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Food Taxes: A New Holy Grail? 2 2 In an effort to reduce the growing prevalence of overweight and obesity, food taxes have been introduced in several European countries, the so-called ‘obesitax’. As yet little evidence is at hand, policy measures are being taken to counterweight the consumption of unhealthy food or the increasing diet-related diseases. Several questions need to be discussed, starting from a general perspective: can food taxes become an appropriate and just policy measure to reduce overweight and obesity and therefore increase consumer’s health? The implementation of an effective and fair food tax is an exercise riddled with uncertainty. Not only is there a need for evidence on the health and economic impact of food taxes, we also have to think about a conceptual and ethical discussion concerning the balance between health imperatives and public health on the one hand, and social and ethical standards on the other hand. 1 - 95 97 - - Ignaas Devisch Artevelde University College, University of Ghent, Belgium Artevelde University College, University Iran ignaas.devisch@ugent.be Social Inequality Food tax Obesity Responsibility 1. Lundberg O, Lahelma E. Nordic health inequalities in the European context. In: Kautto M, Fritzell J, Hvinden B, Kvist J, Uusitalo H, eds. Nordic Welfare States in the European Context. Routledge: London & New York; 2001. p. 42–65. doi: 10.1177/09589287020120010602 ##2. WHO. Obesity: preventing and managing the global epidemic. WHO: Geneva; 2000. doi: 10.1017/s0021932003245508 ##3. White House Task Force on Childhood Obesity. Solving the problem of childhood obesity within a generation. Report to the president. Washington, 2010. doi: 10.1089/bfm.2010.9980   ##4. European Commission. Solidarity In Health: Reducing Health Inequalities in the EU. SEC(2009) 1396, Brussels, 2009. ##5. Alemanno A, Carreño I. Fat taxes in the EU: between fiscal austerity and the fight against obesity. European Journal of Risk Regulation 2011; 4: 571–6. ##6. Caraher M, Cowburn G. Taxing food: implications for public health nutrition. Public Health Nut 2005; 8: 1242–9. doi: 10.1079/phn2005755 ##7. Cantillon B, Van Lancker W. Solidarity and reciprocity in the social investment state: what can be learned from the case of Flemish school allowances and truancy? J Soc Policy 2012; 41: 657–75. doi: 10.1017/s0047279412000359 ##8. Brownell KD, Kersh R, Ludwig DS, Post RC, Puhl RM, Schwartz MB, et al. Personal Responsibility And Obesity: A Constructive Approach to a Controversial Issue. Health Aff (Millwood) 2010; 29: 379–87. doi: 10.1377/hlthaff.2009.0739 ##9. Andreyeva T, Long MW, Brownell KD. The impact of food prices on consumption: a systematic review of research on price elasticity of demand for food. Am J Public Health 2010; 100: 216–22. doi: 10.2105/ajph.2008.151415  ##10. Epstein LH, Dearing KK, Paluch RA, Roemmich JN, Cho D. Price and maternal obesity influence purchasing of low- and high-energy-dense foods. Am J Clin Nutr 2007; 86: 914–22. ##11. French SA. Pricing effects on food choices. J Nutr 2003; 133: 841–3. ##12. Herman DR, Harrison GG, Afifi AA, Jenks E. Effect of a targeted subsidy on intake of fruits and vegetables among low-income women in the Special Supplemental Nutrition Program for Women, Infants, and Children. Am J Public Health 2008; 98: 98–105. doi: 10.2105/ajph.2005.079418 ##13. Steenhuis IHM, Waterlander WE, de Mul A. Consumer food choices: the role of pricing and pricing strategies. Public Health Nutr 2011; 14: 2220–6. doi: 10.1017/s1368980011001637 ##14. Jensen JD, Smed S. Cost-effective design of economic instruments in nutrition policy. Int J Behav Nutr Phys Act 2007; 4: 10. doi: 10.1186/1479-5868-4-10   ##15. Mytton O, Gray A, Rayner M, Rutter H. Could targeted food taxes improve health? J Epidemiol Community Health 2007; 61: 689–94. doi: 10.1136/jech.2006.047746   ##16. Faulkner GE, Grootendorst P, Nguyen VH, Andreyeva T, Arbour-Nicitopoulos K, Auld MC, et al. Economic instruments for obesity prevention: results of a scoping review and modified Delphi survey. Int J Behav Nutr Phys Act 2011; 8: 109. doi: 10.1186/1479-5868-8-109   ##17. Thow AM, Jan S, Leeder S, Swinburn B. The effect of fiscal policy on diet, obesity and chronic disease: a systematic review. Bull World Health Organ 2010; 88: 609–14. doi: 10.2471/blt.09.070987   ##18. Grunert KG, Wills JM. A review of European research on consumer response to nutrition information on food labels. J Public Health 2007; 15: 385–99. doi: 10.1007/s10389-007-0101-9 ##19. Nnoaham KE, Sacks G, Rayner M, Mytton O, Gray A. Modelling income group differences in the health and economic impacts of targeted food taxes and subsidies. Int J Epidemiol 2009; 38: 1324–33. doi: 10.1093/ije/dyp214 ##20. Jha P, Chaloupka FJ, Corrao M, Jacob B. Reducing the burden of smoking world-wide: effectiveness of interventions and their coverage. Drug Alcohol Rev 2006; 25: 597–609. doi: 10.1080/09595230600944511   ##21. Irala-Estévez JD, Groth M, Johansson L, Oltersdorf U, Prättälä R, Martínez-González MA. A systematic review of socio-economic differences in food habits in Europe: consumption of fruit and vegetables. Eur J Clin Nutr 2000; 54: 706–14. doi: 10.1038/sj.ejcn.1601080 ##22. Have MT, van der Heide A, Mackenbach JP, de Beaufort ID. An ethical framework for the prevention of overweight and obesity: a tool for thinking through a programme’s ethical aspects. Eur J Public Health 2013; 23: 299–305. doi: 10.1093/eurpub/cks052 ##23. Barry CL, Brescoll VL, Brownell KD, Schlesinger M. Obesity Metaphors: How Beliefs about the Causes of Obesity Affect Support for Public Policy. Milbank Q 2009; 87: 7–47. doi: 10.1111/j.1468-0009.2009.00546.x ##24. Oliver JE, Lee T. Public Opinion and the Politics of Obesity in America. J Health Polit Policy Law 2005; 30: 923–54. doi: 10.1215/03616878-30-5-923  ##

Challenges for Policy Makers and Organizational Leaders: Addressing Trends in Mental Health Inequalities 2 2 We typically think of acutely and chronically mentally ill patients as those who belong in psychiatric hospitals and the latter category of patients belonging in “regular” hospitals, but the intersection of physical and mental illness draws attention to important challenges for policy-makers and organizational leaders. This article illuminates some broad trends in the health status of people with mental illnesses, canvasses important features of inequalities suffered by people with mental illnesses, and suggests strategies for systemic reform. Most reform recommendations I offer are in the area of healthcare organization leadership and management. Other key reforms will likely be legislative, regulatory, and insurance-related. Social and cultural reforms in organizational practices and structures will also be critical. 1 - 99 101 - - Christy Rentmeester Center for Health Policy and Ethics, School of Medicine, Creighton University, Omaha, Nebraska, USA Center for Health Policy and Ethics, School Iran christyrentmeester@creighton.edu Mental Health Inequality Policy Making Systematic Reform 1. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Lancet 2007; 370: 859–77. doi: 10.1016/s0140-6736(07)61238-0 ##2. Osborn DP. The poor physical health of people with mental illness. West J Med 2001;175: 329–32. doi: 10.1136/ewjm.175.5.329 ##3. Felker B, Yazel JJ, Short, D. Mortality and medical comorbidity among psychiatric patients: a review. Psychiatr Serv 1996; 47: 1356–63. ##4. Goldman LS. Comorbid medical illness in psychiatric patients. Current Psychiatry Report 2000; 2: 256–63. doi: 10.1007/s11920-996-0019-x ##5. Lyketsos CG, Dunn G, Kaminsky MJ, Breakey WR. Medical comorbidity in psychiatric inpatients: Relation to clinical outcomes and hospital length of stay. Psychosomatics 2002; 43: 24–30. doi: 10.1176/appi.psy.43.1.24   ##6. Maricle R, Hoffman W, Bloom J, Faulkner L, Keepers G. The prevalence and significance of medical illness among chronically mentally-ill outpatients. Community Ment Health J 1987; 23: 81–90. doi: 10.1007/bf00757162 ##7. Pavalonis D, DeCarr M, Shutty M. Nursing roles for chronic pain management in the seriously mentally ill. J Am Psychiatr Nurses Assoc 1995; 1: 107–11. doi: 10.1177/107839039500100402 ##8. Farmer S. Medical problems of chronic patients in a community support program. Hosp Community Psychiatry 1987; 38: 745–9. ##9. Appelbaum PS, Grisso T. The MacArthur Treatment Competence Study III: Abilities of patients to consent to psychiatric and medical treatments. Law Hum Behav 1995; 19: 149–74. doi: 10.1007/bf01499323 ##10. Candilis PJ, Foti ME, Holzer JC. End-of-life care and mental illness: A model for community psychiatry and beyond. Community Ment Health J 2004; 40: 3–16. doi: 10.1023/b:comh.0000015214.24404.cc ##11. Dembling BP, Chen DT, Vachon L. Life