Journal articles on the topic 'Harvard Advocate (Organization)'

AbstractThe collaborative London based non-governmental organization network ELRHA (Enhancing Learning and Research for Humanitarian Assistance) supports partnerships between higher education institutions and humanitarian organizations worldwide with the objective to enhance the professionalization of the humanitarian sector. While coordination and control of the humanitarian sector has plagued the response to every major crisis, concerns highlighted by the 2010 Haitian earthquake response further catalyzed and accelerated the need to ensure competency-based professionalization of the humanitarian health care work force. The Harvard Humanitarian Initiative sponsored an independent survey of established academically affiliated training centers in North America that train humanitarian health care workers to determine their individual training center characteristics and preferences in the potential professionalization process. The survey revealed that a common thread of profession-specific skills and core humanitarian competencies were being offered in both residential and online programs with additional programs offering opportunities for field simulation experiences and more advanced degree programs. This study supports the potential for the development of like-minded academic affiliated and competency-based humanitarian health programs to organize themselves under ELRHA's regional “consultation hubs” worldwide that can assist and advocate for improved education and training opportunities in less served developing countries.Burkle Jr FM, WallsAE, HeckJP, SorensenBS, CranmerHH, JohnsonK, LevineAC, KaydenS, CahillB, VanRooyenMJ. Academic affiliated training centers in humanitarian health, Part 1: program characteristics and professionalization preference of centers in North America. Prehosp Disaster Med. 2013:28(2):1-8.

As national healthcare reform continues to place greater emphasis on providing high value care, measures designed to track clinical performance remain relatively overlooked. To that extent, several organizations have attempted to create objective grading systems to evaluate orthopaedic surgeon quality and performance. While attempting to address these issues, ProPublica’s Surgeon Scorecard has provoked national debate among patient advocates and healthcare providers. The methodology behind the Scorecard was developed at the Harvard School of Public Health with an aim to provide a more robust means of comparing surgical performance and outcomes for patients and healthcare organizations. Currently, the Scorecard assesses eight elective surgical procedures, including total knee and hip arthroplasty, through the use of the Medicare Claims Dataset. The impact of the Scorecard on orthopaedic practice has yet to be established. In this discussion, we analyze the Scorecard from the perspective of various stakeholders to identify its benefits and shortcomings, as well as offer direction for further improvement.

Douglas A. Johnson began his career as a human rights activist while earning his undergraduate degree in philosophy (1975) at Macalester College in the United States. He lived at Gandhi’s ashram in India to study nonviolent organizing (1969 to 1970). He served as the director of the Third World Institute in Minneapolis, MN, USA (1973–1979), which functioned as the international social justice program of the Archdiocese of Minneapolis and St. Paul. Johnson’s work included creating and running a political collective; leading development study tours into villages in Guatemala and Honduras; and investigating how transnational companies (e.g., Nestlé) were penetrating the developing world. He was the co-founder of the Infant Formula Action Coalition (INFACT), elected national chairperson (1977–1985), and appointed as Executive Director (1978–1984). His role included representing INFACT before national and international organizations, the human milk substitute industry, the US Congress and Executive Branch, and the press. He initiated and coordinated the first international grass-roots consumer boycott (against Nestlé) in ten nations. He was also a co-founder of the International Nestlé Boycott Committee and the International Baby Food Action Network (IBFAN). He earned a Master’s in Public and Private Management at Yale University (1988). Then he became the first Executive Director of the Center for Victims of Torture, in Minneapolis (1988–2012), the first treatment center for torture victims in the US. Since 2013, he has been teaching human rights theory and practice, and sharing lessons he has learned, as a Lecturer in Public Policy at the Harvard Kennedy School, Harvard University (US). (This interview was conducted via Zoom and transcribed verbatim. It has been edited for ease of readability. DJ refers to Doug Johnson and LD refers to Laura Duckett.)

In February 2016, the Florida State University (FSU) Faculty Senate passed an institutional Open Access (OA) Policy by unanimous vote,1 following the lead of many public and private universities across the United States. This was the culmination of many years of outreach and advocacy by OA champions at FSU, with a diverse, talented team of faculty and librarians making significant contributions along the way. This was also just one instance of a growing trend across North America and globally, with impressive growth in the number of OA policies and mandates adopted by research organizations and funders over the past decade. The adoption of an OA policy still presents many challenges with respect to policy compliance,2 and there are open questions about the long-term impact of different OA policy requirements and implementation models.3 At the same time, OA policy adoption remains an important goal for many institutions, a symbolic affirmation of faculty support for the principles of OA. An OA policy can help an institution raise the profile of its institutional repository (IR), invigorate outreach efforts and content recruitment, and, in the case of Harvard Model policies, safeguard the author rights of its faculty.4

Introduction:Climate change is intricately related to human health and impacts acute and chronic diseases leading to increased demands on the health care system.Aim:The University of Colorado Graduate Medical Education (GME) Fellowship in Climate Change and Health Science Policy (CCHSP) aims to train and equip a new generation of clinicians knowledgeable in climate science, proficient in climate health education, and facile with advocacy skills in order to become leaders in health policy.The CCHSP fellowship is funded by the Living Closer Foundation and hosted through the University of Colorado Department of Emergency Medicine. It is a one to two-year program tailored to the fellow’s specific goals with the opportunity to earn an MPH or MA. Clinical work is supported through the UCHealth network. Site placement occurs at partnering organizations, including the National Institutes of Health, the Centers for Disease Control and Prevention, and fieldwork throughout the world (via Colorado School of Public Health, Harvard FXB Center for Health and Human Rights).The first fellow was recruited in 2017 and has participated in and completed multiple projects: technical contributor to the US Government’s Fourth National Climate Assessment; advocating for women’s health policy in India; authorship of climate change and health resource documents for the World Bank; climate change leadership within SAEM; advocacy work with local and state governments; multiple research publications.Discussion:As climate change continues to impact human health with widespread consequences, we need effective and articulate leaders to affect policy. Although this Fellowship originated in Emergency Medicine, its competencies and structure are replicable for other clinical specialties. Climate change will be one of the core global health challenges for generations. A strong foundation of clinicians who understand its causes and the strategies for adaptation and mitigations are necessary to optimize health outcomes amidst this growing threat.

