Biomedical ethics test

The test will evaluate your knowledge of the reading assignments related to the textbook and the Case of Larry Nassar.

There will be 1 test worth 200 points or 20% of your final grade.

The test will become available at 8 AM ET on the Friday of Week 12. On this day or very soon after please log into the course website and follow the link to “Test”. Click on the link called “Test Questions” and follow the link to open the exam. Every student will have a unique set of ten questions. Copy and paste your questions into a Microsoft Word document. Begin your research, and develop and refine your responses.

The test will be comprised of 10 essay questions. Both content and format will be assessed when determining your score. Content refers to the message of your response. Format refers to the presentation of that message (things like proper spelling, grammar, punctuation and sentence structure, etc.)

Your responses are required to be in your own words. The use of direct quotes in your response is not appropriate and will result in reduced points.

You must develop your response to each question with scholarly peer-reviewed (SPR) sources (this means peer-reviewed journal articles or textbooks). At least 2 SPR sources must be cited and referenced in your response per test question. At least one of the cited and referenced sources must be from a peer-reviewed scholarly journal article (again, per question). Sources should be cited and referenced in either AMA or APA format (choose one and use it throughout your test). Even if the question requests your opinion, you must provide cited references to support your response. Place your references used for a question at the end of each answer.

Once you have completed the test, save the Microsoft Word document to your computer. This document should be uploaded to the Turnitin link named, “Submit Test Answers Here”. Turnitin is a plagiarism detection software program and is used throughout this course. The examination is due on the Friday of Week 13.

Reminder about Academic Integrity: This examination is an individual requirement. You are not to discuss or share your work (including, but not limited to, your research, materials used, or responses to specific items) with any other person. Academic integrity violations include cheating on examinations, plagiarism, falsification, forgery, and obstruction, multiple submissions, facilitating academic dishonesty, misconduct in research and creative endeavors, misuse of academic records, misuse of intellectual property and violation of ethical and professional standards. A plagiarism detection software program is typically used at Indiana State University. Please protect yourself from and avoid any such action or situation where you are tempted. An important means to protect yourself from an academic integrity violation is to AVOID PROCRASTINATION. There is no penalty for submitting this examination ahead of time.

Once available,

Sep • Oct 2017

400

SPORTS HEALTH

[ Editorial ]

H
uman culture is the synthesis of our worldly experience,
for better or worse. Therefore, cultural change in any
society is often an arduous process complicated by

traditions, age-dependent philosophies, and gender-related
attitudes. Consequently, culture often dictates norms of behavior
and acceptable boundaries for human relationships and
interactions, reflecting our ethical and moral principles and
representing our values as human beings.

Various segments of society often further develop cultural
standards dependent on their reason for organization;
professions, sports, religions, and politics all can influence
cultural norms. Athletic cultures, for instance, are heavily
influenced by their innate desire to compete and win.
Understandably, the world of sport demands high levels of
dedication, motivation, and discipline, often generating a unique
culture. Consequently, the extreme single-mindedness that some
athletic pursuits demand can clash with cultural guidelines and
norms, creating conflicts for the athlete in society. These
conflicts often raise questions about the value of elite
competition and the price of victory.

Athletic pursuit dilemmas can cause mental anguish for adult
athletes while they pursue their dreams and may result in
regrets later in life about opportunities lost and effort spent.
However, the more serious scenario is when children are placed
into high-demand athletic environments under high pressure
from adults to train and compete before they have developed
the mental capacity to decide their own preferences. These
children can become vulnerable to abuse in environments that
have not been fortified to adequately protect them. A prominent
example of such an unhealthy, shocking environment was
outlined in a recent publication on the sport of gymnastics.2 In
short, this publication reviewed the alleged sexual abuse of 365
gymnasts over a 20-year period. Not only is the number of the
young women involved shocking, but the duration—20
years—suggests a long-standing cultural problem in the sport of
gymnastics.

The long-standing concerns about gymnastics and the recent
allegations against the sport prompted USA Gymnastics to
conduct an independent review of their policies, procedures,
and bylaws related to sexual abuse and misconduct. They chose
Deborah Daniels, a former federal prosecutor, to conduct the
investigation,1 partnering with Praesidium,5 an organization with

25 years of experience specializing in preventing sexual abuse
in youth and vulnerable adults.

