Zohar Lederman

Introducing One Health to the Ethical Debate About Zoonotic Diseases in Southeast Asia

Abstract Pandemic plans recommend phases of response to an emergent infectious disease (EID) outbreak, and are primarily aimed at preventing and mitigating human‐to‐human transmission. These plans carry presumptive weight and are increasingly being operationalized at the national, regional and international level with the support of the World Health Organization (WHO). The conventional focus of pandemic preparedness for EIDs of zoonotic origin has been on public health and human welfare. However, this focus on human populations has resulted in strategically important disciplinary silos. As the risks of zoonotic diseases have implications that reach across many domains outside traditional public health, including anthropological, environmental, and veterinary fora, a more inclusive ecological perspective is paramount for an effective response to future outbreaks.

One Health, Vaccines and Ebola: The Opportunities for Shared Benefits

The 2013 Ebola virus outbreak in West Africa, as of writing, is declining in reported human cases and mortalities. The resulting devastation caused highlights how health systems, in particular in West Africa, and in terms of global pandemic planning, are ill prepared to react to zoonotic pathogens. In this paper we propose One Health as a strategy to prevent zoonotic outbreaks as a shared goal: that human and Great Ape vaccine trials could benefit both species. Only recently have two phase 2/3 Ebola human vaccine trials been started in West Africa. This paper argues for a conceptual change in pandemic preparedness. We first discuss the ethics of One Health. Next, we focus on the current Ebola outbreak and defines its victims. Third, we present the notion of a ‘shared benefit’ approach, grounded in One Health, and argue for the vaccination of wild apes in order to protect both apes and humans. We believe that a creation of such inter-species immunity is an exemplar of One Health, and that it is worth pursuing as a coextensive public health approach.

Zika in Singapore: insights from One Health and social medicine.

The detection of the Zika virus in Singapore in the last week of August 2016 has generated concern in the community, particularly among pregnant women, and prompted the authorities to take swift action to contain the spread of the virus. In addition to public health efforts currently under way, including the lively ethical discourse on dealing with this mild disease and its significant risk of congenital malformations, we believe that important insights can also be found in the One Health (OH) approach. OH is an ethical, ecological approach that takes into consideration justice and respect for human and animal populations as well as the environment.(1-3) This approach considers the wider social and environmental factors that shape disease transmission, and helps us to identify three populations that are particularly vulnerable but may be overlooked in this scenario: transient foreign workers, their sexual partners and local monkey populations.

Family presence during resuscitation: extending ethical norms from paediatrics to adults

Many families of patients hold the view that it is their right to be present during a loved ones resuscitation, while the majority of patients also express the comfort and support they would feel by having them there. Currently, family presence is more commonly accepted in paediatric cardiopulmonary resuscitation (CPR) than adult CPR. Even though many guidelines are in favour of this practice and recognise potential benefits, healthcare professionals are hesitant to support adult family presence to the extent that paediatric family presence is supported. However, in this paper, we suggest that the ethical case to justify family presence during paediatric resuscitation (P-FPDR) is weaker than the justification of family presence during adult resuscitation (A-FPDR). We go on to support this claim using three main arguments that people use in clinical ethics to justify FPDR. These include scarcity of evidence documenting disruption, psychological benefits to family members following the incident and respect for patient autonomy. We demonstrate that these arguments actually apply more strongly to A-FPDR compared with P-FPDR, thereby questioning the common attitude of healthcare professionals of allowing the latter while mostly opposing A-FPDR. Importantly, we do not wish to suggest that P-FPDR should not be allowed. Rather, we suggest that since P-FPDR is commonly (and should be) allowed, so should A-FPDR. This is because the aforementioned arguments that are used to justify FPDR in general actually make a stronger case for A-FPDR.

One Health and paradigms of public biobanking

In this paper, the authors consider the idea of the public biobank governance framework with respect to the innovative paradigm of One Health. The One Health initiative has been defined as an integrative and interdisciplinary effort to improve the lives and well-being of human beings and non-human animals, as well as to preserve the environment. Here, we use this approach as a starting presumption with respect to institutional design. We examine the theoretical and legal framework underlying the concept of biobanking that, being public orientated, is for the public good. We suggest that this account of research practice does not ethically correlate with One Health principles. Instead, we argue that One Health requires a model of biobanking that is based on universal goods, that is, goods that serve human beings as well as non-human animals and the environment, and which we define in detail. Our purpose is to begin a discussion on how One Health principles might be implemented in health initiatives.