Abstract By modernizing cancer journal roles and editorial policy there may be greater rigor, biological understanding, scientific generalizability, reproducibility, transparency, and inclusion in cancer research. A path to identifying, addressing and correcting of structural inequities in health has been recently established by three major medical journal’s editorial policies to date and continue to be influenced by the reality of several reviews of publications over years and decades of clinical trials in cancer where specifically race and ethnicity demographics of study populations have been under-reported. The NIH has acknowledged the importance of demographic reporting and the FDA has established that data reporting in clinical trials is important. Question: What is needed to transform the ecosystem to ensure standards in promoting diversity, inclusion, and equity in cancer research? There are several considerations for stakeholders in organizations to address the issue of demographic reporting in research which includes both gender and race. There are metrics intrinsic to journal leadership which may include (i) demographics and diversity of leadership and editorial boards (ii) demographics and diversity of research staff. There are author considerations such as (i) diverse representation of authors (ii) Inclusion of a citation diversity statement, with attention to diversity in referenced citations (iii) statement of efforts and policy made to provide for inclusive environment, mentorship, and participation. Specifically, to ensure diversity and inclusion in non-therapeutic and therapeutic research, demographic and non-demographic variables in basic, clinical, and outcomes research should be considered by investigators and statisticians. For example, a statement of US and/or ex-US demographics of the disease, to whom the research question applies, and for whom the intervention is intended, and eligibility requirements that are scientifically justified. ASCO, AACR, MRCT- Harvard recommend action and policies for publicly reporting robust demographic characteristics on the enrolled clinical trial sample as part of the future modernization of journal editorial policy. The issue of demographic collection and reporting in research may be influenced by a variety of factors which include journal requirements, author demographics, investigator gender and race standards, bias, actual under-representation of the study population in the research consistent with the disease under study or rigor in the collection of demographics of the study population. There is a need for greater transparency of researcher, author standards, and journal requirements, leading to transparent research participant demographic reporting consistent with the research question. In all cases, the ability for any researcher, health care advocate or student to fully understanding the next question that needs to be answered and the demographics of study participants for inclusion is not fully optimized. Citation Format: Jeanne M. Regnante, Barbara Bierer, Karen Winkfield. Emerging editorial policies, researcher and author standards in promoting diversity, inclusion, and equity in research: A focus on cancer [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A024.

A flood of emails from various list serves filled our in-boxes with the shocking news: One of the world’smost prominent African American scholars, Dr. Henry Louis Gates, Jr. of Harvard University, had beenaccused of breaking into his own home. After America’s psychological honeymoon prompted byelection of the first President of African descent, some were forced to grapple with questions ofwhether racism still exists. The aforementioned incident answers these inquiries with a resounding,"Yes." Examples of accounts of continued racial prejudice and discrimination suggest the need forsupport systems and advocacy groups such as minority academic and professional organizations tolevel the social playing field.

Photo by Waranont (Joe) on Unsplash INTRODUCTION The age-adjusted COVID-19 mortality rate among Black Americans is twice as high as White Americans.[1] This shocking evidence of health disparities, coincident to a public reckoning with the history of racism in the US, highlights the inverse relationship between race and health. Public sentiment may now favor addressing these pressing public health issues, but the sprawling healthcare system largely focuses on clinical care; it lacks tools to influence the social determinants of health at the point of the healthcare institution. Reinvigorating organizational ethics, sometimes called institutional ethics, may provide such a tool. BACKGROUND Organizational ethics became part of the healthcare system during the upheavals in financing and organization of health care in the 1990s. Yet organizational ethics in a medical setting must be more than simple business ethics.[2] Just as health care professionals are granted special privileges in society in exchange for adherence to a code of medical ethics and duties, healthcare organizations and systems also must now adhere to ethical requirements in exchange for their privileged position that includes the right to provide, and be reimbursed for, health care.[3] In the 1990s, ethicists began to discuss how clinical ethics committees might develop an understanding of business ethics in order to provide comprehensive organizational ethics reviews.[4] Some bioethicists even believed that the challenges of integrating business and medical care would compel ethics committees to look outward, engaging in public advocacy around ethical issues in health care.[5] To fulfill the mission of maintaining organizational ethics standards within the healthcare system, ethics committees would need to advocate for patients in the public sphere. Ethics committees might even take positions at odds with those of the healthcare institutions in which they work. Organizational ethics committees might have served as watchdogs, ensuring that healthcare organizations fulfill their fiduciary duties to their patients and communities. Bioethicists soon realized that the vision of a robust ethics committee involving administrators, bioethicists, and medical staff advising multiple divisions of large organizations and policy makers would fall short.[6] The two ethical systems remained separate: most organizations developed a combination of a clinical ethics committee adjunct to the medical staff with a compliance department to oversee organizational ethics. However, organizational ethics really goes beyond compliance; it “cannot be addressed by focusing narrowly on business matters or by quasi-legal mechanisms to assure that behavior conforms to pre-established codes or rules.”[7] As a result, there is no centralized entity with power in each healthcare institution that can treat healthcare inequities as an institutional ethical failure that must be addressed. Current research on specific inequitable outcomes due to bias in clinical care includes specialties such as maternal care,[8]cardiac care,[9] pain management, and technology.[10] Implicit bias and racist clinical interactions, once identified, may be addressed through staff training and other interventions. Yet the ethics of clinical care requires little attention to the social determinants of health such as high levels of police surveillance in the community which may cause increased rates of hypertension,[11] pre-term birth,[12] and may affect mental health. Leaving these problems to the public health realm disconnects health practitioners and institutions from the ability to remedy some of the causes of health problems in their patients. Simply treating the effects of racism in the practice of medicine is not curative – it is really palliative care.