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Law, Ethics, and Public Health in the Vaccination Debates: Politics of the Measles Outbreak
Get PDFThe measles outbreak of early 2015 is symptomatic of a larger societal problem–the growing number of parents who decide against vaccinating their children. This failure is causing the resurgence of childhood diseases once eliminated from the United States.
This article explores the legal and ethical landscape of vaccine exemptions. While all states require childhood vaccinations, they differ significantly in the types of religious and/or philosophical exemptions permitted, the rigor of the application process, and available review mechanisms. States with relaxed exemption policies disproportionately experience more outbreaks of vaccine-preventable disease.
Vaccine exemptions are an illustration of the “tragedy of the commons,” in which parents choose not to vaccinate their children, relying on the fact that other parents will vaccinate their children, thus providing community immunity. However, the net result of many individual decisions not to vaccinate is the collapse of herd immunity and thus an upsurge in preventable disease and death.
The failure to vaccinate puts others at risk, thus violating an important ethical principle. However, punishing individual parents could entrench political opposition to vaccine policy. The most ethical and effective solution is for state legislatures to tighten vaccination laws, making it more difficult to obtain non-medical exemptions
Strengthening the Detection of and Early Response to Public Health Emergencies: Lessons from the West African Ebola Epidemic
Get PDFBackground
In the year since the World Health Organization (WHO) notified of an Ebola outbreak in West Africa, more than 24,000 cases have been reported and over 10,000 individuals have died. Moreover, countless non-Ebola deaths have occurred as a result of health system closings and an international aid effort in the $USD billions has been invested in control efforts. While the international response to the West African Ebola virus disease epidemic eventually exemplified the great potential of the global public health community, the protracted early response also revealed critical gaps, which likely resulted in exacerbation of the epidemic. It is incumbent on international health partners to learn from missteps that occurred in the early stages of the epidemic and strengthen our public health capacity to better respond to future public health emergencies.
Findings and Recommendations
Strategies to consider to improve capacity to respond global health emergencies include: 1) development of a more precise system to risk stratify geographic settings susceptible to disease outbreaks, 2) reconsideration of the 2005 International Health Regulations Criteria to allow for earlier responses to localized epidemics before they reach epidemic proportions, 3) increasing the flexibility of the World Health Organization director general to characterize epidemics with more granularity, 4) development of guidelines for best practices to promote partnership with local stakeholders and identify locally acceptable response strategies, and, most importantly, 5) making good on international commitments to establish a fund for public health emergency preparedness and response.
Conclusions
The recent success of the global action to stem the Ebola virus disease epidemic is laudable but should not encourage complacency in our efforts to improve the global public health infrastructure. The current epidemic has revealed both the danger posed by disease outbreaks in states with weak health systems and their widespread impact in an increasingly globalized world. The power of global health law and global health institutions will remain seriously unrealized and deeply compromised if the Ebola epidemic does not spur fundamental reform
A Retrospective and Prospective Analysis of the West African Ebola Virus Disease Epidemic: Robust National Health Systems at the Foundation and an Empowered WHO at the Apex
Get PDFThe West African Ebola epidemic is a pivotal moment for the global health system. Just as the depth of the crisis ultimately spurred an unprecedented response, the failures of leadership demand innovative reforms. This analysis offers a template for these reforms, responding to the profound harms posed by fragile national health systems, delays in the international response, deficient resource mobilization, ill-defined responsibilities, and insufficient coordination. The scope of the reforms must address the failures evident in the Ebola response, as well as entrenched weaknesses that enabled the epidemic to reach its heights, transforming the existing inchoate, organically developed global health architecture into a purposeful, organized system.
At the apex of the global health system should be an empowered, highly capable World Health Organization (WHO), using its powerful normative tools including its treaty-making ability, with technical excellence including anthropologic, legal, and other competencies, and operational capacity. Member states should fund WHO primarily through assessed contributions and at the level required to fully meet its global responsibilities, and enable WHO to re-assert control over the regions, including through Executive Board selection of Regional Directors. In an invigorated global health system, civil society will be able to effectively engage in WHO policymaking. The World Health Assembly would enhance the International Health Regulations, including to improve monitoring of capacities, clarify responsibilities, and increase transparency of the Emergency Committees, while an independent working group would advise the Director-General on declaration public health emergencies of international concern.
National health systems must be strengthened, including with sufficient numbers of well-trained, equitable distributed, sufficient numbers of health workers, particularly at the community-level building trust and engaging communities, working in safe conditions. Global resources need to support national systems, including a global health workforce and new financing, with an International Health Systems Fund to strengthen health systems and emergency contingency fund and Pandemic Emergency Facility to prepare for and respond to health emergencies
The Americans with Disabilities Act at 25: The Highest Expression of American Values
Get PDFEnacted in 1990, the Americans with Disabilities Act (ADA) is a watershed piece of legislation which enshrines in law a social promise of equality and inclusion into all facets of life, while offering an inspiring model that much of the world has come to embrace. This editorial launches JAMA’s theme issue on the 25th anniversary of the ADA by detailing the Act’s history, main provisions, and far-reaching impacts on health, providing a context for the three Original Investigations and six scholarly Viewpoints that make up the theme issue. The editorial begins with a discussion of the ADA’s history, highlighting the indispensable role of the broad disability rights coalition. The editorial then turns to an overview of the law and its main provisions, before discussing its domestic impact, both in integrating those with disabilities into society and reducing discrimination in health care settings—while acknowledging the law’s unfinished business. Finally, the editorial examines the international influence the ADA has had before concluding by highlighting what remains to be done to integrate those with disabilities fully into American society and calling for the U.S. to ratify the UN Convention on the Rights of Persons with Disabilities
Precipice Regulations and Perverse Incentives: Comparing Historic Preservation Designation and Endangered Species Listing
Get PDFThe insight upon which this article is built is that the common structures of these two legal regimes create incentives toward destroying the resources they seek to protect. The shift from legal freedom to exploit resources to strict limitation on property modification and the lengthy and public process to designate or list specific resources for protection provide the motive and the opportunity to legally frustrate the application of the statutes. This article seeks to understand how these perverse incentives are created and how they can be lessened. The procedural and substantive provisions of both legal regimes have evolved to reduce the perverse incentives created by the formal precipice character of the regulatory structure.