Justice Is the Missing Link in One Health: Results of a Mixed Methods Study in an Urban City State

Background One Health (OH) is an interdisciplinary collaborative approach to human and animal health that aims to break down conventional research and policy ‘silos’. OH has been used to develop strategies for zoonotic Emerging Infectious Diseases (EID). However, the ethical case for OH as an alternative to more traditional public health approaches is largely absent from the discourse. To study the ethics of OH, we examined perceptions of the human health and ecological priorities for the management of zoonotic EID in the Southeast Asia country of Singapore. Methods We conducted a mixed methods study using a modified Delphi technique with a panel of 32 opinion leaders and 11 semi-structured interviews with a sub-set of those experts in Singapore. Panellists rated concepts of OH and priorities for zoonotic EID preparedness planning using a series of scenarios developed through the study. Interview data were examined qualitatively using thematic analysis. Findings We found that panellists agreed that OH is a cross-disciplinary collaboration among the veterinary, medical, and ecological sciences, as well as relevant government agencies encompassing animal, human, and environmental health. Although human health was often framed as the most important priority in zoonotic EID planning, our qualitative analysis suggested that consideration of non-human animal health and welfare was also important for an effective and ethical response. The panellists also suggested that effective pandemic planning demands regional leadership and investment from wealthier countries to better enable international cooperation. Conclusion We argue that EID planning under an OH approach would benefit greatly from an ethical ecological framework that accounts for justice in human, animal, and environmental health.

The land of no milk and no honey: force feeding in Israel

AbstractIn 2015, the Israeli Knesset passed the force-feeding act that permits the director of the Israeli prison authority to appeal to the district court with a request to force-feed a prisoner against his expressed will. A recent position paper by top Israeli clinicians and bioethicists, published in Hebrew, advocates for force-feeding by medical professionals and presents several arguments that this would be appropriate. Here, we first posit three interrelated questions: 1. Do prisoners have a right to hunger-strike? 2. Should governing institutions force-feed prisoners and/or is it ethical to force-feed prisoners? 3. Should healthcare professionals force-feed prisoners? We then focus on the first and third questions. We first briefly provide several arguments to support the right of prisoners to refuse treatment. Next, we critically review the arguments presented in the Israeli position paper, demonstrating that they are all misguided at best. Lastly, we briefly present arguments against force-feeding by medical professionals. We conclude that healthcare providers should not participate in the force-feeding of prisoners.

Prisoners’ competence to die: hunger strike and cognitive competence

Several bioethicists have recently advocated the force-feeding of prisoners, based on the assumption that prisoners have reduced or no autonomy. This assumed lack of autonomy follows from a decrease in cognitive competence, which, in turn, supposedly derives from imprisonment and/or being on hunger strike. In brief, causal links are made between imprisonment or voluntary total fasting (VTF) and mental disorders and between mental disorders and lack of cognitive competence. I engage the bioethicists that support force-feeding by severing both of these causal links. Specifically, I refute the claims that VTF automatically and necessarily causes mental disorders such as depression, and that these mental disorders necessarily or commonly entail cognitive impairment. Instead, I critically review more nuanced approaches to assessing mental competence in hunger strikes, urging that a diagnosis of incompetence be made on a case-by-case basis—a position that is widely shared by the medical community.

Hidden in Plain Sight: Family Presence During Resuscitation on Prime-Time Media

Family presence during resuscitation (FPDR) remains a highly contentious issue among professional caregivers in the acute setting. Generally, even though empirical evidence and professional guidelines support FPDR, healthcare providers instinctively oppose it. The origins of this recalcitrant opposition is likely to be multifold, but the media, which often exposes students of medical professions to cardiopulmonary resuscitation (CPR) for the first time, may be a significant contributing factor. More specifically, medical dramas play a potential role in the transmission of medical information and etiquette. The objective of the study described here was to examine the way family presence during resuscitation is depicted in current prime-time medical drama TV shows and to compare these to an older prime-time medical drama.

Attitudes of Singapore Emergency Department staff towards family presence during cardiopulmonary resuscitation

Background Family presence during adult cardiopulmonary resuscitation is still not widely implemented. Based on empirical evidence, various national and international professional organizations recommend allowing relatives to be present during resuscitation. However, healthcare providers worldwide are still reluctant to make it standard care. Purpose This paper is a part of an ongoing cross-cultural study that aims to solicit attitudes of healthcare providers working in emergency departments towards family presence during cardiopulmonary resuscitation. This paper reports the qualitative data from surveying healthcare providers working in an emergency department at a university-affiliated hospital in Singapore. Method Healthcare workers were asked to fill out an online survey, including both quantitative and qualitative questions. Their attitudes were critically analyzed and compared with existing empirical data. Results Majority of healthcare workers (71.6%) believed that relatives should not be present during cardiopulmonary resuscitation and 52% thought that relatives would not want to be present. Conclusion Most emergency department doctors and nurses in Singapore do not support family presence during cardiopulmonary resuscitation. Their concerns included: family’s possible interruption of patient care, the relatives’ well-being, and their own interests, as well as limited physical space and resources. Most of these concerns do not stand in the face of existing empirical data or ethical scrutiny. We therefore recommend in favor of family presence during cardiopulmonary resuscitation.