The voluminous 100-page report1 outlines the at-risk
environment of young gymnasts, emphasizing how vulnerable
young girls are in a sport that depends on very close
relationships between athletes, coaches, and medical personnel.
This environment often limit

57Mountjoy M. Br J Sports Med January 2019 Vol 53 No 1

‘Only by speaking out can we create
lasting change’: what can we learn from
the Dr Larry Nassar tragedy?
Margo Mountjoy1,2

As it turns out… Dr Nassar was not a
doctor, he in fact is, was, and forever shall
be, a child molester and a monster of a
human being. End of story. He abused my
trust, he abused my body and he left scars
on my psyche that may never go away.

McKayla Maroney, Olympic Gold
Medallist, London 2012.

Dr Larry Nassar was sentenced on 24
January 2018 to 40–125 years in prison in
Eaton County and 40–175 years in Ingham
County, Michigan, USA, for first-degree
criminal sexual conduct in addition to 60
years in Federal court for child pornog-
raphy. During the court proceedings, 156
women who call themselves the ‘army of
survivors’, spoke about their abuse expe-
riences in emotional and powerful victim
impact statements. In the course of his
professional career, Dr Nassar is alleged to
have sexually abused approximately 256
female athletes from 1998 to 2015, often
in front of parents. His victims were mainly
gymnasts, some as young as 6 years of
age. For some victims, the abuse occurred
repetitively, up to 10 years in duration.
Dr Nassar stated that his ‘medical treat-
ments’ (which were invasive pelvic floor
‘therapy’ where he would digitally pene-
trate girls’ vaginas and anuses) would cure
physical injuries. He abused them in his
clinic, his home, at training camps and at
competition venues where he treated them
alone in his hotel room, often after having
sedated the athlete with sleeping pills.
Dr Nassar referred to himself as the ‘body
whisperer’.1

What is unique about this sexual abuse
case is that Dr Nassar is an osteopathic
sport medicine physician. One of our
colleagues. One of our fraternity. Larry
was the physician for the USA Gymnastics
team and worked at four Olympic Games.
He was a practising sport medicine physi-
cian for a prestigious university in the

NCAA collegiate system in the USA, the
team physician for a national sport feder-
ation and a member of the US Olympic
medical team; all coveted positions that
connote success and accomplishment in
our sport medicine culture. In these roles,
the team physician is in a position of great
privilege, responsibility and power.

What is sexuaL abuse iN spOrt?
Sexual abuse in sport is defined by the IOC
as ‘any conduct of a sexual nature, whether
non-contact, contact or penetrative, where
consent is coerced/manipulated or is not
or cannot be given’.2 Consent for sexual
activity does not apply to children given
their inability to understand the concept.3
Sexual abuse has been categorised as a
relational threat to child athletes. In the
Nassar case, the abuse can also be classi-
fied as an organisational threat with the
added complexity that the abuse included
medical misma

285© The Author(s) 2016
D.H. Barrett et al. (eds.), Public Health Ethics: Cases Spanning the Globe,
Public Health Ethics Analysis 3, DOI 10.1007/978-3-319-23847-0_9

Chapter 9
Public Health Research

Drue H. Barrett , Leonard W. Ortmann , Natalie Brown ,
Barbara R. DeCausey , Carla Saenz , and Angus Dawson

9.1 Introduction

Having a scientifi c basis for the practice of public health is critical. Research leads
to insight and innovations that solve health problems and is therefore central to
public health worldwide. For example, in the United States research is one of the ten
essential public health services (Public Health Functions Steering Committee 1994 ).
The Principle s of the Ethical Practice of Public Health , developed by the Public
Health Leadership Society ( 2002 ), emphasizes the value of having a scientifi c basis

The opinions, fi ndings, and conclusions of the authors do not necessarily refl ect the offi cial
position, views, or policies of the editors, the editors’ host institutions, or the authors’ host
institutions.