[13] ANALYSIS The term “organizational ethics” is too limited to encompass the scope of change needed to address structural racism and the social determinants of health in today’s healthcare institutions. Structural Justice Ethics[14] better describes a plan and a process that requires the healthcare system and professionals to look both inward and outward to take on the structural causes of racism and health disparities. Building on organizational and clinical ethics, Structural Justice Ethics could amplify the research on systemic issues such as the effects of social determinants of health, racism in clinical care, and necessary advocacy with the local community. To be effective and complete, organizations should recognize duties to patients that arrive at their doorstep, damaged by generations of subordination and racism. To ethically treat patients who have experienced racism, the system and health practitioners must acknowledge and work to reduce the inequities in society that cause harm to their health in the clinical setting. Accreditation companies such as The Joint Commission could amend their standards to require top-rated healthcare organizations to form new Structural Justice Ethics committees in their organizations, taking affirmative steps to acknowledge the ethical implications of racism and the social determinants of health. Many bioethicists have already called for the field of bioethics to address racism as an ethical issue in healthcare, some even calling for a new Black Bioethics.[15] This frustration with the profession of bioethics has developed in other areas, such as disability ethics and feminist ethics, and reflects a belief that mainstream bioethics is a rigidly principlist endeavor. The education of new bioethicists is grounded in practical philosophy graduate programs, entwined with academia’s history of exclusivity. As a relatively young academic subject, bioethics has the potential to expand and grow into a more practical and justice-oriented tool, learning how to counter the overly individualistic bioethics that has roots in our racist and Protestant-dominant history.[16] Expanding organizational ethics into Structural Justice Ethics in health care could bring Black bioethicists into the center of healthcare ethics and provide the tools to implement changes needed to address racism in health care. Healthcare organizations should not expect Black healthcare practitioners to take on these Structural Justice Ethics roles as “extra” work. Too often, people of color are expected to bear the burden of explaining racism and working to eradicate it.[17]The Structural Justice Ethics committee should be a new model, centered in ethics and policy, with professional-level staffing that reflects the racial and ethnic makeup of the community it serves. Calling on bioethicists as moral agents in the world, and particularly within the medical system, to act as social justice advocates against systemic injustice in a system where they have privilege and power seems logical and surprisingly necessary. “Going forward, bioethics needs to engage with the nuances of race with the same vigor that it has approached discussions of moral theories and biotechnologies.”[18] Graduate-level bioethics programs have expanded significantly in recent years, with 45 current master’s level programs,[19] and there should be a wealth of professionals ready to oversee the role of encouraging and monitoring justice in the system. These programs focus primarily if not exclusively on the dominant paradigm of bioethics, yet as ethics programs, they should be able to course-correct and embrace greater diversity in people and thought. Structural Justice Ethicists can guide healthcare organizations to become learning institutions open to the idea that bias and inequity are ethical harms that they can and should address. Some may question whether such close attention to Black health care needs amounts to reparations or “reverse” discrimination, a controversial topic in our political discussions. However, when posed as an ethical duty of health care, there is no option to continue to treat Black people unethically. Of course, healthcare systems will have to balance competing budgetary interests; even with unlimited funding, disparities in health care would not disappear overnight.[20] In a fair process where decisionmakers must weigh the demands of stakeholders, the ethical obligation to address the social determinants of health must have an advocate. Moreover, setting high ethical standards is not the same as government spending to make reparations for past harms. In fact, Structural Justice Ethics does not look to the past at all but looks to the needs of subordinated communities of patients as they exist today. Any community that is harmed by structural injustice in health care can be the focus of a Structural Justice Ethics review. The Joint Commission and other accrediting organizations can require healthcare organizations to meet the challenges of health inequities by adopting new Structural Justice Ethics committees, just as The Joint Commission added organizational ethics to its requirements in 1995. Admittedly, Structural Justice Ethics is an amorphous concept and its role within healthcare institutions needs to be refined and assigned specific tasks. However, there is substantial research on the social determinants of health; the challenge for the Structural Justice Ethics is to recommend systemic changes from within, rather than beginning this research anew. The Joint Commission’s Center for Transforming Healthcare, as a data-driven and process-oriented patient safety organization, is well-primed to take on this task. The Center can collaborate with existing academic and governmental health equity researchers to set short- and long-term goals for Structural Justice Ethics committees. To begin with, a Structural Justice Ethics committee can pose the question of “how is racism operating here” and: a. connect with current research on specific inequitable outcomes due to bias in medicine and bring best practices to the attention of medical staff. b. work with human resources and medical staff to support and increase diverse populations in the workforce. c. ensure that implicit bias and other trainings are properly provided to all staff, as well as expanding the scope of such trainings to address developing areas such as epistemic harm, or the harm of one’s own physical experience being discounted by medical professionals.[21] The health care workforce should also be trained in Title VI law.[22] d. evaluate research data on the organization’s own potential disparate outcomes due to race, to determine areas for improvement both within and outside of the organization. e. invite the local community to come in for listening and learning sessions, to better understand the community’s concerns and perspective on health equity. f. improve advocacy on behalf of community members to state and local authorities, effectively taking a stand for health care equity for local stakeholders. Dr. Camara P. Jones describes a collaborative endeavor like this as critical to anti-racist work and likens it to adopting a community health center model where the health facility takes responsibility for the health and well-being of the local community.[23] AMA policy already encourages this type of effort in opinion 8.11 of the AMA Code, which states that, alongside diagnosis and treatment, “physicians also have a professional commitment to prevent disease and promote health and well-being for their patients and the community.”[24] A theoretical framework and concrete plan for radical improvement in the ethics of the healthcare system will help all healthcare professionals. Some healthcare practitioners may not recognize their own biases and need training to meet best practices standards in light of health inequities. Other healthcare practitioners may feel disillusioned because they know they face individual patients suffering the effects of structural racism, yet they can treat only the illness.[25] The scope of the problem may overwhelm practitioners, and without a belief that the system is committed to improvement, practitioners may become numb to the suffering, a trauma reaction that affects both the practitioners and their patients. Unfortunately, when current medical students ask the question, “what can I do to fight systemic racism?” the answer is usually “call it out.” But putting the onus on newly minted individual practitioners to call out racism in an established structure is unrealistic, unfair, and destined to be unsuccessful. Just as we should not expect subordinated individuals to “overcome” their social determinants of health, we should not expect health professionals to make this change individually. Addressing injustices in the institution and adjusting medical ethics accordingly can alleviate the burden of these ethical dilemmas. CONCLUSION Structural Justice Ethics must be woven into the ethics committees at the institutional level. Organizational ethics committees can evaluate healthcare organizations by their integrity, i.e., how well their actions fulfill the moral obligations they have undertaken.