expectancy and causes of death in a population treated for serious mental illness. Psychiatr Serv 1999; 50: 1036–42. ##12. Bonhoeffer K. Die psychosen im gefolge von akuten infektiouen allgemeiner krankungen und inneren erkrankungen. Handbach der Psychiatrie (Ed. Aschaffenburg GL). Deuticke: Leipzig, Germany; 1912. ##13. Jeste DV, Gladsjo JA, Lindamer LA, Lacro JP. Medical comorbidity in schizophrenia. Schizophr Bull 1996; 22: 413–30. doi: 10.1093/schbul/22.3.413 ##14. Harris EC, Barraclough B. Excess mortality of mental disorder. Br J Psychiatry 1998; 173: 11–53. doi: 10.1192/bjp.173.1.11 ##15. Schulz R, Beach SR, Ives DG, Martire LM, Ariyo AA, Kop WJ. Association between depression and mortality in older adults: the Cardiovascular Health Study. Arch Intern Med 2000; 160: 1761–8. doi: 10.1001/archinte.160.12.1761 ##16. Liptzin B, Gottlieb GL, Summergrad P. The future of psychiatric services in general hospitals. Am J Psychiatry 2007; 164: 1468–72. doi: 10.1176/appi.ajp.2007.07030541   ##17. Iglehart J. The Mental Health Maze and the Call for Transformation. N Engl J Med 2004; 350: 507–14. doi: 10.1056/nejmhpr032740 ##18. Druss BG, Rosenheck RA. Mental disorders and access to medical care in the United States. Am J Psychiatry 1988; 155: 1775–7. ##19. Young JK, Foster DA. Cardiovascular procedures in patients with mental disorders. JAMA 2000; 283: 3198–9. ##20. Druss BG, Bradford DW, Rosenheck RA, Radford MJ, Krumholz HM. Mental disorders and use of cardiovascular procedures after myocardial infarction. JAMA 2000; 283: 506–11. doi: 10.1001/jama.283.4.506 ##21. Kendrick T. Cardiovascular and respiratory risk factors and symptoms among general practice patients with long-term mental illness. Br J Psychiatry 1996; 169: 733–9. doi: 10.1192/bjp.169.6.733 ##22. Karasu TB, Waltzman SA, Lindermayer JP, Buckly PJ. The medical care of patients with psychiatric illness. Hosp Community Psychiatry 1980; 31: 463–72. ##23. Rentmeester CA. Postcolonial Bioethics: A Lens for Considering the Historical Roots of Racial and Ethnic Inequalities in Mental Health. Camb Q Healthc Ethics 2012; 21: 366–74. doi: 10.1017/s0963180112000084 ##24. Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders. Improving the Quality of Health Care for Mental and Substance Use Conditions. National Academies Press: Washington, DC; 2006. ##25. Mitchell JB, Dickey B, Liptzin B, Sederer LI. Bringing psychiatric patients into the Medicare prospective payment system: Alternatives to DRGs. Am J Psychiatry 1987; 144: 610–5. ##26. Rentmeester CA. Should a Good Healthcare Professional Be (at Least a Little) Callous? J Med Philos 2007; 32: 43–64. doi: 10.1080/03605310601152982 ##27. Rentmeester CA. Moral Damage to Healthcare Professionals and Trainees: Legalism and other Consequences for Patients and Colleagues. J Med Philos 2008; 33: 27–43. doi: 10.1093/jmp/jhm006 ##28. Bermudes RA, Keck PE, Welge JA. The prevalence of the metabolic syndrome in psychiatric inpatients with primary psychotic and mood disorders. Psychosomatics 2006; 47: 491–7. doi: 10.1176/appi.psy.47.6.491   ##29. Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes. Diabetes Care 2004; 27: 596–601. doi: 10.2337/diacare.27.2.596 ##30. Casey DE, Haupt DW, Newcomer JW, Henderson DC, Sernyak MJ, Davidson M, et al. Antipsychotic-induced weight gain and metabolic abnormalities: implications for increased mortality in patients with schizophrenia. J Clin Psychiatry 2004; 65: 4–18. ##31. Marder SR, Essock SM, Miller AL, Buchanan RW, Casey DE, Davis JM, et al. Physical health monitoring of patients with schizophrenia. Am J Psychiatry 2004; 161: 1334–49. ##32. Citrome L, Blonde L, Damatarca C. Metabolic Issues in Patients with Severe Mental Illness. South Med J 2005; 98: 714–9. doi: 10.1097/01.smj.0000167621.49292.11 ##33. Goldenberg D, Holland J, Schachter S. Palliative care in the chronically mentally ill. Handbook of psychiatry in palliative medicine. Oxford University Press: New York; 2000. pp. 91–6. ##34. Summergrad P, Hackett TP. Alan Gregg and the rise of general hospital psychiatry. Gen Hosp Psychiatry 1987; 9: 439–45. doi: 10.1016/0163-8343(87)90054-5 ##

A Brief Philosophical Encounter with Science and Medicine 2 2 We show a lot of respect for science today. To back up our claims, we tend to appeal to scientific methods. It seems that we all agree that these methods are effective for gaining the truth. We can ask why science has its special status as a supplier of knowledge about our external world and our bodies. Of course, one should not always trust what scientists say. Nonetheless, epistemological justification of scientific claims is really a big project for philosophers of science. Philosophers of science are interested in knowing how science proves what it does claim and why it gives us good reasons to take these claims seriously. These questions are epistemological questions. Epistemology is a branch of philosophy which deals with knowledge claims and justification. Besides epistemological questions, metaphysical and ethical issues in science are worthy of philosophical scrutiny. This paper gives a short survey of these intellectually demanding issues. 1 - 103 105 - - Amir Ehsan Karbasizadeh Iranian Institute of Philosophy (IRIP), Tehran, Iran Iranian Institute of Philosophy (IRIP), Tehran, Iran amir_karbasi@yahoo.com Philosophy Medicine Science 1. Klee R. Introduction to the Philosophy of Science—Cutting Nature at Its Seams. New York: Oxford University Press; 1997. ##2. Ladyman J. Understanding Philosophy of Science. London: Routledge; 2002. doi: 10.4324/9780203463680 ##3. Bird A. Philosophy of science. London: Routledge; 1998. doi: 10.4324/9780203165348 ##4. Sosa E, Tooley M. Causation. London: Oxford University Press; 1993. ##5. Engelhardt HT. The Philosophy of Medicine: Framing the Field. London: Springer; 2011. ##6. Kenneth F, Schaffner KF, Salmon WC, Norton JD, McGuire JE, Machamer P, et al. Introduction to the philosophy of science. 1th ed. Indianapolis: Hackett Publishing Co, Inc; 1999. ##7. Bresalier M. History and philosophy of Medicine: Unit Guide. Univerity of Bristol; 2006.##

Denial of Treatment to Obese Patients—the Wrong Policy on Personal Responsibility for Health 2 2 In many countries around the world, including Iran, obesity is reaching epidemic proportions. Doctors have recently taken, or expressed support for, an extreme ‘personal responsibility for health’ policy against obesity: refusing services to obese patients. This policy may initially seem to improve patients’ incentives to fight obesity. But turning access to medical services into a benefit dependent on health improvement is a bad policy. It conditions the very aid that patients need in order to become healthier or success in becoming healthier. Whatever else we may think of personal responsibility for health policies, this particular one is absurd. Unfortunately, quite a few personal responsibility for health policies use similar absurd conditioning. They mistakenly use ‘carrots’ or ‘sticks’ for adherence the basic means to the same health outcomes that they seek to promote. This perspective proposes the following rule of thumb: any conditional incentive for healthy choice should be in a currency other than the basic means to that healthy choice. 1 - 107 110 - - Nir Eyal Division of Medical Ethics, Harvard Medical School, Boston, MA, USA Division of Medical Ethics, Harvard Medical Iran nir_eyal@hms.harvard.edu Obesity Patient Compliance Refusal to Treat Health Promotion Motivation 1. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2224–60. ##2. WHO. Obesity. Geneva: WHO; 2013. [updated 2013 March; cited 2013 July 10]. Available from: http://www.who.int/topics/obesity/en/index.html. ##3. CDC. Overweight and Obesity: Adult obesity facts. Atlanta, GA: Centers for Disease Control and Prevention; 2012. [updated 2012 August 13; cited 2013 July 10]. Available from: http://www.cdc.gov/obesity/data/adult.html. ##4. Malekzadeh R, Mohamadnejad M, Merat S, Pourshams A, Etemadi A. Obesity pandemic: an Iranian perspective. Arch Iranian Med 2005; 8: 1–7. ##5. Mirzazadeh A, Sadeghirad B, Haghdoost AA, Bahrein F, Rezazadeh Kermani M. The Prevalence of Obesity in Iran in Recent Decade; a Systematic Review and Meta-Analysis Study. Iran J Public Health 2009; 38: 1–11. ##6. Singer P. Weigh More, Pay More. Project Syndicate 2012. ##7. Campbell D. Doctors back denial of treatment for smokers and the obese. The Observer 2012. ##8. Ramirez X. OB-GYNs in South Florida Reject Overweight and Obese Patients. 2011. [updated May 17; cited 2013, July 12]. Available from: http://www.care2.com/causes/ob-gyns-in-south-florida-reject-overweight-and-obese-patients.html#ixzz2YrmT0AEr. ##9. Firger J. Doctor Turns Away Obese Patients. 