solved Public Health Ethics and Laws Case Study HomeworkDr. Naof Faiz

Public Health Ethics and Laws Case Study HomeworkDr. Naof Faiz Al-AnsaryCase Title: Reducing Sudden Infant Death Syndrome in a Culturally Diverse Society: The New Zealand Cot Death Study and National Cot Death Prevention ProgramSudden Infant Death Syndrome (SIDS) involves the death of apparently healthy sleeping infants, usually within the first year of life. It is a diagnosis of exclusion, that is, it denotes an unknown cause of death (Willinger et al. 1991; American Academy of Pediatrics 2011). It is also known as cot or crib death and is classified as a form of Sudden Death in Infancy (SUDI). Unlike many public health issues, SIDS unites clinical and forensic considerations, as this finding of cause of death can determine attribution of criminal (and moral) responsibility. Police collect evidence and coroners assess the circumstances of the death and release judgments. This is the method by which a SIDS death is determined. Context heightens the ethical significance of SIDS diagnosis, research, and prevention. In 1991, when the New Zealand Cot Death Study (NZCDS) commenced, New Zealand’s rate of SIDS was high by international standards at 4 deaths per 1,000 live births (Mitchell et al. 1997) compared, for example, to the Netherlands (1.3/1,000 in 1989) (de Jonge et al. 1989) and Hong Kong (0.3/1,000 in 1986–1987) (Lee et al. 1989). Within New Zealand, SIDS deaths occurred in the indigenous Māori population at twice the rate of the non-Māori population (Mitchell et al. 1994). The reason for this significant disparity was not well understood.The NZCDS was the first national case-control study designed to identify risk factors for SIDS. By comparing infants whose deaths were attributed to SIDS with a representative sampleof live births, within a year, the NZCDS had identified a number of risk factors. The study confirmed an association between increased risk of SIDS and lower socioeconomic status, along with a range of associated maternal factors, including fewer years of education, younger age at first pregnancy, greater number of previous pregnancies, and lower attendance at prenatal classes (Mitchell et al. 1991). The NZCDS selected three risk factors to address among this range of findings: lack of breast-feeding, maternal smoking, and placing infants to sleep in a prone position (Mitchell et al. 1991). The ensuing national prevention campaign focused on publicizing these risks, which parents were seen as able to influence. These were categorized as ‘modifiable risk factors.’ Many parents changed their practices in response to the campaign (Cowan 2010). Abandonment of the prone sleeping position was the most readily and widely adopted measure and is credited with delivering the largest proportion of the national reduction in SIDS rates (Mitchell et al. 1997). Factors that were less susceptible to parental alteration were classified as ‘non-modifiable risk factors.’ Non-modifiable factors included the baby’s sex, the mother’s age, and the family’s socioeconomic status.Analysis of the second year’s data revealed another risk factor: bed-sharing (Mitchell et al. 1992). Bed-sharing was categorized as a modifiable risk factor, and parents were advised to avoid sleeping on the same surface as their baby or allowing others (for instance, other children) to do so. The study’s findings were immediately fed into the prevention campaign. Communicating with parents about this particular risk factor became more problematic than initially anticipated. The difficulties partly reflected a developing understanding about the subtle nature of bed-sharing risk. While early messages counselled against all bed-sharing, subsequent findings prompted adjustments (Cowan 2010). Now bed-sharing is not viewed as a significant risk unless coupled with maternal smoking or with the baby’s bedmate being intoxicated orexcessively tired. Other factors such as the baby’s age, the site, and duration of bed-sharing have also been identified as affecting the magnitude of risk. These considerations make it difficult to summarize the risk in a way that is scientifically sound and that parents can easily understand. Also, the prevention campaign took place against a backdrop of numerous changes in prevailing thought since the 1950s about the causes of SIDS. These changes were associated with changing advice about parental practices, which created uncertainty within families about which advice should be followed. The cultural significance attributed to bed-sharing meant that there were different reactions among groups to advice not to bed-share. While