[26] Our healthcare system has avoided the moral obligation to address racism and the social determinants of health by focusing on clinical ethics, leaving public health to academics and the government. Expanding organizational ethics to take on the issues of structural injustice within each healthcare institution will help organizations better measure, change, and ultimately fulfill their moral obligations to their patients and communities. [1] “Color of Coronavirus: COVID-19 Deaths Analyzed by Race and Ethnicity,” APM Research Lab, accessed June 1, 2021, https://www.apmresearchlab.org/covid/deaths-by-race. [2] M. Constantinescu, “Seeing the Forest beyond the Trees: A Holistic Approach to Health-Care Organizational Ethics,” in Contemporary Debates in Bioethics: European Perspectives, 2018, 86–96, https://doi.org/10.2478/9783110571219-009. [3] See Norman Daniels, Just Health: Meeting Health Needs Fairly (Cambridge: Cambridge University Press, 2008) at 219. [4] Elizabeth Heitman and Ruth Ellen Bulger, “The Healthcare Ethics Committee in the Structural Transformation of Health Care: Administrative and Organizational Ethics in Changing Times,” HEC Forum 10, no. 2 (June 1, 1998): 152–76, 162, https://doi.org/10.1023/A:1008865603499. [5] Cohen, Cynthia B. "Ethics Committees as Corporate and Public Policy Advocates." The Hastings Center Report 20, no. 5 (1990): 36+. Gale Academic OneFile (accessed May 6, 2021). https://link.gale.com/apps/doc/A8998890/AONE?u=nysl_oweb&sid=AONE&xid=84a1cade. [6] Linda L. Emanuel, “Ethics and the Structures of Healthcare Special Section: Issues in Organization Ethics and Healthcare,” Cambridge Quarterly of Healthcare Ethics 9, no. 2 (2000): 151–68, 166. [7] George Khushf and Rosemarie Tong, “Setting Organizational Ethics within a Broader Social and Legal Context,” HEC Forum 14, no. 2 (June 2002): 77–85, 78. [8] Olivia Pham, Usha Ranji Published: Nov 10, and 2020, “Racial Disparities in Maternal and Infant Health: An Overview - Issue Brief,” KFF (blog), November 10, 2020, https://www.kff.org/report-section/racial-disparities-in-maternal-and-infant-health-an-overview-issue-brief/. [9] Eberly Lauren A. et al., “Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center,” Circulation: Heart Failure 12, no. 11 (November 1, 2019): e006214, https://doi.org/10.1161/CIRCHEARTFAILURE.119.006214. [10] Michael W. Sjoding et al., “Racial Bias in Pulse Oximetry Measurement,” New England Journal of Medicine 383, no. 25 (December 17, 2020): 2477–78, https://doi.org/10.1056/NEJMc2029240. [11] Alyasah Ali Sewell et al., “Illness Spillovers of Lethal Police Violence: The Significance of Gendered Marginalization,” Ethnic and Racial Studies 44, no. 7 (July 22, 2020): 1–26, https://doi.org/10.1080/01419870.2020.1781913. [12] Brad N. Greenwood et al., “Physician–Patient Racial Concordance and Disparities in Birthing Mortality for Newborns,” Proceedings of the National Academy of Sciences 117, no. 35 (September 1, 2020): 21194–200, https://doi.org/10.1073/pnas.1913405117. [13] The term “palliative care” as applied to patients suffering from the social determinants of health was used by Dr. Michelle Morse at a webinar entitled “Medical Stereotypes: Confronting Racism and Disparities in US Health Care: A Health Policy and Bioethics Consortium” presented by the Harvard Petrie-Flom Center on February 12, 2021. [14] Linda L. Emanuel coined the term “Structural Ethics” in 2000. This term did not seem to generate much interest from the bioethics community at the time. Her explanation of this term is consistent with my thinking, although I expand it to address the health system as an entity, and focus on improving health equity. [15] Keisha Shantel Ray, “Black Bioethics and How the Failures of the Profession Paved the Way for Its Existence | Bioethics.Net,” www.bioethics.net, August 6, 2020, http://www.bioethics.net/2020/08/black-bioethics-and-how-the-failures-of-the-profession-paved-the-way-for-its-existence/; Yolonda Y. Wilson, “Racial Injustice and Meaning Well: A Challenge for Bioethics,” The American Journal of Bioethics 21, no. 2 (February 1, 2021): 1–3, https://doi.org/10.1080/15265161.2020.1866875. [16] See Catherine Myser, “Differences from Somewhere: The Normativity of Whiteness in Bioethics in the United States,” The American Journal of Bioethics 3, no. 2 (May 2003): 1–11, https://doi.org/10.1162/152651603766436072. [17] Ushe Blackstock, “Why Black Doctors like Me Are Leaving Academic Medicine,” STAT (blog), January 16, 2020, https://www.statnews.com/2020/01/16/black-doctors-leaving-faculty-positions-academic-medical-centers/. [18] Zamina Mithani, Jane Cooper, and Boyd J. Wesley, “Race, Power, and COVID-19: A Call for Advocacy within Bioethics,” The American Journal of Bioethics21, no. 2 (2021): 11–18, 13 https://doi.org/10.1080/15265161.2020.1851810. [19] “Graduate Programs,” The Hastings Center, accessed 2 June, 2021, https://www.thehastingscenter.org/publications-resources/bioethics-careers-education/graduate-programs-2/. [20] Norman Daniels, Just Health: Meeting Health Needs Fairly, at 299. [21] Ian James Kidd and Havi Carel, “Epistemic Injustice and Illness,” Journal of Applied Philosophy 34, no. 2 (2017): 172–90, https://doi.org/10.1111/japp.12172. [22] Ruqaiijah Yearby, “Sick and Tired of Being Sick and Tired: Putting an End to Separate and Unequal Health Care in the United States 50 Years after the Civil Rights Act of 1964,” Health Matrix 25, no. 1 (January 1, 2015): 1–33, at 11. [23] Jones CP, Maybank A, Nolen L, Fields N, Ogunwole M, Onuoha C, Williams J, Tsai J, Paul D, Essien UR, Khazanchi, R. “Episode 5: Racism, Power, and Policy: Building the Antiracist Health Systems of the Future.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. January 19, 2021. [24] Sienna Moriarty, “AMA Policies and Code of Medical Ethics’ Opinions Related to Health Promotion and Community Development,” AMA Journal of Ethics 21, no. 3 (March 1, 2019): 259–61, https://doi.org/10.1001/amajethics.2019.259. [25] Constantinescu, “Seeing the Forest beyond the Trees,” at 92. [26] Ana Smith Iltis, “Organizational Ethics: Moral Obligation and Integrity,” in Institutional Integrity in Health Care, ed. Ana Smith Iltis, Philosophy and Medicine (Dordrecht: Springer Netherlands, 2003), 175–82, https://doi.org/10.1007/978-94-017-0153-2_10.

The field of global surgery has gained attention since the publication of the Lancet Commission landmark report in 2015. The authors estimated that 5 billion people worldwide do not have access to safe, affordable surgical and anesthesia services. The paper “Global Neurosurgery: The Unmet Need,” published in 2016, launched the modern global neurosurgery era by advocating for the system-level thinking and programs required to address limited neurosurgical care in low-resource settings. At present, many individuals, academic institutions, governmental agencies, and nongovernmental organizations (NGOs) are involved in the global neurosurgery movement. These include the Program in Global Surgery and Social Change at Harvard Medical School, Duke Global Neurology and Neurosurgery, Weill Cornell Tanzania Neurosurgery Project, CURE Children’s Hospital of Uganda, and the Virtue Foundation in Mongolia. Nonetheless, as global neurosurgery efforts continue to expand, it is essential to align global neurosurgery activity in order to prevent duplication of effort. In 2019, the World Federation of Neurosurgical Societies (WFNS) established the Global Neurosurgery Committee (GNC) to promote access to safe, affordable, and timely neurosurgical care worldwide. The GNC initially included five primary objectives – Amplify, Align, Advance, Assimilate, and Advocate – with the sixth objective, Communication, added in 2021. In this manuscript, we provide an update on the Align objective team.