2012. [updated August 29; cited 2013 July 10]. Available from: http://www.everydayhealth.com/weight/0829/doctor-turns-away-obese-patients.aspx. ##10. Zimmerman R. Mass. Doctor Won’t Accept New Patients Who Are Obese. 2012. [updated August 30; cited 2013 July 10]. Available from: http://commonhealth.wbur.org/2012/08/mass-doctor-wont-accept-new-patients-who-are-obese. ##11. Wikler D. Personal and Social Responsibility for Health. In: Anand S, F Peter, AK Sen, editors. Public Health, Ethics, and Equity. New York: Oxford University Press; 2006. p. 109–34. ##12. Yousefi P. Overweight/obesity and lifestyle characteristics among Iranian pre-school children. Umeå: Umeå University; 2011. ##13. Schmidt H, Voigt K, Emanuel EJ. The ethics of not hiring smokers. N Engl J Med 2013; 368: 1369–71. doi: 10.1056/nejmp1301951 ##14. Schmidt H, Voigt K, Wikler D. Carrots, Sticks, and Health Care Reform—Problems with Wellness Incentives. N Engl J Med 2010; 362: 1–3. doi: 10.1056/nejmp0911552 ##15. Asch DA, Muller RW, Volpp KG. Conflicts and compromises in not hiring smokers. New Engl J Med 2013; 368: 1371–3. doi: 10.1056/nejmp1303632 ##16. Marmot M. Fair Society Healthy Lives. In: Eyal N, OF Norheim, SA Hurst, D Wikler, editors. Inequalities in Health: Concepts, Measures, and Ethics. New York: Oxford University Press; 2013, Forthcoming. ##17. Eyal N. Motivating prevention: from carrots and sticks to “carrots” and “sticks”. Virtual Mentor 2008; 10: 756–62. doi: 10.1001/virtualmentor.2008.10.11.oped1-0811 ##18. Andrews M. Some Doctors Ask Patients To Sign ‘Pain Contracts’ To Get Prescriptions. Kaiser Health News 2011. ##19. Eyal N. Why treat noncompliant patients? Beyond the decent minimum account. J Med Philos 2011; 36: 572–88. doi: 10.1093/jmp/jhr051##

Health and Wellness Policy Ethics 2 2 This perspective is an ethical brief overview and examination of “wellness” policies in the modern workplace using practical examples and a general application of utilitarianism. Many employers are implementing policies that provide incentives to employees who lead a “healthy” lifestyle. The authors address how these policies could adversely affect “non-healthy” employees. There are a wide variety of ethical issues that impact wellness policies and practices in the workplace. The authors conclude that wellness programs can be ethical, while also providing a general reflective analysis of healthcare challenges in order to reflect on the externalities associated with such policies in the workplace. 1 - 111 113 - - Frank Cavico The H. Wayne Huizenga School of Business and Entrepreneurship, Nova Southeastern University, Ft. Lauderdale, Florida, USA The H. Wayne Huizenga School of Business Iran cavico@nova.edu - - Bahaudin Mujtaba The H. Wayne Huizenga School of Business and Entrepreneurship, Nova Southeastern University, Ft. Lauderdale, Florida, USA The H. Wayne Huizenga School of Business Iran mujtaba@nova.edu Wellness Policies Healthy Employees Discrimination Ethics Utilitarianism 1. Mujtaba BG, Cavico FJ. A Review of Employee Health and Wellness Programs in the United States. Public Policy and Administration Research 2013; 3: 1–15. ##2. Sizemore SC. A Fatter Butt Equals a Skinnier Wallet: Why Workplace Wellness Programs Discriminate Against the Obese and Violate Federal Employment Law. Wyoming Law Review 2011; 11: 639–72. ##3. Santich Kate. The price of poor health. Sun-Sentinel 2013, April 28: 4D. ##4. Kwoh L. Shape Up or Pay Up: Firms Put in New Health Penalties. Wall St J 2013, April 6-7: A1–10. ##5. Schmidt H, Voigt K, Wikler D. Carrots, sticks, and health care reform--problems with wellness incentives. N Engl J Med 2010; 362: e3. doi: 10.1056/nejmp0911552 ##6. Cavico FJ, Mujtaba BG. Business Ethics: The Moral Foundation of Effective Leadership, Management, and Entrepreneurship. Boston: Pearson; 2009. ##7. Cavico FJ, Mujtaba BG. Legal Challenges for the Global Manager and Entrepreneur. Iowa: Kendall-Hunt; 2008. ##

Medicine and the Task of Healing 2 2 To understand the traditional description of medicine as a practice of healing, it is necessary to examine its relationships with both science and ethics. The “scientific” component of medicine includes an acknowledgment of the influence of social, cultural and environmental factors on the functioning of the organism. The “ethical” component is often presented as merely supplementary but actually provides the conditions of possibility of knowledge. “Healing” then appears as what joins the two together: the site where science is applied in the service of ethics and where ethics encounters science. This perspective allows us to reconsider medicine as a project to healing complex wounds that manifest themselves at the physical, psychological, emotional and cultural levels. 1 - 115 116 - - Paul Komesaroff Centre for Ethics in Medicine and Society, Monash University, Melbourne, Australia Centre for Ethics in Medicine and Society, Iran paul.komesaroff@monash.edu Medicine Ethics Science Healing 1. Komesaroff PA. Objectivity, science and society. London: Routledge; 2009. ##2. Komesaroff PA. Experiments in love and death. Melbourne: Melbourne University Press; 2008. doi: 10.1007/s11673-009-9205-y  ##

Ethical Agreement and Disagreement about Obesity Prevention Policy in the United States 2 2 An active area of public health policy in the United States is policy meant to promote healthy eating, reduce overconsumption of food, and prevent overweight/obesity. Public discussion of such obesity prevention policies includes intense ethical disagreement. We suggest that some ethical disagreements about obesity prevention policies can be seen as rooted in a common concern with equality or with autonomy, but there are disagreements about which dimensions of equality or autonomy have priority, and about whether it is justifiable for policies to diminish equality or autonomy along one dimension in order to increase it along another dimension. We illustrate this point by discussing ethical disagreements about two obesity prevention policies. 1 - 117 120 - - Anne Barnhill Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA Department of Medical Ethics and Health Policy, Iran anne.barnhill@gmail.com - - Katherine F. King Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada Li Ka Shing Knowledge Institute, St. Michael’s Iran katherinefking@gmail.com Obesity Prevention Public Health Ethics Food Policy Food tax Autonomy Justice 1. Mello MM, Studdert DM, Brennan TA. Obesity—the new frontier of public health law. N Engl J Med 2006; 354: 2601–10. doi: 10.1056/nejmhpr060227 ##2. Silver L, Bassett MT. Food safety for the 21st century. JAMA 2008; 300: 957–9. doi: 10.1001/jama.300.8.957   ##3. Dietz WH, Hunter AS. Legal preparedness for obesity prevention and control: the public health framework for action. J Law Med Ethics 2009; 37: 9–14. doi: 10.1111/j.1748-720x.2009.00386.x ##4. Center for Science in Public Interest. Trans Fat Bans in Restaurants. Available from: http://www.cspinet.org/transfat/ ##5. Bernstein S. San Francisco bans Happy Meals. Los Angeles Times [serial on the Internet]. [updated 2010 Nov 2; cited 2013 Aug 1]; Available from: http://articles.latimes.com/2010/nov/02/business/la-fi-happy-meals-20101103 ##6. Severson K. Los Angeles Stages a Fast Food Intervention. New York Times [serial on the Internet]. [updated 2008 Aug 13; cited 2013 Aug 1]. Available from: http://www.nytimes.com/2008/08/13/dining/13calo.html ##7. Barnhill A. Impact and Ethics of Excluding Sweetened Beverages from the SNAP Program. Am J Public Health 2011; 101: 2037–43. doi: 10.2105/ajph.2011.300225 ##8. Brownell KD, Frieden TR. Ounces of Prevention—The Public Policy Case for Taxes on Sugared Beverages. N Engl J Med 2009; 360: 1805–8. doi: 10.1056/nejmp0902392 ##9. Grynbaum MM. Bloomberg Plans a Ban on Large Sugared Drinks. New York [serial on the Internet]. [updated 2012 May 30; cited 2013 Aug 1]; Available from: http://www.nytimes.com/2012/05/31/nyregion/bloomberg-plans-a-ban-on-large-sugared-drinks.html ##10. Holm S. Obesity interventions and ethics. Obes Rev 2007; 8: 207–10. doi: 10.1111/j.1467-789x.2007.00343.x    ##11. Purcell M. Raising healthy children: Moral and political responsibility for childhood obesity. J Public Health Policy 2010; 31: 433–46. doi: 10.1057/jphp.2010.28   ##12. Have MT, van der Heide A, Mackenbach JP, de Beaufort ID. An ethical framework for the prevention of overweight and obesity: a tool for thinking through a programme’s ethical aspects. Eur J Public Health 2012; 23: 299–305. doi: 10.1093/eurpub/cks052 ##13. Barnhill A, King KF. Evaluating equity critiques in food policy: the case of sugar-sweetened beverages. J Law Med Ethics 41: 301–9. ##14. Kirkland A. The environmental account of obesity: a case for feminist skepticism. Signs 2011; 36: 463–85. doi: 10.1086/655916   ##15. The Checkup. Is a Soda Tax Fair? Washingtonpost. [cited 2013 Aug2]; Available from: http://voices.washingtonpost.com/checkup/2009/08/is_a_soda_tax_fair.html ##16. Cheh M. 10 Myths About the Soda Tax. [cited 2013 Aug 2]; Available from: http://www.marycheh.com/index.php?option=com_content&view=article&id=145&Itemid=79 ##17. Chamberlain A, Prante G. Who pays taxes and who receives government spending? An analysis of federal, sate and local tax and spending distributions, 1991-2004. Tax Foundation; 2007 Mar. Report No.: 1. doi: 10.2139/ssrn.976507 ##18. Center on Budget and Policy Priorities. Which States Tax the Sale of Food for Home Consumption in 2009? 