Part I describes each regulatory regime and specifies the ways the regimes create incentives to destroy the resources they aim to protect. Part I also reviews the literature identifying such perverse incentives and what is known about the incidence of actual destruction. Part II addresses actual and suggested changes to the procedures for designation or listing the resources, while Part III looks at substantive changes in the laws that may have the purpose or effect of moderating negative incentives. Finally, part IV concludes by considering the extent to which accommodation reforms further, or compromise, the values that historic preservation and biodiversity laws advance
Inference under Stability of Risk Preferences
Get PDFWe leverage the assumption that preferences are stable across contexts to partially identify and conduct inference on the parameters of a structural model of risky choice. Working with data on households\u27 deductible choices across three lines of insurance coverage and a model that nests expected utility theory plus a range of non-expected utility models, we perform a revealed preference analysis that yields household-specific bounds on the model parameters. We then impose stability and other structural assumptions to tighten the bounds, and we explore what we can learn about households\u27 risk preferences from the intervals defined by the bounds. We further utilize the intervals to (i) classify households into preference types and (ii) recover the single parameterization of the model that best fits the data. Our approach does not entail making distributional assumptions about unobserved heterogeneity in preferences
A Comment on the Supreme Court\u27s Decision in Ohio v. Clark: The Court\u27s Confrontation Clause Jurisprudence Evolves
No full textIn Ohio v. Clark, the U.S. Supreme Court held admissible in defendant’s criminal trial for child abuse, a teacher’s testimony that the three-year-old victim, upon being pressed for an answer, told his pre-school teacher that the defendant was responsible for the physical abuse noted by the teachers on the child. This on-the-stand report of the child’s out-of-court statement, was admissible even though the child did not take the witness stand for possible cross examination and jury scrutiny of his demeanor to gauge his accuracy
What Can Be Done, If Anything, About the Dangerous Penchant of Public Trust Scholars to Overextend Joseph Sax’s Original Conception: Have We Produced a Bridge Too Far?
Get PDFThis Article examines the tendency of many legal scholars to overextend the scope of a previous scholar’s original idea—in this case, Professor Joseph Sax’s reconceptualization of the largely moribund common law public trust doctrine. Legal scholars are induced to write immoderately either to enhance their standing within the academic community or, more selflessly, to achieve law reform. These expansionist tendencies, however, are not without risk—a common law doctrine that becomes too unmoored from its historical shackles may lose the support of the courts that is required for its implementation. The Article examines whether a combination of academic norms and hortatory institutional standards might minimize that risk by encouraging derivative scholars to think critically about the impact of their writings on the original idea lest they unintentionally jeopardize the initial author’s objectives. The purpose of the Article is not to discourage derivative, even revisionist scholarship, but only to make second generation scholars more reflective about the potential real world consequences of their writings
The Zombie First Amendment
Get PDFScholarly and popular critiques of contemporary free speech jurisprudence have noted an attitude of unquestioning deference to the political power of money. Rather than sheltering the ability to speak truth to power, they have lamented, the contemporary first amendment shelters power’s ability to make and propagate its own truth. This essay relates developments in recent first amendment jurisprudence to a larger struggle now underway to shape the distribution of information power in the era of informational capitalism. In particular, it argues that cases about political speech — cases that lie at the first amendment’s traditional core — tell only a small part of the story. The contemporary first amendment must be situated within a larger story about the realignment of information flows within circuits of power that serve emerging global interests, and to tell that story one must look to disputes about the speech implications of private economic regulation. As a result of that struggle, free speech jurisprudence about information rights and harms is becoming what is best described as a zombie free speech jurisprudence, within which speech, money, and information processing are equivalent, and speech advancing economic interests receives the strongest protection of all.
Part II discusses a group of seemingly disparate cases about the contours of the contemporary first amendment, identifying two common themes. First, the cases construct a broad equivalence between speech and money that is heavily influenced by notions of information as property. Second, the idea of information as proprietary supports actions defining flows of unauthorized speech as contraband. Part III argues that first amendment decisions don’t create distributional inequities in information power; they are symptoms of it. It explores the genealogy of the contemporary crop of free speech zombies, tracing their origins to deeper realignments in the legal regimes that more directly constitute and reinforce private economic power. First amendment jurisprudence has yet to acknowledge these realignments, and that failure of recognition is both intellectual and moral. Even so, the first amendment cannot serve as law’s primary tool for rebalancing freedom of expression in the information age
The Normative Authority of the World Health Organization
Get PDFThe World Health Organization (WHO) was born after the devastation of World War II, as a normative agency endowed with unprecedented constitutional powers. But even as it has achieved stunning successes, such as the eradication of smallpox, it has failed to live up to the exalted expectations of the postwar health and human rights movement e exemplified most recently by its inadequate response to the Ebola epidemic. Our aim is to offer innovative ideas for restoring the Organization to its leadership position by exercising its normative authority, even as it faces a crowded and often chaotic global health architecture. Before doing so, it will be helpful to summarize the main tensions the Organization faces in today\u27s global health landscape