The Journal of the International Child Neurology Association (JICNA), was officially launched in February 2015 although the proceedings of the 13th International Child Neurology Congress in 2014 was, published under the platform in the previous year. The JICNA editorial team was announced, and constituted of members of the International Child Neurology Association (ICNA) executive board with representation from all geographical regions and across all major child neurology disciplines. The launch of JICNA represented a major milestone in the history of the association, founded in 1973 with the goal of promoting education and research in child neurology worldwide. Open access publishing in child neurology hardly existed before, and JICNA thus became the first fully open access multidisciplinary peer reviewed ejournal in child neurology. JICNA has steadily progressed over its initial years and now in its 7th year, is poised to establish itself as a major open access platform for disseminating scientific research in child neurology. Closely integrated with its parent organization the ICNA and ICNApedia, the association’s flagship knowledge environment platform, JICNA editorial policy is aimed at both facilitating access to and disseminating research, particularly from resource poor settings. As part of this remit, JICNA adopts the association's consensus position on scientific issues treated within its published articles. The special articles published from the ICNA Advocacy Committee on genetic testing for rare disorders [1] and other articles in the pipeline on “vaccination against measles” and “stem cell therapy in neurological disorders” reflect the journal’s ethos. The ongoing global pandemic caused by the novel coronavirus (SARS-Cov2) and its disease (COVID-19) has highlighted more than ever the importance and need for open science. The dissemination of scientific research following the outbreak has no doubt brought to attention the significant changes that have occured in the field of scientific publishing, with how research is communicated and how researchers engage, share and contribute. The COVID-19 pandemic has seen a spate of preprint articles, which, while potentially life-saving, also risk dissemination of poor-quality work. While we are not against such author-led rapid publication workflows, we would advise caution against its potential risks. The pandemic again has shown that timely access of researchers to information and knowledge is key to fighting global diseases and problems that threaten humanity. It remains a sad truth that researchers across the world remain cut off from a vast body of information and knowledge that ought to have been readily accessible by them. The scientific community has long been aware of the hindrance of traditional publishing models to the dissemination of scientific research. Research can only flourish through collaboration, and it is imperative that research is made more visible by breaking cost, language and geographic barriers. Although governments, major universities and funders, such as Harvard University and the Wellcome Trust, have long acknowledged and taken steps to promote this, urging their academics to consider open access venues for publishing their work, there still remains much progress to be made. The four main factors considered by authors in deciding their choice of journal are visibility, cost, prestige and speed. “Brand-name” journals are still favoured by authors to promote their academic career prospects. While an open-access publishing model in itself is not a hindrance to a journal’s success, it is acknowledged that JICNA should gain an impact factor and improve its visibility further. JICNA has now been consistently publishing, following a stringent peer review, original articles, trial reports, case studies and timely reviews, since its inception in 2015. JICNA is currently indexed in Google Scholar, CrossRef and the Directory of Open Access Journals (DOAJ) and will, this year, be making a submission to PubMed Central® & MEDLINE®. The journal also subscribes to robust archiving systems including CLOCKSS & PORTICO. In the current environment, where the open access publishing model is at danger of being exploited by predatory publishers with lax editorial policies and peer-reviews risk perpetuating bad research, a journal like JICNA certainly assumes greater significance. The ICNA is committed to maintaining JICNA free of cost to its readers, with an expedited publication workflow while ensuring strict peer-review standards. The JICNA editorial board is extremely thankful to all the peer reviewers and members of the editorial board, without whose support this would not have been possible. JICNA follows the Committee on Publication Ethics (COPE) Best Practice Guidelines and is committed to upholding standards of ethical behaviour at all stages of the publication process. The journal is published under the terms of the Creative Commons Attribution-Non-Commercial-ShareAlike 4.0 International License, permitting any user to “distribute, remix, tweak, and build upon the work,” provided that they credit the original authors in all cases, ensuring the copyright remaining with the main author. We would like to once again thank all authors, peer-reviewers and the editorial board for their valuable contributions to the success of the journal. We are looking to further expand our panel of reviewers and editorial board from across the various subspecialties in child neurology.

Photo by Sean Pollock on Unsplash ABSTRACT Bioethics and Corporate Social Responsibility (CSR) were born out of similar concerns, such as the reaction to scandal and the restraint of irresponsible actions by individuals and organizations. However, these fields of knowledge are seldom explored together. This article attempts to explain the motives behind the gap between bioethics and CSR, while arguing that their shared agenda – combined with their contrasting principles and goals – suggests there is potential for fruitful dialogue that enables the actualization of bioethical agendas and provides a direction for CSR in health-related organizations. INTRODUCTION Bioethics and Corporate Social Responsibility (CSR) seem to be cut from the same cloth: the concern for human rights and the response to scandal. Both are tools for the governance of organizations, shaping how power flows and decisions are made. They have taken the shape of specialized committees, means of stakeholder inclusion at deliberative forums, compliance programs, and internal processes. It should be surprising, then, that these two fields of study and practice have developed separately, only recently re-approaching one another. There have been displays of this reconnection both in academic and corporate spaces, with bioethics surfacing as part of the discourse of CSR and compliance initiatives. However, this is still a relatively timid effort. Even though the bioethics-CSR divide presents mostly reasonable explanations for this difficult relationship between the disciplines, current proposals suggest there is much to be gained from a stronger relationship between them. This article explores the common history of bioethics and corporate social responsibility and identifies their common features and differences. It then explores the dispute of jurisdictions due to professional and academic “pedigree” and incompatibilities in the ideological and teleological spheres as possible causes for the divide. The discussion turns to paths for improving the reflexivity of both disciplines and, therefore, their openness to mutual contributions. I. Cut Out of the Same Cloth The earliest record of the word “bioethics” dates back to 1927 as a term that designates one’s ethical responsibility toward not only human beings but other lifeforms as well, such as animals and plants.