2009 Nov. [cited 2013 Aug 2]; Available from: http://www.cbpp.org/cms/?fa=view&id=1230 ##19. Some states like the sweet taste of soda and candy taxes. Stateline [serial on the Internet]. 2010. [cited 2013 Aug 12]; Available from: http://www.pewstates.org/projects/stateline/headlines/some-states-like-the-sweet-taste-of-soda-and-candy-taxes-85899374842 ##20. Nys TRV. Paternalism in Public Health Care. Public Health Ethics 2008;1: 64–72. doi: 10.1093/phe/phn002 ##21. Arpaly N. Varieties of Autonomy. Unprincipled Virtue. New York: Oxford University Press; 2003. p. 117–48. doi: 10.1093/0195152042.003.0004   ##22. Colby SE, Johnson L, Scheett A, Hoverson B. Nutrition marketing on food labels. J Nutr Educ Behav 2010; 42: 92–8. doi: 10.1016/j.jneb.2008.11.002   ##23. Nestle M, Ludwig DS. Front-of-package food labels. JAMA 2010; 303: 771–2. doi: 10.1001/jama.2010.179 ##24. Cowburn G, Stockley L. Consumer understanding and use of nutrition labelling: a systematic review. Public Health Nutr 2005; 8: 21–8. doi: 10.1079/phn2005666 ##25. Cohen D, Farley TA. Peer Reviewed: Eating as an Automatic Behavior. Prev Chronic Dis 2008; 5: A23. ##26. Lang T, Rayner G. 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Is Patient Choice the Future of Health Care Systems? 2 2 Patient and user choice are at the forefront of the debate on the future direction of health and public services provision in many industrialized countries in Europe and elsewhere. It is used both, as a means to achieve desired policy goals in public health care systems such as greater efficiency and improved quality of care, and as a good with its own intrinsic value. However, the evidence suggests that its impact on efficiency and quality is at best a very limited while it might have negative consequences on equity because the pre-existing inequalities of income and education could influence patients’ access to information and, consequently, choices. The paper attempts to introduce multidisciplinary frameworks to account for the social and cultural factors guiding patients’ choices and to explain the rationale, processes and outcomes of decision making in health care. 1 - 121 123 - - Marianna Fotaki Warwick Business School, University of Warwick, Coventry, UK Warwick Business School, University of Warwick, Iran marianna.fotaki@wbs.ac.uk Patient Choice Efficiency Quality of Care Market Public Good Health Ethics 1. Williams J, Rossiter A. Choice: the evidence. The operation of choice systems in practice: national and international evidence. London: The Social Market Foundation; 2004. ##2. Beusekom I, Tönshoff S, de Vries H, Spreng C, Keeler EB. Possibility or utopia? Consumer choice in health care: A literature review. Santa Monica: RAND Corporation; 2004. ##3. Le Grand J. The other invisible hand. Princeton University Press; 2007. doi: 10.1017/s004727940800233x   ##4. Department of Health. Fair for all, personal to you. A consultation on choice, responsiveness and equity. London: Department of Health; 2003. ##5. Vrangbæk K, Østergren K, OkkelsBirk H, Winblad U. Patient reactions to hospital choice in Norway, Denmark and Sweden. Health Econ Policy Law 2007; 2: 125–52. doi: 10.1017/s174413310700401x ##6. Ashton T, Mays N, Devlin N. Continuity through change: the rhetoric and reality of health reform in New Zealand. Soc Sci Med 2005; 61: 253–62. doi: 10.1016/j.socscimed.2004.07.004 ##7. Vaillancourt-Rosenau P, Lako C. An experiment with regulated competition and individual mandates for universal health care: The new Dutch health insurance system. J Health Polit Policy Law 2008; 33: 1031–52. doi: 10.1215/03616878-2008-033 ##8. Lisac M. Health care reform in Germany: Not the big bang. Health Policy Monitor. 2006. [cited 2013 July 13]. Available from: http://www.hpm.org/en/Surveys/Bertelsmann_Stiftung_-_Germany/08/Health_care_reform_in_Germany__Not_the_big_bang.html ##9. Gray B. Trust and trustworthy care in the managed care era. Health Aff 1997; 16: 34–49. doi: 10.1377/hlthaff.16.1.34 ##10. Blair A. We must not waste this precious period of power. Speech given at South Camden Community College, 23 January 2003. ##11. Fotaki M. Towards developing new partnerships in public services: users as consumers, citizens and/or co-producers driving improvements in health and social care in the UK and Sweden. Public Adm 2011; 89: 933–95. doi: 10.1111/j.1467-9299.2010.01879.x ##12. Giddens A. Living in a post-traditional society. In: Beck U, Giddens A, Lash S, eds. Reflexive modernisation: politics, traditions and aesthetics in the modern social order. Cambridge: Polity; 1994. doi: 10.1177/144078339703300220 ##13. Blomqvist P. The choice revolution: privatization of Swedish welfare services in the 1990s. Soc Policy Adm 2004; 38: 139–55. doi: 10.1111/j.1467-9515.2004.00382.x ##14. Barley S. 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What people want, need and expect from public services. London: 2020 Public Services Trust at RSA prepared by Ipsos MORI. ##20. Fotaki M, Boyd A, Smith L, Ruth McDonald R, Roland M, Sheaff R, et al. Patient choice and the organisation and delivery of health services: Scoping review. A report to the NCCSDO. London, 2006. ##21. Kahneman D, Tversky A. Prospect theory: An analysis of decision under risk. Econometrica 1979; 47: 263–91. doi: 10.2307/1914185 ##22. Mol A. The logic of care. London: Routledge; 2008. doi: 10.3384/cu.2000.1525.124533##

Biopharmaceutical Innovation System and the Influence of Policies: The Case of Taiwan (2000-2008) 2 2 This article discusses the influence of policies on the development of biopharmaceuticals. We choose the experiences of Taiwan for our empirical study and focus on the evolution between 2000 and 2008; in the period of time the country provides an interesting example for further exploration of biopharmaceutical policies. Among all the policies, the two National Programs (National Research Program for Genetic Medicine and National Science and Technology Program for Biotechnology and Pharmaceuticals) and the Law of Pharmaceutical Affairs showed the contrasting effects on the innovation system of biopharmaceuticals. As a result, the government generated very limited positive influence on the innovation of biopharmaceuticals. 1 - 125 130 - - Chao Chen Chung Department of Political Sciences, National Cheng Kung University, Taiwan Department of Political Sciences, National Iran chaochen.chung@gmail.com Biotechnology Pharmaceuticals Taiwan Innovation System Policy 1. Nelson R. National innovation systems: a comparative analysis. Oxford: Oxford University Press; 1993. doi: 10.1016/s0737-6782(95)90054-3 ##2. Freeman C. Technology policy and economic performance: lessons from Japan Pinter. London, New York: Frances Printer Publishers: 1987. ##3. Malerba F. Secotral systems of innovation and production. Res Policy 2002; 31: 247–64. doi: 10.1016/s0048-7333(01)00139-1 ##4. Bergek A, Jacobsson S, Carlsson B, Lindmark S, Rickne A. Analyzing the functional dynamics of technological innovation systems: a scheme of analysis. Res Policy 2008; 37: 407–29. doi: 10.1016/j.respol.2007.12.003 ##5. Chung CC. National, sectoral and technological innovation systems: The case of Taiwanese pharmaceutical biotechnology and agricultural biotechnology innovation systems (1945–2000). Science and public policy 2012; 39: 271–81. doi: 10.1093/scipol/scs008 ##6. Cho PR. Lilly will end the 15 years of many factoring in Taiwan The facilities whose output value is 60 million US dollars is searching for buyer. Economic Daily News. The United News, Taipei. ##7. DCB. The yearbook of pharmaceutical industry 2007. Taipei: Development center of biotechnology; 2007. ##8. MedicineNet. Definition of Me-too drug. [cited 2013 July 25]. Available from: http://www.medterms.com/script/main/art.asp?articlekey=33748 ##9. Ho Yt. Developing biotechnology Linking Taipei, 2004. ##10. DCB. The yearbook of Chinese herbal medicine industry 2004. Taipei: Development Center of Biotechnology; 2004. ##11. DCB. The yearbook of pharmaceutical industry 2005. Taipei: Development center of biotechnology; 2005. ##12. NSC. Science and technology yearbook 2004. Taipei: National Science Council; 2004. ##13. Laboratories NAR. Science and Technology Yearbook 2008. Taipei; National Science Council; 2008.##

