Introduction and Overview
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Learning Through Conflict: Ethical Debates in
Sexual and Reproductive Health / John W. Townsend (offsite
link*)
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A Question of Ethics: Research and Practice in
Reproductive Health / Saumya RamaRao, Barbara Friedland, and John W.
Townsend
The intent of the ethical guidelines and regulations, developed over
time, that govern research on human subjects is to ensure that research
participants are well-informed volunteers, protected from harm, ensured
potential benefit, and enrolled in an egalitarian fashion. This study
discusses ethical issues that researchers and program planners grapple
with in the area of sexual and reproductive health. We illustrate the
dilemmas that arise in the application of the ethical principles, how
they have been addressed, lessons learned, and remaining challenges. The
illustrations come both from research and from service-delivery
situations. (Studies in Family Planning 2007; 38[4]: 229–241) (offsite
link*)
Ethical Issues in Reproductive Health Services
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Ethical and Human Rights Perspectives on
Providers’ Obligation to Ensure Adolescents’ Rights to Privacy /
Karin Ringheim
The rights of adolescents to privacy and confidentiality as stipulated
in international human rights conventions are poorly protected in
reproductive health-care settings. Fear that their private information
will become known, particularly to a parent, has been shown to be a
major factor in adolescents’ failure to seek the services they need. The
tension between parental interests in guiding the development of
children and public interest in maintaining a healthy population is
considered in light of the ethical principles that bear upon these
decisions. In practice, health-care workers are the intermediaries who
must ensure that the privacy rights of adolescent clients are protected.
They are bound through obligations engendered in human rights
conventions as well as by ethical principles, especially that of
nonmaleficence, to provide the young with information and confidential
services, skills that must be acquired through training. Enhancing the
survival of adolescents promotes the greater social good. (Studies in
Family Planning 2007; 38[4]: 245–252) (offsite
link*)
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Harm Reduction or Women’s Rights? Debating Access
to Emergency Contraceptive Pills in Canada and the United States /
L.L. Wynn, Joanna N. Erdman, Angel M. Foster, and James Trussell
This article compares the ethical pivot points in debates over
nonprescription access to emergency contraceptive pills in Canada and
the United States. These include women’s right to be informed about the
contraceptive method and its mechanism of action, pharmacists’
conscientious objection concerning the dispensing of emergency
contraceptive pills, and rights and equality of access to the method,
especially for poor women and minorities. In both countries, arguments
in support of expanding access to the pills were shaped by two competing
orientations toward health and sexuality. The first, “harm reduction,”
promotes emergency contraception as attenuating the public health risks
entailed in sex. The second orientation regards access to pills as a
question of women’s right to engage in nonprocreative sex and to choose
from among all reproductive health-care options. The authors contend
that arguments for expanding access to emergency contraceptive pills
that frame issues in terms of health and science are insufficient bases
for drug regulation; ultimately, women’s health is also a matter of
women’s rights. (Studies in Family Planning 2007; 38[4]: 253–267) (offsite
link*)
Ethical Issues in HIV Testing
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Ethical and Public Health Considerations in HIV
Counseling and Testing: Policy Implications / Sara E. Yeatman
HIV counseling and testing is broadly considered a critical component of
HIV transmission-prevention and treatment efforts. Given the severity of
the AIDS pandemic in sub-Saharan Africa, the potential societal benefit
of testing is invoked to call for its massive expansion and to justify a
shift from voluntary to routine testing. Surprisingly little evidence
has demonstrated, however, that such a shift will result in the intended
benefits to communities, particularly that of reducing the horizontal
transmission of HIV. This analysis addresses and critiques the
assumptions underlying a serostatus-based approach to behavior change
and discusses the ethical consequences of transferring control of the
decision to be tested from the individual to the provider. It concludes
with a discussion of the implications for HIV counseling and testing
policies and proposes alternatives to routine testing that have the
potential to be effective while preserving the right to know one’s HIV
status. (Studies in Family Planning 2007; 38[4]: 271–278) (offsite
link*)
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Routine Testing for HIV/AIDS in Sub-Saharan
Africa: A Philosopher’s Perspective / George M. Brockway
This article summarizes some important arguments for and against
instituting a routine testing regimen for HIV/AIDS in sub-Saharan
Africa. After reviewing these competing positions and noting their areas
of agreement and disagreement, the author recommends an alternative way
to solve the main sticking point between them, that is, how to test a
large majority of the population while still respecting their human
rights to autonomy and freedom from unnecessary harm. This article
argues that the proposed solution would respect the rights to autonomy
of the individual to a sufficient degree and stands a greater chance of
being both practicable and effective than the alternatives. (Studies in
Family Planning 2007; 38[4]: 279–283) (offsite
link*)
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The Sexual Ethics of HIV Testing and the Rights
and Responsibilities of Partners / Ruth Dixon-Mueller
The discourse of much of the international AIDS community champions the
rights of individuals in low-income countries to “just say no” to
routine HIV testing in health-care settings and, if tested and found
positive, not to inform their sexual partner(s) if such disclosure could
result in substantial personal harm. This study contends that the right
of individuals to refuse testing ignores the right of their sexual
partners—male or female, regular or casual—to be informed of the health
risks to which they may be exposed on entering or continuing a sexual
relationship or engaging in particular sexual acts. If, as the UN has
declared, all persons have the right to decide freely and responsibly on
matters relating to their sexuality, including their sexual and
reproductive health, free from coercion, discrimination, and violence,
then all persons have the right and the responsibility to know their own
and their partner’s serostatus and to protect themselves and their
partner(s) from sexually transmitted infections (STIs). Support by AIDS
activists for policies of routine STI/HIV testing, counseling, and
disclosure between both partners in a sexual relationship would help to
promote an ethic of equal rights and shared responsibility for sexual
behavior and its consequences. (Studies in Family Planning 2007; 38[4]:
284–296) (offsite
link*)
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Should Caregivers Be Compelled to Disclose
Patients’ HIV Infection to the Patients’ Sex Partners Without Consent?