[1] Based on Kantian ethics, the term was coined as a response to the great prestige science held at its time. It remained largely forgotten until the 1970s, when it resurfaced in the United States[2] as the body of knowledge that can be employed to ensure the responsible pursuit and application of science. The resurgence was prompted by a response to widespread irresponsible attitudes toward science and grounded in a pluralistic perspective of morality.[3] In the second half of the twentieth century, states and the international community assumed the duty to protect human rights, and bioethics became a venue for discussing rights.[4] There is both a semantic gap and a contextual gap between these two iterations, with some of them already being established. Corporate social responsibility is often attributed to the Berle-Dodd debate. The discussion was characterized by diverging views on the extent of the responsibility of managers.[5] It was later settled as positioning the company, especially the large firm, as an entity whose existence is fomented by the law due to its service to the community. The concept has evolved with time, departing from a largely philanthropic meaning to being ingrained in nearly every aspect of a company’s operations. This includes investments, entrepreneurship models, and its relationship to stakeholders, leading to an increasing operationalization and globalization of the concept.[6] At first sight, these two movements seem to stem from different contexts. Despite the difference, it is also possible to tell a joint history of bioethics and CSR, with their point of contact being a generalized concern with technological and social changes that surfaced in the sixties. The publishing of Silent Spring in 1962 by Rachel Carson exemplifies this growing concern over the sustainability of the ruling economic growth model of its time by commenting on the effects of large-scale agriculture and the use of pesticides in the population of bees, one of the most relevant pollinators of crops consumed by humans. The book influenced both the author responsible for the coining bioethics in the 1971[7] and early CSR literature.[8] By initiating a debate over the sustainability of economic models, the environmentalist discourse became a precursor to vigorous social movements for civil rights. Bioethics was part of the trend as it would be carried forward by movements such as feminism and the patients’ rights movement.[9] Bioethics would gradually move from a public discourse centered around the responsible use of science and technology to academic and government spaces.[10] This evolution led to an increasing emphasis on intellectual rigor and governance. The transformation would unravel the effort to take effective action against scandal and turn bioethical discourse into governance practices,[11] such as bioethics and research ethics committees. The publication of the Belmont Report[12] in the aftermath of the Tuskegee Syphilis Experiment, as well as the creation of committees such as the “God Committee,”[13] which aimed to develop and enforce criteria for allocating scarce dialysis machines, exemplify this shift. On the side of CSR, this period represents, at first, a stronger pact between businesses and society due to more stringent environmental and consumer regulations. But afterward, a joint trend emerged: on one side, the deregulation within the context of neoliberalism, and on the other, the operationalization of corporate social responsibility as a response to societal concerns.[14] The 1990s saw both opportunities and crises that derived from globalization. In the political arena, the end of the Cold War led to an impasse in the discourse concerning human rights,[15] which previously had been split between the defense of civil and political rights on one side and social rights on the other. But at the same time, agendas that were previously restricted territorially became institutionalized on a global scale.[16] Events such as the European Environment Agency (1990), ECO92 in Rio de Janeiro (1992), and the UN Global Compact (2000) are some examples of the globalization of CSR. This process of institutionalization would also mirror a crisis in CSR, given that its voluntarist core would be deemed lackluster due to the lack of corporate accountability. The business and human rights movement sought to produce new binding instruments – usually state-based – that could ensure that businesses would comply with their duties to respect human rights.[17] This rule-creation process has been called legalization: a shift from business standards to norms of varying degrees of obligation, precision, and delegation.[18] Bioethics has also experienced its own renewed identity in the developed world, perhaps because of its reconnection to public and global health. Global health has been the object of study for centuries under other labels (e.g., the use of tropical medicine to assist colonial expeditions) but it resurfaced in the political agenda recently after the pandemics of AIDS and respiratory diseases.[19] Bioethics has been accused from the inside of ignoring matters beyond the patient-provider relationship,[20] including those related to public health and/or governance. Meanwhile, scholars claimed the need to expand the discourse to global health.[21] In some countries, bioethics developed a tight relationship with public health, such as Brazil,[22] due to its connections to the sanitary reform movement. The United Kingdom has also followed a different path, prioritizing governance practices and the use of pre-established institutions in a more community-oriented approach.[23] The Universal Declaration on Bioethics and Rights followed this shift toward a social dimension of bioethics despite being subject to criticism due to its human rights-based approach in a field characterized by ethical pluralism.[24] This scenario suggests bioethics and CSR have developed out of similar concerns: the protection of human rights and concerns over responsible development – be it economic, scientific, or technological. However, the interaction between these two fields (as well as business and human rights) is fairly recent both in academic and business settings. There might be a divide between these fields and their practitioners. II. A Tale of Jurisdictions It can be argued that CSR and business and human rights did not face jurisdictional disputes. These fields owe much of their longevity to their roots in institutional economics, whose debates, such as the Berle-Dodd debate, were based on interdisciplinary dialogue and the abandonment of sectorial divisions and public-private dichotomies.[25] There was opposition to this approach to the role of companies in society that could have implications for CSR’s interdisciplinarity, such as the understanding that corporate activities should be restricted to profit maximization.[26] Yet, those were often oppositions to CSR or business and human rights themselves. The birth of bioethics in the USA can be traced back to jurisdictional disputes over the realm of medicine and life sciences.[27] The dispute unfolded between representatives of science and those of “society’s conscience,” whether through bioethics as a form of applied ethics or other areas of knowledge such as theology.[28] Amid the civil rights movements, outsiders would gain access to the social sphere of medicine, simultaneously bringing it to the public debate and emphasizing the decision-making process as the center of the medical practice.[29] This led to the emergence of the bioethicist as a professional whose background in philosophy, theology, or social sciences deemed the bioethicist qualified to speak on behalf of the social consciousness. In other locations this interaction would play out differently: whether as an investigation of philosophically implied issues, a communal effort with professional institutions to enhance decision-making capability, or a concern with access to healthcare.