Outcome Evaluation of Therapeutic Community Model in Iran 2 2 Background Evaluation of treatment programs in addiction field is a prerequisite to improve the quality of care. This study aimed to investigate the effectiveness of Therapeutic Community (TC) program in Iran.   Methods Individuals who had voluntarily enrolled in the TC center within a period of seven years, from early 2005 to late 2011, entered the study. Those who successfully completed the 14-week residential course were considered as ‘completers’. They were subsequently called in for urine test and interviews using Maudsley Addiction Profile. Urine test was conducted to determine if they were positive for heroin, opium, methadone, methamphetamine, bupronorphine, hashish, and tramadol.   Results A number of 378 individuals with mean (± SD) age of 32.5 ± 7.8 enrolled in the TC program during the study period, 240 individuals of whom completed the 14 weeks course (69.0%). At the end of the sixth year, 22% of the participants were in abstinence. Physical and mental health in abstainers proved to be of better conditions than those of non-abstainers (P<0.05).     Conclusion Considering the TC outcome in other countries, it seems that TC maintains an acceptable effectiveness in Iran. Prospective controlled studies are warranted to investigate the outcomes in more details. 1 - 131 135 - - Nasrindokht Sadir Research Center for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran Research Center for Health Services Management, Iran nasrinsadir@gmail.com - - Mojtaba Shojaei Kerman Social Security Organization, Kerman, Iran Kerman Social Security Organization, Kerman, Iran - - Kamaladdin Moadab Kerman Social Security Organization, Kerman, Iran Kerman Social Security Organization, Kerman, Iran - - Reza Abbasi Kerman Social Security Organization, Kerman, Iran Kerman Social Security Organization, Kerman, Iran - - Abbas Bahrampour Research Center for Social Determinants of Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran Research Center for Social Determinants of Iran abahrampour@yahoo.com - - Nouzar Nakhaee Neuroscience Research Center, Kerman University of Medical Sciences, Kerman, Iran Neuroscience Research Center, Kerman University Iran nakhaeen@yahoo.com Outcome Study Evaluation Substance Abuse Treatment 1. UNODC. World Drug Report 2012. Vienna: United Nations Office on Drugs and Crime; 2012. doi: 10.1590/s1413-81232012001200029 ##2. Nakhaee N, Divsalar K, Meimandi MS, Dabiri S. Estimating the prevalence of opiates use by unlinked anonymous urine drug testing: A pilot study in Iran. Subst Use Misuse 2008; 43: 513–20. doi: 10.1080/10826080701772348 ##3. NIDA. Therapeutic Community : What is a Therapeutic Community? Bethesda, MD: National Institute on Drug Abuse; 2002. ##4. UNODC. Evaluation of Substance Use Treatment Programmes. Vienna: United Nations Office on Drugs and Crime; 2009. doi: 10.1590/s1413-81232012001200029 ##5. Malivert M, Fatséas M, Denis C, Langlois E, Auriacombe M. Effectiveness of therapeutic communities: A systematic review. Eur Addict Res 2012; 18: 1–11. doi: 10.1159/000331007   ##6. Marlatt GA, Gordon JR. Relapse prevention: maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press; 1985. doi: 10.1093/bjsw/bcl044 ##7. Marsden J, Gossop M, Stewart D, Best D, Farrell M, Lehmann P, et al. The Maudsley Addiction Profile (MAP): a brief instrument for assessing treatment outcome. Addiction 1998; 93:1857–68. doi: 10.1046/j.1360-0443.1998.9312185711.x ##8. Afshari R, Zare I, Moeen L. [The effect of group schema therapy approach in improvement of B category personality disorders for substance dependents]. Journal of Psychological models and Methods 2011; 1: 19–35. ##9. Autrique M, Vandeplasschen W, Broekaert E, Sabbe B. The drug-free therapeutic community: Findings and reflections in an evidence-based era. Therapeutic Communities: The International Journal of Therapeutic Communities 2008; 29: 5–15. ##10. Miller WR, Sorensen JL, Selzer JA, Brigham GS. Disseminating Evidence-Based Practices in Substance Abuse Treatment: A Review with Suggestions. J Subst Abuse Treat 2006; 31: 25–39. doi: 10.1016/j.jsat.2006.03.005 ##11. Johnson K, Pan Z, Young L, Vanderhoff J, Shamblen S, Browne T, et al. Therapeutic community drug treatment success in Peru: a follow-up outcome study. Subst Abuse Treat Prev Policy 2008; 3: 26. doi: 10.1186/1747-597x-3-26 ##12. Abdollahnejad MR. Follow-Up evaluation of Tehran Therapeutic Community. Therapeutic Communities: The International Journal of Therapeutic Communities 2008; 29: 57–75. ##13. Darke S, Campbell G, Popple G. Retention, early dropout and treatment completion among therapeutic community admissions. Drug Alcohol Rev 2012; 31: 64–71. doi: 10.1111/j.1465-3362.2011.00298.x ##14. Fernández Hermida JR, Secades Villa R, Fernández Ludeña JJ, Marina González PA. Effectiveness of a therapeutic community treatment in Spain: a long-term follow-up study. Eur Addict Res 2002; 8: 22–9. doi: 10.1159/000049484 ##15. Van Stelle KR, Blumer C, Moberg DP. Treatment retention of dually diagnosed offenders in an institutional therapeutic community. Behav Sci Law 2004; 22: 585–97. doi: 10.1002/bsl.602 ##16. Dekel R, Benbenishty R, Amram Y. Therapeutic communities for drug addicts: prediction of long-term outcomes. Addict Behav 2004; 29: 1833–7. doi: 10.1016/j.addbeh.2004.01.009 ##17. Carroll JF, McGinley JJ. An agency follow-up outcome study of graduates from four inner-city therapeutic community programs. J Subst Abuse Treat 2000; 18: 103–18. doi: 10.1016/s0740-5472(99)00036-7 ##18. aZiaaddini H, Nasirian M, Nakhaee N. Comparison of the efficacy of Buprenorphine and Clonidine in detoxification of opioid-dependents. Addict Health 2012; 4: 79–86.##

Reasons for Discharge against Medical Advice: A Case Study of Emergency Departments in Iran 2 2 Background Incomplete hospitalization is the cause of disease relapse, readmission, and increase in medical costs. Discharge Against Medical Advice (DAMA) in emergency department (ED) is critical for hospitals. This paper aims to explore the underlying reasons behind DAMA in ED of four teaching hospitals in Kerman, Iran.   Methods This was a cross-sectional study in which the samples were drawn from the patients who chose to leave against medical advice from the ED of teaching hospitals in Kerman from February to March 2011. The sampling was based on census. Data were gathered by a self-constructed questionnaire. The reasons for DAMA were divided into three parts: reasons related to patient, medical staff, and hospital environment. The questionnaire was filled out by a face-to-face interview with patient or a reliable companion.   Results There were 121 cases (5.6%) of DAMA out of the total admissions. The main reason of AMA discharges was related to patient factors in 43.9% of cases, while two other factors (i.e., hospital environment and medical staff) constituded 41.2% and 35.2% of cases, respectively. The majority of patients 65.9% (80 cases) were either uninformed or less informed of the entailing side effects and outcomes of their decision to DAMA.    Conclusion In comparison to studies conducted in other countries, the rate of DAMA is markedly higher in Iran. The results revealed that patients awareness of the consequences of their decisions is evidently inadequate. The study suggests a number of recommendations. These include, increasing patient awareness of the potential side effects of DAMA and creating the necessary culture for this, improving hospital facilities, and a more careful supervision of medical staff performance. 1 - 137 142 - - Kaveh Noohi Research Center for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran Research Center for Health Services Management, Iran kavehnouhi@gmail.com - - Samaneh Komsari Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran Research Center for Modeling in Health, Institute Iran s.komsari.health@gmail.com - - Nouzar Nakhaee Neuroscience Research Center, Kerman University of Medical Sciences, Kerman, Iran Neuroscience Research Center, Kerman University Iran nakhaeen@yahoo.com - - Vahid Yazdi Feyzabadi Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran | Research Center for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Department of Health Management and Economics, Iran v-yazdif@razi.tums.ac.ir Emergency Department Discharge against Medical Advice Teaching Hospital Iran 1. 