(PDF) Vulnerability and Marginalized Populations

Running head: DISCUSSION QUESTIONS 1
Discussion Questions
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Discussion Questions
Assignment 4 – Vulnerability and Marginalized Populations
Case 1: Reducing Sudden Infant Death Syndrome in a Culturally Diverse Society
1. Evidence suggests that several factors affect the magnitude of risk and that bedsharing
in the absence of these factors does not significantly increase the risk of SIDS. But the
interplay of risks can be complex and difficult to communicate effectively in a national
campaign. Can a definitive “no bed-sharing” message be defended, on ethical grounds, if it
causes less confusion but overstates the risk to some groups? What are the most important
ethical considerations here?
Sudden Infant Death Syndrome (SIDS) is a complex health and ethical problem that
offers several challenges in determining the best prevention approach to reduce the number of
incidences (Wrigley & Dawson, 2016). Some factors have been identified to increase the risk of
SIDs and have been classified as modifiable and non-modifiable. The modifiable factors include
bed sharing, maternal smoking, breast feeding, prone sleeping position, and attendance level to
prenatal classes. The factors that have been classified as non-modifiable include social economic
status, baby’s sex, and the mother’s age. There have been concerns regarding the best campaigns
that would help promote awareness of the risks factors that parents can modify to reduce the
degree of vulnerability. For instance, bed sharing was identified as one of the major risk factors
that can be modified. However, it is not considered as a significant risk factor if other underlying
factors such as maternal smoking, duration of bed-sharing, and the baby’s age. Therefore, it is
difficult to scientifically define the risk factor in a clear manner that parents can understand.
Also, the campaign against bed-sharing was faced with varying degrees of criticism and
reactions among the Māori and Polynesian families because the childrearing practice is deeply

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rooted to their traditions (Wrigley & Dawson, 2016). This is a risky strategy because it may
result in alienating this group of people.
A definitive “no-bed-sharing” message cannot be defended if the cultural sensitivity of
different groups of parents is not taken into account (Hawkes, 2013; Wrigley & Dawson, 2016).
If a recommendation that just exclusively states “no bed-sharing,” it might be misleading
because parents may not be able to make informed decision, especially, if the child has a
relatively low risk of SIDS. Also, such a recommendation would not consider any discussions
regarding the reasons why parents practice bed-sharing (Wrigley & Dawson, 2016). As a result,
health practitioners might not raise the topic and may result to parents lying about their behavior.
The most important ethical consideration is that the baby should receive the best care
with minimum harm caused, autonomy, and beneficence. It can be argued that “no-bed sharing”
message aims to prevent harm to the babies but considerable harm may occur if it results in
alienating the target group because of the cultural beliefs thus fail to reduce the rates of SIDS
(Wrigley & Dawson, 2016). In regards to autonomy, parents have the right to make informed
decisions. Therefore, they should be sufficiently informed that bed sharing as a risk for SIDS is
relatively dependent on the presence of other factors. If the other factors, such as lack of
exposure to maternal smoking, healthy terms births, or exclusive breastfeeding, are considered,
the child’s risk for bed-sharing related SIDS will be significantly lower.
2. What weight should be attributed to the cultural significance of bed-sharing when
generating guideline s, and why? Should risks that relate to culturally significant parental
practices, such as bed-sharing, be treated differently from risks relating to practices that
are not held to be culturally significant?

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The cultural significance is highly sensitive and should be regarded as a critical factor
when generating guidelines because the level of acceptability of the recommendations given will
be dependent on how controversial the message is in relation to the cultural behavior (Wrigley &
Dawson, 2016). In certain cultures, such as the Māori and Polynesian populations, bed-sharing is
a common practice that has been linked with a relatively low risk level of SIDS. However, other
modifiable and non-modifiable factors such as lack of attendance to prenatal classes, maternal
smoking, low social economic status, age of first time mothers, and fewer years of education are
more prevalent among the Maori parents in comparison to non-Maori parents. Consequently,
among the Maori children, bed-sharing, in conjunction with other the mentioned factors, poses a
greater risk for SIDS than to non-Maori children (Wrigley & Dawson, 2016). It is therefore very
important to consider the cultural significance of bed-sharing among different communities in
relation to other social economic and behavioral factors that influence the risk for SIDS when
generating guidelines.
The culturally significant parental practices related risks such as bed-sharing should be
treated differently from other factors because of the complexities associated with the different
reactions among people with different traditions (Wrigley & Dawson, 2016). For instance, the
message of no bed-sharing had serious implication because it was not culturally sensitive,
therefore, some people from Māori and Polynesian ended up rejecting to comply or turning away
from SIDS prevention campaigns. Conversely, the factors that involve
8. Parents can control some risk factors for SIDS, but others involve broader societal
issues, such as socioeconomic status. Does social justice require that prevention campaigns
targeting parental practices be coupled with efforts to tackle social and economic
disparities and inequities? Who should be responsible for ensuring that this is the case?