bed-sharing is not traditional among New Zealand European (Pākehā) families, it is firmly rooted inMāori and Polynesian child-rearing practices (Tipene-Leach et al. 2000). In these communities, bed- s haring is seen as positive and beneficial, promoting bonding between mother and child and enabling mothers to comfort and care for their child (Abel et al. 2001; Tipene-Leach et al. 2000).The message that bed-sharing is risky had serious implications, then, for Māori and Polynesian child-rearing practices. The early years of the SIDS prevention campaign succeeded in reducing the rate of SIDS, but the tenor of the anti-bed-sharing message alienated many, particularly indigenous Māori, consequently turning whānau (wider family networks) away from SIDS prevention messages altogether. Some interpreted the campaign as blaming Māori for infant deaths. After an infant death, the involvement of police, pathologists, and a coroner’s court compounds overtones of culpability, intensifying the guilt and grief associated with the loss of a child (Clarke and McCreanor 2006). Several years after the ongoing SIDS prevention campaign was launched, rates of SIDS among Māori remained disproportionately high. In 2009, the rate of SIDS for Māori was 1.5 per 1,000 live births, compared with 0.6/1,000 for Pacific Peoples, and0.3/1,000 for Other, including Pākehā (Ministry of Health 2012). Several modifiable risk factors for SIDS, including maternal smoking and bed-sharing are more prevalent in the Māori community. Māori parents less frequently attend prenatal classes than non-Māori parents. Along with the modifiable factors, many non-modifiable factors are more likely to apply to Māori families, including lower socioeconomic status, younger age of mother at first pregnancy, greater number of pregnancies, and fewer years of education. These contributors to rates of SIDS among Māori do not receive the same level of scrutiny in the media as modifiable parental practices, and prevention campaigns continue to focus upon altering parental practices. A sense of injustice and a perception that the state lacks a true commitment to addressing the societal factors underpinning SIDS prevails in parts of the Māori community. The prevention campaign’s focus upon discouraging bed-sharing contributes to the community’s sense that the campaign undermines rather than supports traditional Māori practices. In particular, the coronial process— the investigations into the cause of death, the invasive process of autopsy, and the slow return of the body to whānau— cannot easily accommodate the deep-felt need of whānau to complete the traditional Tangihanga process, the spiritual rituals and burial proceedings following a death. Nor is the high profile of the bed-sharing risk matched by a commitment to tackle other risk factors, which may require more resources. Some have therefore called for examination of the process by which risk factors are categorized as modifiable or non-modifiable. The government has committed substantial resources to culturally appropriate SIDS prevention for Māori and Polynesian families and is conducting trials of appropriate supports for families to bed-share safely (Tipene-Leach 2010).Meanwhile, criminal proceedings against Māori parent s relating to the deaths of their infants while co-sleeping continue to receive media attention (R v Tukiwaho 2012; APNZ 2013).No wonder, then, that the strong sense of parental responsibility for SIDS deaths, where bed- sharing is a factor, remains. Although inequities underwrite the high exposure of Māori families to both modifiable and non-modifiable risk factors, both government-funded health promotion and media coverage of SIDS remain focused on parental practice.Following high-profile media coverage of the greater burden of SIDS among Māori, new funding is available for a SIDS prevention campaign to reduce SIDS in Māori and Polynesian families. Part of this funding is reserved for the generation of new guidelines acceptable to Māori. There is also an opportunity to brief the Minister of Health and the Minister of Social Development about measures that can reduce rates of SIDS deaths among Māori infants. Discussion QuestionsPlease submit your typed responses via e-mail prior to class on Wednesday November 28 and be prepared to discuss your answers in class.1. Evidence suggests that several factors affect the magnitude of risk and that bed-sharing 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?2. What weight should be attributed to the cultural significance of bed-sharing when generating guidelines, 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?