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Ashghly Farahani M, Mohammadi I, Ahmadi FA, Maleki M, Hajizadeh E. [Barriers to patient education in the CCU and post CCU: a grounded theory study]. Iran J Nurs 2009; 22: 55–73. ##17. Skelton A. Evolution not revolution? The struggle for the recognition and development of patient education in the UK. Patient Education 2001; 44: 23–7. doi: 10.1016/s0738-3991(01)00098-2 ##18. Hekmatpou D, Anoosheh M, Alhani F. [Pathology of patient education: A qualitative study]. Iran J Nurs 2007; 20: 51–60. ##19. Heyrani A, Maleki M, Barati Marnani A, Ravaghi H, Sedaghat M, Jabbari M, et al. Clinical governance implementation in a selected teaching emergency department: A systems approach. Implemen Sci 2012; 7: 84. doi: 10.1186/1748-5908-7-84   ##20. Emami Razavi H, Masoumi GR, Jalili M, Siah tir M. [Indicators for hospital emergencies departments]. 2011. Available from: http://balini.tbzmed.ac.ir ##21. Manouchehri J, Goodarzynejad H, Khoshgoftar Z, Sheikh Fathollahi M, Aghamohammadi Abyaneh M. Discharge against Medical Advice among Inpatients with Heart Disease in Iran. J Tehran Heart Cent 2012; 7: 72–7. ##22. Tavalaiee A, Asarii SA, Habibi M, Khodami HR ,Vahabi SY, Noohi S, et al. [Discharge Against Medical Active from Psychiatric Ward]. Journal of Military Medicine 2006; 8: 24–30. ##23. Roodpeyma S, Eshagh Hoseyni S. Discharge of children from hospital against medical advice. World J Pediatr 2010; 6: 353–6. doi: 10.1007/s12519-010-0202-3   ##24. Duno R, Pousa E, Sans J, Tolosa C, Ruiz A. Discharge against medical advice at a general hospital in Catalonia. Gen Hosp Psychiatry 2003; 25: 46–50. doi: 10.1016/s0163-8343(02)00253-0 ##25. Abdulrasheed NA, Babalola MO. Clinical spectrum of discharge against medical advice in a developing country. Indian J Surg 2008; 70: 68–72. doi: 10.1007/s12262-008-0018-8 ##26. Seaborn MH, Osmun WE. Discharge against medical advice: A community hospitals experience. Can Journal Rural Med 2004; 9: 148–53. ##27. Fiscella K, Meldrum S, Franks P. 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Patients’ Awareness of Their Rights: Insight from a Developing Country 2 2 Background Considering the effect of human right observance on patients’ satisfaction from the treatment process, in Iran the Patient Rights Charter (PRC) was developed by the Ministry of Health and Medical Education (MOHME) in 2001 and enforced to all hospitals across the country. The purpose of the current study was to evaluate patients’ awareness of their rights based on PRC in two tertiary teaching hospitals affiliated with Shiraz University of Medical Sciences (SUMS) in Iran.   Methods Current study was a cross-sectional descriptive and analytical survey. The research sample consisted of 200 inpatients and data were gathered through questionnaires filled out during the interview. The rate of awareness of patients was measured on a Likert scale ranging from 1 to 4. Validity and reliability of the questionnaire were confirmed. Data were analysed by descriptive and analytical statistics.   Results In 30.5% of cases, the total awareness of patients was weak, in 59.4% was moderate, and in 10.1% of them was good. The most awareness was about trust and assurance to confidentiality of treatment team, and the least was about providing sufficient information about treatment options and their complications. There was a significant relationship between educational level and the place of residency with patients’ awareness (P<0.001).  Conclusion Total awareness of patients from their rights was medium. Although compared to similar studies this rate was not unsatisfactory, attempts should be made to improve it. Health care organizations are to deliver PRC to patients and make sure they have proper information about their rights. Assuring observance of patients’ rights requires not only informing healthcare policy makers and providers, but also educating citizens about what they must expect from their governments and health care providers. This will consequently improve the quality of services. 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Globalization as a Driver or Bottleneck for Sustainable Development: Some Empirical, Cross-National Reflections on Basic Issues of International Health Policy and Management 2 2 Background This article looks at the long-term, structural determinants of environmental and public health performance in the world system.   Methods In multiple standard ordinary least squares (OLS) regression models, we tested the effects of 26 standard predictor variables, including the ‘four freedoms’ of goods, capital, labour and services, on the following indicators of sustainable development and public health: avoiding net trade of ecological footprint global hectare (gha) per person; avoiding high carbon emissions per million US dollars GDP; avoiding high CO2 per capita (gha/cap); avoiding high ecological footprint per capita; avoiding becoming victim of natural disasters; a good performance on the Environmental Performance Index (EPI); a good performance on the Happy Life Years (HLYs) scale; and a good performance on the Happy Planet Index (HPI).   Results Our research showed that the apprehensions of quantitative research, critical of neo-liberal globalization, are fully vindicated by the significant negative environmental and public health effects of the foreign savings rate. High foreign savings are indeed a driver of global footprint, and are a blockade against a satisfactory HPI performance. The new international division of labour is one of the prime drivers of high CO2 per capita emissions. Multinational Corporation (MNC) penetration, the master variable of most quantitative dependency theories, blocks EPI and several other socially important processes. Worker remittances have a significant positive effect on the HPI, and HLYs.   Conclusion We re-analysed the solid macro-political and macro-sociological evidence on a global scale, published in the world’s leading peer-reviewed social science, ecological and public health journals, which seem to indicate that there are contradictions between unfettered globalization and unconstrained world economic openness and sustainable development and public health development. We suggest that there seems to be a strong interaction between ‘transnational capitalist penetration’ and ‘environmental and public health degradation’. Global policy-making finally should dare to take the globalization-critical organizations of ‘civil society’ seriously. This conclusion not only holds for the countries of the developed “West”, but also, increasingly, for the growing democracy and civil society movements around the globe, in countries as diverse as Brazil, Russia, China, or ever larger parts of the Muslim world. 1 - 147 155 - - Arno Tausch Department of Political Science, Innsbruck University, Innsbruck, Austria; Corvinus University, Budapest, Hungary Department of Political Science, Innsbruck Iran arno.tausch@uibk.ac.at international relations International Political Economy International Migration 1. Jorgenson AK. Consumption and Environmental Degradation: A Cross-National Analysis of the Ecological Footprint. 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Informal Payments in Healthcare: A Case Study of Kerman Province in Iran 2 2 Background Informal payments for health care, which are common in many countries, can have negative effects on health care access, equity and health status as they lead people to forgo or delay seeking care, or to sell assets to pay for care. Many countries are putting reforms in place with the aim of reducing informal payments. In order to be successful, such policies should be informed by the underlying causes of such payments. This study attempts to explore why, how, and in what ways informal payments occur.   Methods We conducted face-to-face interviews with a purposeful sample of 45 participants, including patients, healthcare providers and officials, in Kerman province in Iran, in 2010. The research participants were asked about the nature of informal payments, the reasons behind both asking and making those payments. We analysed the data using content analysis.   Results We found that people make informal payments for several reasons, namely cultural, quality-related and legal. Providers ask for informal payments because of tariffs, structural and moral reasons, and to demonstrate their competence. Informal payments were found to be more prevalent for complex procedures and are usually asked for directly.   Conclusion Informal payments are present in Iran’s health system as in other countries. What makes Iran’s condition slightly different from other countries is the peculiarity of reasons behind asking informal payments and the disadvantages associated with these kinds of payments. Iran could overcome this dilemma by precise investigation of the reasons to inform appropriate policy formulation. Some policies such as raising salaries, justifying the tariffs and cost-sharing, defining a benefits package of services, and improving accountability and transparency in the health system could be taken by the government to alleviate the problem. 