D. H. Barrett , PhD (*) • L. W. Ortmann , PhD
Offi ce of Scientifi c Integrity, Offi ce of the Associate Director for Science,
Offi ce of the Director , Centers for Disease Control and Prevention , Atlanta , GA , USA
e-mail: [email protected]

N. Brown , MPH
Human Research Protections Offi ce, Offi ce of Scientifi c Integrity, Offi ce of the Associate
Director for Science, Offi ce of the Director , Centers for Disease Control and Prevention ,
Atlanta , GA , USA

B. R. DeCausey , MPH, MBA
Clinical Research Branch, Division of Tuberculosis Elimination, National Center for HIV/
AIDS, Viral Hepatitis, STD, and TB Prevention , Centers for Disease Control and Prevention ,
Atlanta , GA , USA

C. Saenz , PhD
Regional Program on Bioethics, Offi ce of Knowledge Management, Bioethics, and Research ,
Pan American Health Organization , Washington , DC , USA

A. Dawson , PhD
Center for Values, Ethics and the Law in Medicine, Sydney School of Public Health ,
The University of Sydney , Sydney , Australia

mailto:[email protected]

286

for action. Principle fi ve specifi cally calls on public health to seek the information
needed to carry out effective policies and programs t

95© The Author(s) 2016
D.H. Barrett et al. (eds.), Public Health Ethics: Cases Spanning the Globe,
Public Health Ethics Analysis 3, DOI 10.1007/978-3-319-23847-0_4

Chapter 4
Disease Prevention and Control

Michael J. Selgelid

4.1 Introduction

Ethical issues surrounding public health policy and practice regarding disease pre-
vention and control often involve confl icting rights and values. Such confl icts partly
arise from tension between individual and community interests or tension involving
cultural beliefs and practices. This chapter outlines how such confl icts and tensions
arise in the context of disease prevention and control by exploring ethical issues
associated with mandatory treatment and vaccination, disease screening and sur-
veillance , diseases prone to stigma, access to care , health promotion incentives , and
emergency response .

4.2 Mandatory Treatment and Vaccination

In standard biomedical ethics (as opposed to public health ethics) discourse, the
patient’s right to informed consent to medical intervention is often considered sac-
rosanct. A primary aim of informed consent is to avoid medical paternalism , such as
coercing a patient to do something for his or her own benefi t. The transition in clini-
cal practice from medical paternalism to informed consent was largely based on the
ideas that (1) a well-informed patient is better placed than the doctor to determine
which actions are in the patient’s best interests (Goldman 1980 ) and (2) that a
patient’s autonomy should, in any case, be respected.

The opinions , fi ndings , and conclusions of the author do not necessarily refl ect the offi cial posi-
tion , views , or policies of the editors , the editors ’ host institutions , or the author ’ s host
institution .

M. J. Selgelid , MA, PhD (*)
Centre for Human Bioethics , Monash University , Melbourne , Australia
e-mail: [email protected]

mailto:[email protected]

96

In public health, however, treatment and vaccination may, in addition to the health
of the individual, be important to population health . As such, individual patients are
not the only stakeholders whose interests must be considered. In the context of tuber-
culosis (TB) , coercive treatment is common—in so far as, in many jurisdictions,
patients with active TB are required to undergo

203© The Author(s) 2016
D.H. Barrett et al. (eds.), Public Health Ethics: Cases Spanning the Globe,
Public Health Ethics Analysis 3, DOI 10.1007/978-3-319-23847-0_7

Chapter 7
Vulnerability and Marginalized Populations

Anthony Wrigley and Angus Dawson

7.1 Introduction

Public health practitioners attempt to identify and then remove, or at least reduce,
threats of harm. However, harm does not affect everyone in the same way. Some
people and communities are resilient, whereas others are more susceptible to poten-
tial harm. Much public health work is carried out by, or on behalf of, government s.
Where people or communities are at great risk of harm, government has a clear and
fi rm responsibility to protect its citizens. One way of describing a potential source
of such a risk of harm is to focus on the idea of vulnerability . This introduction
explores the concept of ‘vulnerability’ and the role that it may play in public health.

Vulnerability is a concept often used in public health ethics and more broadly in
bioethics —but its exact meaning is unclear. Roughly, it indicates that an individual
or group is thought to have a particular status that may adversely impact upon their
well-being, and that this implies an ethical duty to safeguard that well-being because
the person or group is unable to do so adequately themselves. This concept, although
important, consistently eludes precise defi nition. The diffi culty in defi ning the con-
cept arises from disagreement as to how to characterize the idea of “special status”
and to whom it applies. As a result, more and more categories of individuals and
groups are being classifi ed as vulnerable in an ever-increasing range of situations.
This raises the concern that almost everyone can be classifi ed as vulnerable in some

The opinions , fi ndings , and conclusions of the authors do not necessarily refl ect the offi cial posi-
tion , views , or policies of the editors , the editors ’ host institutions , or the authors ’ host
institutions .