/ Babafemi Odunsi
The emergence of the HIV/AIDS pandemic has added to the tension between
patients’ private interests and public health interests regarding
medical confidentiality. Many people become infected with HIV because
they are unaware of the positive serostatus of their sexual partners.
Informing or warning the sexual partners of HIV-positive patients of the
patients’ serostatus could assist in curtailing the spread of HIV/AIDS
because sexual partners can thereby choose to avoid having unprotected
sex with infected persons. By law, however, doctors have a duty to their
patients to protect their medical confidentiality. Doctors, therefore,
face a dilemma concerning which should prevail: patients’ right to
privacy and confidentiality or the importance to society of controlling
the spread of the pandemic. Most medical regulatory bodies do not take
clear-cut positions on the issue, leaving the decision to the discretion
of individual doctors. The question of whether doctors should be legally
empowered to breach the confidence of patients to protect the patients’
sexual partners is discussed here with reference to the existing laws of
Canada, the United States, and Nigeria. (Studies in Family Planning
2007; 38[4]: 297–306) (offsite
link*)
Ethical Issues in Reproductive Health Research
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Confidentiality Concerns with Mapping
Survey Data in Reproductive Health Research / Jill E. Sherman and
Tamara L. Fetters
The increasing availability of georeferenced datasets creates new
opportunities to perform spatial analysis of social science and public
health survey data, but also raises ethical issues regarding the
potential for unintended violation of the confidentiality of
respondents. This article examines these ethical challenges by
reflecting on the experience of a study mapping the facilities that
provide abortion-related services in Cambodia. The technique of masking
is examined as a potential method for preventing reidentification of
respondents in georeferenced surveys. Broader solutions are offered for
ways to balance the potentially conflicting goals of spatial analysis
and protection of confidentiality. (Studies in Family Planning 2007;
38[4]: 309–321) (offsite
link*)
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Using Mystery Clients to Assess Condom
Negotiation in Malawi: Some Ethical Concerns / Francine van den
Borne
To halt the HIV/AIDS epidemic in Malawi, donors supported the government
in promoting safer sex among women who solicit sex with men in and
around bars. In 1996, a qualitative study explored the changing dynamics
of concurrent sexual partnerships, using a variety of researchers and
methods. Although most international ethical research codes prescribe
the informed consent of research subjects, the present author, as
principal investigator for that study, included the mystery-client
method, which omits informants’ consent. Five trained, pilot-tested, and
closely supervised male researchers contacted 101 bar girls and
“freelancing” women in trading and urban centers to assess the women’s
ability to negotiate condom use. The men posed as clients but were
instructed not to have sex with their informants. This approach provided
important contextualized information to improve HIV
transmission-prevention programs, yet it raises ethical concerns. This
article is intended to contribute to the dialogue and debate on ethical
research involving mystery clients and to encourage other researchers to
share their ethical dilemmas and show how they have addressed them.
(Studies in Family Planning 2007; 38[4]: 322–330) (offsite
link*)
Reproductive Health and the State
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Ethics, Ideology, and Reproductive Health Policy
in the United States / Andrzej Kulczycki
The 1994 International Conference on Population and Development held in
Cairo recognized the centrality of reproductive health to human rights
and development. Progress on the Cairo agenda has slowed for numerous
reasons, however. The United States, once an enthusiastic promoter of
this agenda and still the world’s leading reproductive health donor, has
revised its reproductive health policies radically since the 2000
presidential election of George W. Bush. This study examines how
policies have been reconfigured in five key reproductive health areas,
sparking controversy both in the United States and internationally.
These categories are the content of sex education, access to emergency
contraception and to abortion services, condom effectiveness, and
HIV/AIDS prevention. The analysis presented here elucidates how
ideological considerations have superseded public health and ethical
concerns and reflects on health and ethical consequences. (Studies in
Family Planning 2007; 38[4]: 333–351) (offsite
link*)
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Reproductive Health in Iran: Pragmatic
Achievements, Unmet Needs, and Ethical Challenges in a Theocratic System
/ Amir H. Mehryar, Shirin Ahmad-Nia, and Shahla Kazemipour
Since its revival in 1989, the reproductive health and family planning
program of Iran has made great strides in raising the contraceptive
prevalence rate and reducing fertility. The majority of couples are
using modern methods promoted and provided by the national program,
although a sizable proportion of couples continue to depend on the
traditional method of withdrawal. The longstanding urban–rural gap in
contraceptive prevalence rates has been reduced to about 10 percent,
which is mainly the result of better-educated urban couples’ continued
practice of withdrawal. Despite its enormous success in meeting the
needs of married couples, in narrowing the urban–rural gap in access to
and use of modern contraceptives, and in reducing fertility, the Iranian
family planning program is open to criticism for confining its target
audience to married couples and failing to address the issue of
abortion. The restrictive aspects of the program are often justified on
the grounds of religious values and fear of encouraging sexual
promiscuity. Because of the theocratic nature of the political system
and the immense power enjoyed by Shiite ulama (religious leaders), no
step can be taken to address these restrictions without their implicit
support and approval. This study describes some of the ethical issues
facing the reproductive health program of Iran and indicates how
pragmatic approaches adopted by the ruling Shiite ulama to solve some of
the social and medical challenges of a rapidly modernizing society may
be extended to overcome ethical hurdles faced by the reproductive health
program. (Studies in Family Planning 2007; 38[4]: 352–361) (offsite
link*)
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a fee.
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