1 - 157 162 - - Mahmood Nekoeimoghadam Research Center for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran Research Center for Health Services Management, Iran mahmood.nekoeimoghadam@gmail.com - - Atefeh Esfandiari Research Center for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran | Department of Health Management and Economics, School of Public Health, Tehran University of Medical Research Center for Health Services Management, Iran atefehesfandiari88@gmail.com - - Fateme Ramezani Research Center for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran Research Center for Health Services Management, Iran ramezani_s64@yahoo.com - - Mohammadreza Amiresmaili Research Center for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran Research Center for Health Services Management, Iran mohammadreza.amiresmaili@gmail.com Informal Payment Health Services Iran’s health system 1. Setayesh M, Nakhaee N, Rohani A. [Assessment of people viewpoint about informal payment to Kerman physicians]. Iranian Journal of Ethics in Science and Technology 2007; 2: 81–8. ##2. Onwujekwe O, Dike N, Uzochukwu B, Ezeoke O. Informal payments for healthcare: Differences in expenditures from consumers and providers perspectives for treatment of malaria in Nigeria. Health Policy 2010; 96: 72–9. doi: 10.1016/j.healthpol.2009.12.014   ##3. Vian T, Grybosk K, Sinoimeri Z, Hall R. Informal payments in government health facilities in Albania: Results of a qualitative study. Soc Sci Med 2006; 62: 877–87. doi: 10.1016/j.socscimed.2005.07.005 ##4. Chereches RM, Ungureanu MI, Sandu P, Rus IA. Defining informal payments in healthcare: A systematic review. Health Policy 2013; 110: 105–14. doi: 10.1016/j.healthpol.2013.01.010 ##5. Liaropoulos L, Siskou O, Kaitelidou D, Theodorou M, Katostaras T. Informal payments in public hospitals in Greece. Health Policy 2008; 87: 72–81. doi: 10.1016/j.healthpol.2007.12.005 ##6. Chawla M, Berman P, Windak A, Kulis M. Provision of ambulatory health services in Poland: a case study from Krakow. Soc Sci Med 2004; 58: 227–35. doi: 10.1016/s0277-9536(03)00006-6 ##7. Killingsworth J, Hossain N, Hedrick-Wong Y, Thomas S, Rahman A, Begum T. Unofficial fees in Bangladesh: price, equity and institutional issues. Health Policy Plan 1999; 14: 152–63. doi: 10.1093/heapol/14.2.152 ##8. Stringhini S, Thomas S, Bidwell P, Mtui T, Mwisongo A. Understanding informal payments in health care: motivation of health workers in Tanzania. Hum Resour Health 2009; 7: 53. doi: 10.1186/1478-4491-7-53 ##9. Barber S, Bonnet F, Bekedam H. Formalizing under-the-table payments to control out-of-pocket hospital expenditures in Cambodia. Health Policy Plan 2004; 19: 199–208. doi: 10.1093/heapol/czh025 ##10. Gaal P, Belli P, McKee M, Szócska M. Informal payments for health care: definitions, distinctions, and dilemmas. J Health Polit Policy Law 2006; 31: 251–93. doi: 10.1215/03616878-31-2-251 ##11. Vian T, Burak LJ. Beliefs about informal payments in Albania. Health Policy Plan 2006; 21: 392–401. doi: 10.1093/heapol/czl022 ##12. Akashi H, Yamada T, Huot E, Kanal K, Sugimoto T. User fees at a public hospital in Cambodia: effects on hospital performance and provider attitudes. Soc Sci Med 2004; 58: 553–64. doi: 10.1016/s0277-9536(03)00240-5 ##13. Delcheva E, Balabanova D, McKee M. Under-the-counter payments for health care: Evidence from Bulgaria. Health Policy 1997; 42: 89–100. doi: 10.1016/s0168-8510(97)00061-4 ##14. Lewis M. Informal payments and the financing of health care in developing and transition countries. Health Aff 2007; 26: 984–97. doi: 10.1377/hlthaff.26.4.984 ##15. Lewis MA. Who is paying for health care in Eastern Europe and Central Asia? Washington D.C.: World Bank Publications; 2000. ##16. Thompson R. Health sector reform. Int J Health Plann Manage 2006; 15: 169–87. ##doi: 10.1002/1099-1751(200007/09)15:33.0.CO;2-2 ##17. Ensor T. Informal payments for health care in transition economies. Soc Sci Med 2004; 58: 237–46. doi: 10.1016/s0277-9536(03)00007-8 ##18. Ghiasipour M, Abolghasem P, Arab M, Mahmoodi M, Abutorabi A. [The Analysis of Informal Payments Among Hospitals Covered Under Tehran University of Medical Sciences (TUMS) 2009]. Hospital Quarterly 2011; 10: 1–14 ##19. Miller WL, Koshechkina TY. If you pay, we’ll operate immediately. J Med Ethics 2000; 26: 305–11. doi: 10.1136/jme.26.5.305 ##20. Ozgen H, Sahin B, Belli P, Tatar M, Berman P. Predictors of Informal Health Payments: The Example from Turkey. J Med Syst 2010; 34: 387–96. doi: 10.1007/s10916-008-9251-8 ##21. Tourani S, Amiresmaili MR, Maleki MR, Hadian M. An interview survey on health priority setting practice in Iran. Research Journal of Biological Sciences 2009; 4: 1193–201. ##22. Takian A, Rashidian A, Kabir MJ. Expediency and coincidence in re-engineering a health system: an interpretive approach to formation of family medicine in Iran. Health Policy Plan 2011; 26: 163–73. doi: 10.1093/heapol/czq036 ##23. De Bruin A, Picavet HSJ, Nossikov A. Health interview surveys: towards international harmonization of methods and instruments. WHO Reg Publ Eur Ser 1996; 58: 1–161. ##24. Stepurko T, Pavlova M, Gryga I, Groot W. Empirical studies on informal patient payments for health care services: a systematic and critical review of research methods and instruments. BMC Health Serv Res 2010; 10: 273. doi: 10.1186/1472-6963-10-273 ##25. Tomini S, Maarse H. How do patient characteristics influence informal payments for inpatient and outpatient health care in Albania: Results of logit and OLS models using Albanian LSMS 2005. BMC Public Health 2011; 11: 375. doi: 10.1186/1471-2458-11-375 ##26. Aarva P, Ilchenko I, Gorobets P, Rogacheva A. Formal and informal payments in health care facilities in two Russian cities, Tyumen and Lipetsk. Health Policy Plan 2009; 24: 395–405. doi: 10.1093/heapol/czp029 ##27. Azadarmaki T, Bikaranbehesht M. [Offering In the Iranian Daily Life]. Barge Farhang 2010; New: 196–209. ##28. Shahriari H, Belli P, Lewis M. Institutional issues in informal health payments in Poland. World Bank Draft Report, 2001. ##29. Tourani S, Maleki MR, Hadian M, Amiresmaili MR. [A survey on present status of health services priority setting in Iran]. Payesh 2011; 10: 217–30.##

Comparison of the Effects of Public and Private Health Expenditures on the Health Status: a Panel Data Analysis in Eastern Mediterranean Countries 2 2 Background Health expenditures are divided in two parts of public and private health expenditures. Public health expenditures contain social security spending, taxing to private and public sectors, and foreign resources like loans and subventions. On the other hand, private health expenditures contain out of pocket expenditures and private insurances. Each of these has different effects on the health status. The present study aims to compare the effects of these expenditures on health in Eastern Mediterranean Region (EMR).   Methods In this study, infant mortality rate was considered as an indicator of health status. We estimated the model using the panel data of EMR countries between 1995 and 2010. First, we used Pesaran CD test followed by Pesaran’s CADF unit root test. After the confirmation of having unit root, we used Westerlund panel cointegration test and found that the model was cointegrated and then after using Hausman and Breusch-Pagan tests, we estimated the model using the random effects.   Results The results showed that the public health expenditures had a strong negative relationship with infant mortality rate. However, a positive relationship was found between the private health expenditures and infant mortality rate (IMR). The relationship for public health expenditures was significant, but for private health expenditures was not.   Conclusion The study findings showed that the public health expenditures in the EMR countries improved health outcome, while the private health expenditures did not have any significant relationship with health status, so often increasing the public health expenditures leads to reduce IMR. But this relationship was not significant because of contradictory effects for poor and wealthy peoples. 1 - 163 167 - - Enayatollah Homaie Rad School of Health Management and Information Sciences, Tehran University of Medical sciences, Tehran, Iran School of Health Management and Information Iran ehomaie@yahoo.com - - Sajad Vahedi School of Health Management and Information Sciences, Shiraz University of Medical sciences, Shiraz, Iran School of Health Management and Information Iran vahedi.s3@gmail.com - - Abedin Teimourizad School of Health Management and Information Sciences, Shiraz University of Medical sciences, Shiraz, Iran School of Health Management and Information Iran teimouriz@gmail.com - - Firooz Esmaeilzadeh School of Health Management and Information Sciences, Tehran University of Medical sciences, Tehran, Iran School of Health Management and Information Iran firooz.esmaeilzadeh@gmail.com - - Mohamad Hadian School of Health Management and Information Sciences, Tehran University of Medical sciences, Tehran, Iran School of Health Management and Information Iran mohamadhadian@yahoo.com - - Amin Torabi Pour School of Public Health, Tehran University of Medical Sciences, Tehran, Iran School of Public Health, Tehran University Iran torabipoor@yahoo.com EMR countries Public Health Expenditures Private Health Expenditures Panel Data 1. 