A. Wrigley , PhD
Centre for Professional Ethics , Keele University , Staffordshire , UK

A. Dawson , PhD (*)
Center for Values, Ethics and the Law in Medicine, Sydney School of Public Health ,
The University of Sydney , Sydney , Australia
e-mail: [email protected]

mailto:[email protected]

204

way

177© The Author(s) 2016
D.H. Barrett et al. (eds.), Public Health Ethics: Cases Spanning the Globe,
Public Health Ethics Analysis 3, DOI 10.1007/978-3-319-23847-0_6

Chapter 6
Environmental and Occupational Public
Health

Bruce Jennings

6.1 Environment and Workplace: Key Venues
for Public Health

Environmental health and occupational health and safety have long been established
subfi elds of public health research , policy , and practice (Frumkin 2010 ). More so
perhaps than areas such as infectious disease or health promotion , environmental and
occupational health remind us that the health of a society is profoundly affected by
its economic system and economic development . Today, the environmental health
fi eld is largely concerned with a human-made (anthropogenic) environment brought
about by urbanization, the extraction of natural resources, industrial manufacture, the
physical separation of home and workplace, and the transportation systems needed
to support this mode of economy and pattern of living. Economic development alters
the natural environment and sometimes harms ecosystems in terms of the humanly
useful services they provide, their diversity , and their resilience. We are coming to
understand that all of this has signifi cant consequences for human health.

Environmental health has been understood as a public health issue in relation to
air quality, water quality, and exposure to environmental pollutants that are toxic,
carcinogenic, or teratogenic or are chemically bioactive in other ways. The rise of
fossil fuels as the energy base for economic production and transportation, the
industrial-scale advances in mining and metallurgy, and the creation and widespread
presence of synthetic chemical substances have contributed to environmental health
risks throughout the past two centuries. Indeed, these changes have redefi ned the
meaning of environmental health. For the most part, environmental health involves

The opinions , fi ndings , and conclusions of the author do not necessarily refl ect the offi cial position ,
views , or policies of the editors , the editors ’ host institutions , or the author ’ s host institution .

B. Jennings , MA (*)
Center for Biomedical Ethics and Society , Vanderbilt University , Nashville , TN , USA
e-mail: [email protected]

mailto:[email protected]<

61© The Author(s) 2016
D.H. Barrett et al. (eds.), Public Health Ethics: Cases Spanning the Globe,
Public Health Ethics Analysis 3, DOI 10.1007/978-3-319-23847-0_3

Chapter 3
Resource Allocation and Priority Setting

Norman Daniels

3.1 Resource Allocation in Public Health

There has been much discussion of resource allocation in medical systems, in the
United States and elsewhere. In large part, the discussion is driven by rising cost s
and the resulting budget pressures felt by publicly funded systems and by both
public and private components of mixed health systems. In some publicly funded
systems, resource allocation is a pressing issue because resources expended on one
disease or person cannot be spent on another disease or person. Some of the same
concern arises in mixed medical systems with multiple funding sources.

Although much has been written on resource allocation issues in medicine, there
has been less discussion about how resource allocation affects public health. Federal,
state, and local public health budgets in the United State s constrain investments in
health at those levels. In this regard, they are more like some foreign medical
systems than the more fragmented and mixed public-private medical system of the
United States. In the context of budget cuts domestically and in many countries
responding to an economic downturn, how to invest (and allocate) public health
resources is a pressing issue.

Most investments in public health aim to reduce population health risk s, but
some risks are greater than others, and resource allocation decisions must respond
to risks. Sometimes resource allocation decisions focus on the immediate payoff of
reducing risks from a specifi c disease, whereas other resource allocation decisions
affect the infrastructure needed to respond to health risks over time. In addition,
resource allocation decisions may determine who faces risks—the distribution of

The opinions, fi ndings, and conclusions of the author do not necessarily refl ect the offi cial position,
views, or policies of the editors, the editors’ host institutions, or the author’s host institution.