[30] In these situations, the emergence and regulation of bioethics would be way less rooted in disputes over jurisdictions. This contentious birth of bioethics would have several implications, most related to where the bioethicist belongs. After the civil rights movements subsided, bioethics moved from the public sphere into an ivory tower: intellectual, secular, and isolated. The scope of the bioethicist would be increasingly limited to the spaces of academia and hospitals, where it would be narrowed to the clinical environment.[31] This would become the comfort zone of professionals, much to the detriment of social concerns. This scenario was convenient to social groups that sought to affirm their protagonism in the public arena, with conservative and progressive movements alike questioning the legitimacy of bioethics in the political discourse.[32] Even within the walls of hospitals and clinics, bioethics would not be excused from criticism. Afterall, the work of bioethicists is often unregulated and lacks the same kind of accountability that doctors and lawyers have. Then, is there a role to be played by the bioethicist? This trend of isolation leads to a plausible explanation for why bioethics did not develop an extensive collaboration with corporate social responsibility nor with business and human rights. Despite stemming from similar agendas, bioethics’ orientation towards the private sphere resulted in a limited perspective on the broader implications of its decisions. This existential crisis of the discipline led to a re-evaluation of its nature and purpose. Its relevance has been reaffirmed due to the epistemic advantage of philosophy when engaging normative issues. Proper training enables the bioethicist to avoid falling into traps of subjectivism or moralism, which are unable to address the complexity of decision-making. It also prevents the naïve seduction of “scientifying” ethics.[33] This is the starting point of a multitude of roles that can be attributed to the bioethicists. There are three main responsibilities that fall under bioethics: (i) activism in biopolicy, through the engagement in the creation of laws, jurisprudence, and public policies; (ii) the exercise of bioethics expertise, be it through the specialized knowledge in philosophical thought, its ability to juggle multiple languages related to various disciplines related to bioethics, or its capacity to combat and avoid misinformation and epistemic distortion; (iii) and, intellectual exchange, by exercising awareness that it is necessary to work with specialists from different backgrounds to achieve its goals.[34] All of those suggest the need for bioethics to improve its dialogue with CSR and business and human rights. Both CSR and business and human rights have been the arena of political disputes over the role of regulations and corporations themselves, and the absence of strong stances by bioethicists risks deepening their exclusion from the public arena. Furthermore, CSR and business and human rights are at the forefront of contemporary issues, such as the limits to sustainable development and appropriate governance structures, which may lead to the acceptance of values and accomplishment of goals cherished by bioethics. However, a gap in identifying the role and nature of bioethics and CSR may also be an obstacle for bridging the chasm between bioethics and CSR. III. From Substance to Form: Philosophical Groundings of CSR and Bioethics As mentioned earlier, CSR is, to some extent, a byproduct of institutionalism. Institutional economics has a philosophical footprint in the pragmatic tradition[35], which has implications for the purpose of the movement and the typical course of the debate. The effectiveness of regulatory measures is often at the center of CSR and business and human rights debates: whatever the regulatory proposal may be, compliance, feasibility, and effectiveness are the kernel of the discussion. The axiological foundation is often the protection of human rights. But discussions over the prioritization of some human rights over others or the specific characteristics of the community to be protected are often neglected.[36] It is worth reinforcing that adopting human rights as an ethical standard presents problems to bioethics, given its grounding in the recognition of ethical pluralism. Pragmatism adopts an anti-essentialist view, arguing that concepts derive from their practical consequences instead of aprioristic elements.[37] Therefore, truth is transitory and context dependent. Pragmatism embraces a form of moral relativism and may find itself in an impasse in the context of political economy and policymaking due to its tendency to be stuck between the preservation of the status quo and the defense of a technocratic perspective, which sees technical and scientific progress as the solution to many of society’s issues.[38] These characteristics mean that bioethics has a complicated relationship with pragmatism. Indeed, there are connections between pragmatism and the bioethics discourse. Both can be traced back to American naturalism.[39] The early effort in bioethics to make it ecumenical, thus building on a common but transitory morality,[40] sounds pragmatic. Therefore, scholars suggest that bioethics should rely on pragmatism's perks and characteristics to develop solutions to new ethical challenges that emerge from scientific and technological progress. Nonetheless, ethical relativism is a problem for bioethics when it bleeds from a metaethical level into the subject matters themselves. After all, the whole point of bioethics is either descriptive, where it seeks to understand social values and conditions that pertain to its scope, or normative, where it investigates what should be done in matters related to medicine, life sciences, and social and technological change. It is a “knowledge of how to use knowledge.” Therefore, bioethics is a product of disillusionment regarding science and technology's capacity to produce exclusively good consequences. It was built around an opposition to ethical relativism—even though the field is aware of the particularity of its answers. This is true not only for the scholarly arena, where the objective is to produce ethically sound answers but also for bioethics governance, where relativism may induce decision paralysis or open the way to points of view disconnected from facts.[41] But there might be a point for more pragmatic bioethics. Bioethics has become an increasingly public enterprise which seeks political persuasion and impact in the regulatory sphere. When bioethics is seen as an enterprise, achieving social transformation is its main goal. In this sense, pragmatism can provide critical tools to identify idiosyncrasies in regulation that prove change is needed. An example of how this may play out is the abortion rights movement in the global south.[42] Despite barriers to accessing safe abortion, this movement came up with creative solutions and a public discourse focused on the consequences of its criminalization rather than its moral aspects. IV. Bridging the Divide: Connections Between Bioethics and CSR There have been attempts to bring bioethics and CSR closer to each other. Corporate responsibility can be a supplementary strategy for achieving the goals of bioethics. The International Bioethics Committee (IBC), an institution of the United Nations Educational, Scientific and Cultural Organization (UNESCO), highlights the concept that social responsibility regarding health falls under the provisions of the Universal Declaration on Bioethics and Human Rights (UDBHR). It is a means of achieving good health (complete physical, mental, and social well-being) through social development.