like those described here are important to the success of policies and capacity-building programs aiming to increase access to hospice and palliation, and perhaps to improving other aspects of health and healthcare. Exploring and responding to the realities of socioeconomic and cultural conditions will enhance public and policy dialogue and improve the design of interventions to increase access to palliative and hospice care. Improving access to palliative and hospice care in the Caribbean demonstrates beneficence and helps to fulfill human rights conventions.

Climate change matters.

One manifestation of climate change is the increasingly severe extreme weather that causes injury, illness and death through heat stress, air pollution, infectious disease and other means. Leading health organisations around the world are responding to the related water and food shortages and volatility of energy and agriculture prices that threaten health and health economics. Environmental and climate ethics highlight the associated challenges to human rights and distributive justice but rarely address health or encompass bioethical methods or analyses. Public health ethics and its broader umbrella, bioethics, remain relatively silent on climate change. Meanwhile global population growth creates more people who aspire to Western lifestyles and unrestrained socioeconomic growth. Fulfilling these aspirations generates more emissions; worsens climate change; and undermines virtues and values that engender appreciation of, and protections for, natural resources. Greater understanding of how virtues and values are evolving in different contexts, and the associated consequences, might nudge the individual and collective priorities that inform public policy toward embracing stewardship and responsibility for environmental resources necessary to health. Instead of neglecting climate change and related policy, public health ethics and bioethics should explore these issues; bring transparency to the tradeoffs that permit emissions to continue at current rates; and offer deeper understanding about what is at stake and what it means to live a good life in today's world.

Climate change is a bioethics problem.

Climate change harms health and damages and diminishes environmental resources. Gradually it will cause health systems to reduce services, standards of care, and opportunities to express patient autonomy. Prominent public health organizations are responding with preparedness, mitigation, and educational programs. The design and effectiveness of these programs, and of similar programs in other sectors, would be enhanced by greater understanding of the values and tradeoffs associated with activities and public policies that drive climate change. Bioethics could generate such understanding by exposing the harms and benefits in different cultural, socioeconomic, and geographic contexts, and through interdisciplinary risk assessments. Climate change is a bioethics problem because it harms everyone and involves health, values, and responsibilities. This article initiates dialog about the responsibility of bioethics to promote transparency and understanding of the social values and conflicts associated with climate change, and the actions and public policies that allow climate change to worsen.

Global bioethics: did the universal declaration on bioethics and human rights miss the boat?

This paper explores the evolution of the Universal Declaration on Bioethics and Human Rights (UDBHR), which was adopted by the United Nations Educational, Scientific and Cultural Organization (Unesco) in 2005. While the draft UDBHR generated controversy among bioethicists, the process through which it evolved excluded mainstream bioethicists. The absence of peer review affects the declaration's content and significance. This paper critically analyses its content, commenting on the failure to acknowledge socioeconomic and other factors that impede its implementation. The UDBHR outlines ideal standards but fails to provide guidance that can be readily applied in different settings. It strives for universality but does not contribute to understanding of universal or global bioethics.

To strengthen consensus, consult the stakeholders.

CIOMS has been criticised for not adequately consulting stakeholders about its revised ethical guidelines regarding medical research. Political and logistical issues that arise in democratic processes and open exchange of information probably contributed to this exclusion. What might CIOMS have done to be more inclusive and attain broader consensus on its proposed revisions? Consensus is dynamic, and evolves as a community digests new information and perspectives. Engaging the public (and particularly the stakeholders) in discussion about the revisions would have generated broader consensus. It would have encouraged more stakeholders (i.e. researchers, potential research participants, research institutions, or governments) to buy in. CIOMS needs a process to encourage dialogue and stakeholder input. The CIOMS guidelines themselves promote stakeholder consultation and capacity building, but CIOMS has done relatively little to distribute or promote its own guidelines. CIOMS should do more to promote its revised guidelines, and engage stakeholders in dialogue. This paper explores the bioethics debate about universal and relative values to illustrate the value of consultation and consensus building. It concludes that like research sponsors, CIOMS and similar organisations have an ethical responsibility to facilitate capacity building in less developed areas, and to participate more actively in consensus building.