N. Daniels , PhD (*)
Department of Global Health and Population , Harvard T.H. Chan School of Public Health ,
Boston , MA , USA
e-mail: [email protected]

mailto:[email protected]

62

risks matters, no

37© The Author(s) 2016
D.H. Barrett et al. (eds.), Public Health Ethics: Cases Spanning the Globe,
Public Health Ethics Analysis 3, DOI 10.1007/978-3-319-23847-0_2

Chapter 2
Essential Cases in the Development of Public
Health Ethics

Lisa M. Lee , Kayte Spector-Bagdady , and Maneesha Sakhuja

2.1 Introduction

While “public health” has been defi ned as what society does to “assure the condi-
tions for people to be healthy” (Institute of Medicine 2003 , xi), public health ethics
is a “systematic process to clarify, prioritize , and justify possible courses of public
health action based on ethical principles , values and beliefs of stakeholders , and
scientifi c and other information ” ( Schools of Public Health Application Service
2013 ). Despite several important characteristics that distinguish public health from
clinical medicine, at its start public health ethics borrowed heavily from clinical
ethics and research ethics (see Chap. 1 ). In the 1980s, with the onset of the AIDS
epidemic and unprecedented advances in biomedicine, the inability of clinical eth-
ics to accommodate the ethical challenges in public health from existing frame-
works led pioneering ethicists to reframe and adapt clinical ethics from an individual
and autonomy focused approach to one that better refl ected the tension between
individual rights and the health of a group or population (Bayer et al. 1986 ;
Beauchamp 1988 ; Kass 2001 ; Childress et al. 2002 ; Upshur 2002 ). Others called for
public health ethics to emphasize relational ethics and political philosophy (Jennings
2007 ). More recently, some authors have suggested outlining foundational values
from which operating principles for public health ethics can be articulated only after
careful consideration of the goals and purpose of public health. This approach
would require us to establish a clear defi nition of the moral endeavor of public

The opinions, fi ndings, and conclusions of the authors do not necessarily refl ect the offi cial posi-
tion, views, or policies of the editors, the editors’ host institutions, or the authors’ host
institutions.

L. M. Lee , PhD, MA, MS (*) • K. Spector-Bagdady , JD, M Bioethics
M. Sakhuja , MHS
Presidential Commission for the Study of Bioethical Issues , Washington , DC , USA
e-mail: [email protected]

http://dx.doi.org/10.1007/978-981-287-561-7_1

241© The Author(s) 2016
D.H. Barrett et al. (eds.), Public Health Ethics: Cases Spanning the Globe,
Public Health Ethics Analysis 3, DOI 10.1007/978-3-319-23847-0_8

Chapter 8
International Collaboration for Global Public
Health

Eric M. Meslin and Ibrahim Garba

8.1 Introduction

There is a long tradition of global collaboration in biomedicine and public health.
Examples range from medical outposts in rural communities run by foreign mis-
sionaries (Good 1991 ) to the early infectious disease programs of the Rockefeller
Foundation (Fosdick 1989 ) and from medical services and training programs for
indigenous populations set up by colonial authorities (Marks 1997 ) to the Pan
American Health Organization (PAHO) established by a collective of sovereign
governments (Cueto 2007 ).

Two complementary sets of factors provide context for understanding collabora-
tion in global public health : fi rst, the factors that inform globalization generally and
global health specifi cally; second, the factors that shape ethical standards for global
health programs generally and global health research specifi cally. Good examples
of both factors are refl ected in this chapter’s case studies.

The opinions, fi ndings, and conclusions of the authors do not necessarily refl ect the offi cial
position, views, or policies of the editors, the editors’ host institutions, or the authors’ host
institutions.

E. M. Meslin , PhD (*)
Indiana University Center for Bioethics , Indianapolis , IN , USA
e-mail: [email protected]

I. Garba , MA, JD, LLM
Indiana University Center for Bioethics , Indianapolis , IN , USA

Public Health Law Program, Offi ce of State, Tribal, Local, and Territorial Support ,
Centers for Disease Control and Prevention , Atlanta , GA , USA

mailto:[email protected]

242

8.2 The Rise of Globalization and Global Health

Collaboration in global health, as we know it today, began taking shape after World
War II when new laws and institutions were established to govern relations among
countries. The war’s end was marked by efforts to establish a body that would
facilitate peaceful relations among member countries. In 1945, the United Nations
(U.N.) was established “to save succeeding generations from the scourge of war”
and to “promote social progress and better standards of life

Former USA Gymnastics team doctor pleads guilty to
sexual assault
Owen Dyer

Montreal

A once renowned sports medicine specialist accused of
molesting at least 125 girls and women while he worked for
USA Gymnastics and for Michigan State University has pleaded
guilty to multiple charges of sexual assault and wi

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