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What should researchers do when they identify a parental practice as risky if resourcing
for broader action is not forthcoming?
The ethical consideration of social justice requires that that such campaigns to promote
social change efforts in support of or with venerable and oppressed groups of people focused
primarily on issue of poverty, equality of opportunities, and discrimination among other types of
injustices (Wrigley & Dawson, 2016). Thus the prevention campaign should consider efforts to
help tackle social and economic disparities to promote equal opportunity access to resources
needed to promote the changes in parental practices in order to reduce risks for SIDS. If
researchers identifies a parental practice as risky but the broader actions to rectify it fail after
implementation, they should conduct analysis to understand the reason and develop
recommendations based on the findings.

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Discussion 4 – International Collaboration for Global Public Health
Case 1: The Ethics of HIV Testing Policies
1. How might an emphasis on protecting human rights in HIV prevention reduce the
importance of public health and social justice?
There have been ethical controversies on the approaches being used to test and prevent
HIV infections from spreading (Meslin & Garba, 2016). Emphasis on mandatory HIV testing
and partner notification may impose ethical concerns in regards to autonomy and may result
increased risk for discrimination and stigma related violence. Conversely, although the
traditional approach that is based on client initiated testing has been shown to be effective, the
epidemic still persists in the resource poor countries. Therefore, this undermines the efforts to
control the HIV epidemic and impeding social justice and public health (Meslin & Garba, 2016).
2. Is opting in, or not opting out, as part of the routine testing strategy, ethically equivalent
to acquiring consent within a voluntary testing site? What are the necessary and sufficient
conditions, ethical or otherwise, for “adequate information ” or “sufficient voluntariness”
in cases of HIV testing ?
The routine testing strategy, opting in or not opting out, is not ethically equivalent to
client initiated testing because in a culture in which patients do not feel comfortable to decline a
recommendation offered by a healthcare practitioner(Meslin & Garba, 2016). The routine testing
approach may fail to consider the clients autonomy in making decision regarding their health.
However, the approach promotes maleficence and beneficence in regards to promoting the public
health and justice in regards to providing equal opportunity to use the health resources for HIV
testing (Meslin & Garba, 2016).

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It is important to consider the social determinants of health (SDH) which are the certain
contextual factors that influence the wellbeing of individuals or groups (Meslin & Garba, 2016).
The SDH framework is based on social justice with the main guiding principle as equity.
Therefore it is essential to consider the social factors such as the socioeconomic status and make
decisions in consideration of the medical interventions and the SDH when allocating resources.
3. Is there an ethical conflict between one’s duty, whether as a physician or a public health
official, whether as the minister of health or simply as a person, to adopt what are
considered to be effective methods of controlling disease, e.g., HIV , and the obligation to
respect indigenous knowledge systems and approaches to public health? If there is a
conflict, which duty should take precedent?
Ethical conflict may arise when implementing an intervention considered to be effective
in preventing HIV. Implementing recommendations adopted from the international communities
of public health may impose challenge to the indigenous knowledge system (Meslin & Garba,
2016). Such interventions have been legitimized by the western culture of research and
methodology that may result in the alienation others in the effort to combat the spread of HIV.
As a figure of authority tasked to implement an intervention, one may be faced with the ethical
conflict in regards to social ethical ideals, human rights, norms and standards. Indigenous
knowledge system regard highly the concept of communalism which is more supportive of
community-based programs that support promotion of the health of the community as opposed to
individual rights and could be effective in controlling HIV in the context of low and middle
income countries (LMIC) (Meslin & Garba, 2016). In such a situation, one should consider an
approaches that are balance considerations for promoting public health and maintaining
individual rights in the context of current socio-ethical and cultural principles.

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4. What policy would you recommend under these circumstances? And what ethical
principles guided your recommendation?
I would recommend a botho-based policy that promotes both routine and voluntary
testing approaches. The routine testing would be doesn’t in the form of opting-out strategy in
areas where there is a high concentration of people infected with HIV but maintain strict
confidentiality and competent pre- and post-counseling services (Meslin & Garba, 2016). In
areas where there are sufficient HIV testing resources, the client initiated approach would be
sufficient. However, educational interventions and messages explaining the importance of being
aware of their serostatus would be communicate vigilantly in both sections of the community.
The ethical principle beneficence and maleficence requires health practitioners to do most good
with minimum harm. By recommending the policy stated, the aim for routine testing is to
promote HIV status awareness and prevention from spreading in order to promote community
health.
5. How would your recommendation provide, if at all, protections against discrimination
and stigma-related violence?
A botho-based public health policy could be the most effective and but still well balanced
approach to preventing harm and promoting health of both the individual and the community
(Jensen, 2010). However and lead to controversies in regards to discrimination and violence that
is stigma-related. In order to minimize stigma related concerns, I would incorporate ethical
preconditions such as competent pre- and post-test counseling and strict confidentiality.
Case 3: Drug Trials in Developing Countries
1. Who are the stakeholders in this case, what is at stake for each of them, and what values
does each bring to the situation?