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Occupational Stress and Turnover Intention: Implications for Nursing Management 2 2 Background The main purpose of this study was to explore the status of occupational stress among hospital nurses in Isfahan, Iran. It also aimed to examine the relationship between nurses’ occupational stress and their intention to leave the hospital.   Methods The study employed a cross-sectional research design. A validated questionnaire was used to collect data from 296 nurses. Respondents were asked to rate the intensity of 30 common occupational stressors using a five-point scale.   Results A third of hospital nurses rated their occupational stress high. The major sources of stress were inadequate pay, inequality at work, too much work, staff shortage, lack of promotion, job insecurity and lack of management support. More than 35% of nurses stated that they are considering leaving the hospital, if they could find another job opportunity. Occupational stress was positively associated with nurses’ turnover intentions.   Conclusion Hospital managers should develop and apply appropriate policies and strategies to reduce occupational stress and consequently nurses’ turnover intention. 1 - 169 176 - - Ali Mohammad Mosadeghrad Health Management and Economics Research Centre, School of Health Management and Information Sciences, Tehran University of Medical Sciences, Tehran, Iran Health Management and Economics Research Iran mosadeghrad@gmail.com Occupational Stress Hospital Nurses Iran 1. Koys DJ. The effects of employee satisfaction, organizational citizenship behaviour, and turnover on organizational effectiveness: A unit-level, longitudinal study. Pers Psychol 2001; 54: 101–14. doi: 10.1111/j.1744-6570.2001.tb00087.x ##2. Shaw JD, Gupta N, Delery JE. Alternative conceptualizations of the relationship between voluntary turnover and organizational performance. 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The Governance of Health Systems; Comment on “A Network Based Theory of Health Systems and Cycles of Well-Being” 2 2 Health systems research aims to understand the governance of health systems (i.e. how health systems function and perform and how their actors interact with each other). This can be achieved by applying innovative methodologies and concepts that are going to capture the complexity and dynamics of health systems when they are affected by shocks. The capacity of health systems to adapt to shocks (i.e. the resilience of health systems) is a new area of investigation. Social network analysis is a great avenue that can help measure the properties of systems and analyse the relationships between its actors and between the structure of a health system and the performance of a health system. A new conceptual framework is presented to define the governance of health systems using a resilience perspective. 1 - 177 179 - - Karl Blanchet Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK Department of Clinical Research, London School Iran karl.blanchet@lshtm.ac.uk Health Systems Social Network Analysis Governance Resilience 1. Rhodes MG. A network based theory of health systems and cycles of well-being. International Journal of Health Policy and Management 2013; 1: 7–15. doi: 10.15171/ijhpm.2013.03 ##2. Kickbusch I. Global Health Governance: Some Theoretical Considerations on the New Political Space. In: Lee K, editor. Health Impacts of Globalization. Basingstoke: Palgrave Macmillan; 2003. ##3. Commission on Macroeconomics and Health. Macroeconomics and health: Investing in health for economic development. Geneva: World Health Organization; 2001. doi: 10.1038/nm0602-551b ##4. 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Factoring Health Equations; Comment on “Do You Recommend an Interdisciplinary Field to Your Graduate Student?” 2 2 The International Journal of Health Policy and Management (IJHPM) is a new journal that aims to stimulate not only inter-disciplinary research relating to health, but even an entire new generation of such journals. The challenges of improving human health worldwide clearly suggest ‘why’ such a journal is needed, but ‘how’ bridges and junctions across fields of study towards this end might be found poses other questions. From the agnosticism of many sciences with respect to human health, to the great faith others place in more esoteric movements for human well-being, both suggest finding common factors in the many equations that affect human health. Particularly, as it is typically defined professionally, it might pose more fundamental challenges than those which appear first. However, the first editorial and edition quietly assure that the journal is in good hands, and that the search for a new generation of journals has begun. 1 - 181 182 - - Michael Rhodes Orrery Consulting, Prins Hendrikkade 160, Amsterdam, The Netherlands Orrery Consulting, Prins Hendrikkade 160, Iran orreryconsulting@gmail.com Health Co-Production Quasi-Health Professional Inter-Disciplinary Research 1. Haghdoost AA, Shahravan A. Do you Recommend an Interdisciplinary Field to Your Graduate Student? International Journal of Health Policy and Management 2013; 1: 1–2. doi: 10.15171/ijhpm.2013.01 ##2. World Association of Medical Editors. [updated 2013 June 2; cited 2013 July 13]. Available from: http://www.wame.org/ ##3. HINARI Access to Research in Health Programme. Available from: http://who.int/hinari/about/en/ ##4. Habibzadeh F, Mahboobeh Y. Journal weighted impact factor: A proposal. J Informetr 2008: 2; 164–72. doi: 10.1016/j.joi.2008.02.001##

Taxing Sugar-Sweetened Beverages: Not a “Holy Grail” but a Cup at Least Half; Comment on “Food Taxes: A New Holy Grail?” 2 2 In this commentary, we argue for the implementation of a sugar-sweetened beverage (SSB) tax as a tool to help address the global obesity and diabetes epidemics. Consumption of SSBs has increased exponentially over the last several decades, a trend that has been an important contributor to the obesity and diabetes epidemics. Prior evidence demonstrates that a SSB tax will likely decrease SSB consumption without significantly increasing consumption of other unhealthy food or beverages. Further, this tax is unlikely to have effects on income inequality and should not contribute to weight-based discrimination. A SSB tax also should raise revenue for government entities that already pay, through health care expenditures and health programs, for the consequences of excess SSB consumption. 1 - 183 185 - - Jason Block Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA, USA Department of Population Medicine, Harvard Iran jblock1@partners.org - - Walter Willett Departments of Nutrition and Epidemiology, Harvard School of Public Health, Boston, MA, USA Departments of Nutrition and Epidemiology, Iran wwillett@hsph.harvard.edu Sugar-Sweetened Beverages Tax Economics Obesity Overweight 1. Devisch I. Food taxes: a new holy grail? International Journal of Health Policy and Management 2013; 1: 95–7. doi: 10.15171/ijhpm.2013.15 ##2. Bleich SN, Wang YC, Wang Y, Gortmaker SL. Increasing consumption of sugar-sweetened beverages among US adults: 1988-1994 to 1999-2004. Am J Clin Nutr 2009; 89: 372–81. doi: 10.3945/ajcn.2008.26883 ##3. 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Food price and diet and health outcomes: 20 years of the CARDIA study. Arch Intern Med 2010; 170: 420–6. doi: 10.1001/archinternmed.2009.545 ##23. Finkelstein EA, Zhen C, Nonnemaker J, Todd JE. Impact of targeted beverage taxes on higher- and lower-income households. Arch Intern Med 2010; 170: 2028–34. doi: 10.1001/archinternmed.2010.449 ##24. Andreyeva T, Long MW, Brownell KD. The impact of food prices on consumption: a systematic review of research on the price elasticity of demand for food. Am J Public Health 2009; 100: 216–22. doi: 10.2105/ajph.2008.151415 ##25. Block JP, Chandra A, McManus KD, Willett WC. Point-of-purchase price and education intervention to reduce consumption of sugary soft drinks. Am J Public Health 2010; 100: 1427–33. doi: 10.2105/ajph.2009.175687 ##26. Schroeter C, Lusk J, Tyner W. Determining the impact of food price and income changes on body weight. J Health Econ 2008; 27: 45–68. doi: 10.1016/j.jhealeco.2007.04.001 ##27. 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