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The stake holders in the case described include the researchers and foreign drug
companies conducting the clinical trials, the Indian population, and the Indian Ministry of Health
and Family Welfare (Meslin & Garba, 2016). The foreign drug companies risk losing their
capital investment if the drug trials fail to provide the intended results. However, these activities
provide business opportunities for both India and the companies, and development of the
infrastructure in the country. The Indian population who participate in the clinical trials risk
suffering adverse effects as a result of the medications but stand to gain monetary incentives, co-
authorship with the researchers, and improved health if the drugs are effective in controlling the
target illness. The clinical trials risk to undermine the efficiency of public health policies
stipulated by the Ministry of Health and Family Welfare (Meslin & Garba, 2016). However, this
but offers opportunities for the amendments or creation of new policies to help govern the
processes and protect the human rights while promoting public health.
2. What are the risks and benefits of enrolling impoverished, uneducated patients living in
developing countries in clinical drug trials? What are the barriers to obtaining true
informed consent from these patients, and what can be done to overcome these barriers?
The risks involved in enrolling participants from low social caste include impeding their
right to provide an appropriate informed consent, exploitation and consequently, health
complications as a result of consuming the drugs (Meslin & Garba, 2016). However, the
participants stand to gain high standard medical healthcare at a low or no cost which would have
otherwise been too expensive for them to afford. The main barriers that prevent such patients
from giving a true informed consent include illiteracy, lack or weak health policies that
exclusively protect the vulnerable population from exploitation, and poverty and insufficient
healthcare infrastructure leaving them susceptible to unwarranted influence such as being offered

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food and monetary compensation for their participation (Meslin & Garba, 2016). To overcome
these barriers, the companies conducting the drug trials should consider targeting patient
population that is literate or and capable of comprehending the relative risks and benefits
involved (Smith, 2003). Also, the government should review the public health policies related to
clinical trials using human participants to improve ethical considerations and human rights
protection clauses, and provide better healthcare infrastructure.
3. What are the ethical implications of tying a researcher’s compensation to the number of
subjects enrolled? Should this practice be permitted?
The approach involving trying the researcher’s compensation to the number enrolled
subjects poses a risk for impeding the participants’ rights for providing a well informed consent
in effort to quickly recruit more patients (Meslin & Garba, 2016). In addition, it is inappropriate
for the researchers to be involved in multiple roles or relationships that may impair their
performance or exploit or harm others. Therefore, this practice should not be permitted because
of the associated ethical implications.
4. Are multinational pharmaceutical companies that benefit from cost-effective drug trials
in developing countries obligated to improve the lives of people living in those countries?
The pharmaceutical companies are obligated to provide benefit to the patients and do no
harm by the ethical codes of conduct (Weigmann, 2015). The main goal for conducting clinical
trials in a foreign nations should be to address the care needs of the population of the host
country. The companies should strictly abide by the set standards such as the Declaration of
Helsinki (DoH) and promote collaboration with local communities. In addition, the DoH states
that the companies should provide standards of care to the control group that is dependent on the
local population (Weigmann, 2015).

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5. Who should be held responsible for adverse events due to a drug trial conducted by a
multinational company in a country where there is limited health insurance, no social
security, and poor enforcement of regulations ? What international or grassroots efforts
might help ensure accountability for adverse events?
In such a case, the companies conducting the clinical trials, and both the local and the
foreign government should be held responsible when adverse effects occur because it should
have instituted sufficient and effective regulations to prevent such issues and ensure the ethical
standards are abided to (Weigmann, 2015).. To help prevent such issues, the governments should
implement standards that guide the conductions of research in international settings such as the
DoH and the biomedical guidelines for conducting research that utilizes human subjects.

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References
Hawkes, N. (2013). Sharing a bed with your baby increases the risk of sudden infant death
syndrome, UK study shows. BMJ: British Medical Journal, 346.
https://doi.org/10.1136/bmj.f3296
Jensen, K., & Gaie, J. B. (2010). African communalism and public health policies: the relevance
ofindigenous concepts of personal identity to HIV/AIDS policies in Botswana. African
Journal of AIDS Research, 9(3), 297-305. doi:10.2989/16085906.2010.530187
Meslin E. M. & Garba, I. (2016). International Collaboration for Global Public Health. In: H.
Barrett D, W. Ortmann L, Dawson A, et al., (Ed). Public Health Ethics: Cases Spanning
the Globe (pp. 241-284). Cham (CH): Springer
Smith, D. (2003). Five principles for research ethics. Monitor on psychology, 34(1), 56.
Retrieved from https://www.apa.org/monitor/jan03/principles.aspx
Weigmann, K. (2015). The ethics of global clinical trials: In developing countries, participation
in clinical trials is sometimes the only way to access medical treatment. What should be
done to avoid exploitation of disadvantaged populations? European Molecular Biology
Organization Reports, 16(5), 566-570. https://dx.doi.org/10.15252%2Fembr.201540398
Wrigley A, & Dawson A. (2016). Vulnerability and Marginalized Populations. In: H. Barrett D,
W. Ortmann L, Dawson A, et al., (Ed). Public Health Ethics: Cases Spanning the Globe
(pp. 203-240). Cham (CH): Springer