[43] Thus, it plays out as a condition for actualizing the goals dear to bioethics and general ethical standards,[44] such as autonomy and awareness of the social consequences of an organization’s governance. On this same note, CSR is a complementary resource for healthcare organizations that already have embedded bioethics into their operations[45] as a way of looking at the social impact of their practices. And bioethics is also an asset of CSR. Bioethics can inform the necessary conditions for healthcare institutions achieving a positive social impact. When taken at face value, bioethics may offer guidelines for ethical and socially responsible behavior in the industry, instructing how these should play out in a particular context such as in research, and access to health.[46] When considering the relevance of rewarding mechanisms,[47] bioethics can guide the establishment of certification measures to restore lost trust in the pharmaceutical sector.[48] Furthermore, recognizing that the choice is a more complex matter than the maximization of utility can offer a nuanced perspective on how organizations dealing with existentially relevant choices understand their stakeholders.[49] However, all of those proposals might come with the challenge of proving that something can be gained from its addition to self-regulatory practices[50] within the scope of a dominant rights-based approach to CSR and global and corporate law. It is evident that there is room for further collaboration between bioethics and CSR. Embedding either into the corporate governance practices of an organization tends to be connected to promoting the other.[51] While there are some incompatibilities, organizations should try to overcome them and take advantage of the synergies and similarities. CONCLUSION Despite their common interests and shared history, bioethics and corporate social responsibility have not produced a mature exchange. Jurisdictional issues and foundational incompatibilities have prevented a joint effort to establish a model of social responsibility that addresses issues particular to the healthcare sector. Both bioethics and CSR should acknowledge that they hold two different pieces of a cognitive competence necessary for that task: CSR offers experience on how to turn corporate ethical obligations operational, while bioethics provides access to the prevailing practical and philosophical problem-solving tools in healthcare that were born out of social movements. Reconciling bioethics and CSR calls for greater efforts to comprehend and incorporate the social knowledge developed by each field reflexively[52] while understanding their insights are relevant to achieving some common goals. - [1]. Fritz Jahr, “Bio-Ethik: Eine Umschau Über Die Ethischen Beziehungen Des Menschen Zu Tier Und Pflanze,” Kosmos - Handweiser Für Naturfreunde 24 (1927): 2–4. [2]. Van Rensselaer Potter, “Bioethics, the Science of Survival,” Perspectives in Biology and Medicine 14, no. 1 (1970): 127–53, https://doi.org/10.1353/pbm.1970.0015. [3]. Maximilian Schochow and Jonas Grygier, eds., “Tagungsbericht: 1927 – Die Geburt der Bioethik in Halle (Saale) durch den protestantischen Theologen Fritz Jahr (1895-1953),” Jahrbuch für Recht und Ethik / Annual Review of Law and Ethics 21 (June 11, 2014): 325–29, https://doi.org/10.3726/978-3-653-02807-2. [4] George J. Annas, American Bioethics: Crossing Human Rights and Health Law Boundaries (Oxford ; New York: Oxford University Press, 2005). [5] Philip L. Cochran, “The Evolution of Corporate Social Responsibility,” Business Horizons 50, no. 6 (November 2007): 449–54, https://doi.org/10.1016/j.bushor.2007.06.004. p. 449. [6] Mauricio Andrés Latapí Agudelo, Lára Jóhannsdóttir, and Brynhildur Davídsdóttir, “A Literature Review of the History and Evolution of Corporate Social Responsibility,” International Journal of Corporate Social Responsibility 4, no. 1 (December 2019): 23, https://doi.org/10.1186/s40991-018-0039-y. [7] Potter, “Bioethics, the Science of Survival.” p. 129. [8] Latapí Agudelo, Jóhannsdóttir, and Davídsdóttir, “A Literature Review of the History and Evolution of Corporate Social Responsibility.” p. 4. [9] Albert R. Jonsen, The Birth of Bioethics (New York: Oxford University Press, 2003). p. 368-371. [10] Jonsen. p. 372. [11] Jonathan Montgomery, “Bioethics as a Governance Practice,” Health Care Analysis 24, no. 1 (March 2016): 3–23, https://doi.org/10.1007/s10728-015-0310-2. [12]. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, “The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research” (Washington: Department of Health, Education, and Welfare, April 18, 1979), https://www.hhs.gov/ohrp/sites/default/files/the-belmont-report-508c_FINAL.pdf. [13] Shana Alexander, “They Decide Who Lives, Who Dies,” in LIFE, by Time Inc, 19th ed., vol. 53 (Nova Iorque: Time Inc, 1962), 102–25. [14]. Latapí Agudelo, Jóhannsdóttir, and Davídsdóttir, “A Literature Review of the History and Evolution of Corporate Social Responsibility.” [15]. Boaventura de Sousa Santos, “Por Uma Concepção Multicultural Dos Direitos Humanos,” Revista Crítica de Ciências Sociais, no. 48 (June 1997): 11–32. [16] Latapí Agudelo, Jóhannsdóttir, and Davídsdóttir, “A Literature Review of the History and Evolution of Corporate Social Responsibility.” [17]. Anita Ramasastry, “Corporate Social Responsibility Versus Business and Human Rights: Bridging the Gap Between Responsibility and Accountability,” Journal of Human Rights 14, no. 2 (April 3, 2015): 237–59, https://doi.org/10.1080/14754835.2015.1037953. [18]. Kenneth W Abbott et al., “The Concept of Legalization,” International Organization, Legalization and World Politics, 54, no. 3 (2000): 401–4019. [19]. Jens Holst, “Global Health – Emergence, Hegemonic Trends and Biomedical Reductionism,” Globalization and Health 16, no. 1 (December 2020): 42–52, https://doi.org/10.1186/s12992-020-00573-4. [20]. Albert R. Jonsen, “Social Responsibilities of Bioethics,” Journal of Urban Health: Bulletin of the New York Academy of Medicine 78, no. 1 (March 1, 2001): 21–28, https://doi.org/10.1093/jurban/78.1.21. [21]. Solomon R Benatar, Abdallah S Daar, and Peter A Singer, “Global Health Challenges: The Need for an Expanded Discourse on Bioethics,” PLoS Medicine 2, no. 7 (July 26, 2005): e143, https://doi.org/10.1371/journal.pmed.0020143. [22]. Márcio Fabri dos Anjos and José Eduardo de Siqueira, eds., Bioética No Brasil: Tendências e Perspectivas, 1st ed., Bio & Ética (São Paulo: Sociedade Brasileira de Bioética, 2007). [23]. Montgomery, “Bioethics as a Governance Practice.” p. 8-9. [24]. Aline Albuquerque S. de Oliveira, “A Declaração Universal Sobre Bioética e Direitos Humanos e a Análise de Sua Repercussão Teórica Na Comunidade Bioética,” Revista Redbioética/UNESCO 1, no. 1 (2010): 124–39. [25] John R. Commons, “Law and Economics,” The Yale Law Journal 34, no. 4 (February 1925): 371, https://doi.org/10.2307/788562; Robert L. Hale, “Bargaining, Duress, and Economic Liberty,” Columbia Law Review 43, no. 5 (July 1943): 603–28, https://doi.org/10.2307/1117229; Karl N. Llewellyn, “The Effect of Legal Institutions Upon Economics,” The American Economic Review 15, no. 4 (1925): 665–83; Carlos Portugal Gouvêa, Análise Dos Custos Da Desigualdade: Efeitos Institucionais Do Círculo Vicioso de Desigualdade e Corrupção, 1st ed. (São Paulo: Quartier Latin, 2021). p. 84-94. [26] Milton Friedman, “A Friedman Doctrine‐- The Social Responsibility of Business Is to Increase Its Profits,” The New York Times, September 13, 1970, sec. Archives, https://www.nytimes.com/1970/09/13/archives/a-friedman-doctrine-the-social-responsibility-of-business-is-to.html. [27] Montgomery, “Bioethics as a Governance Practice.” p. 8. [28] John Hyde Evans, The History and Future of Bioethics: A Sociological View, 1st ed. (New York: Oxford University Press, 2012). [29] David J. Rothman, Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making, 2nd pbk. ed, Social Institutions and Social Change (New York: Aldine de Gruyter, 2003). p. 3. [30] Volnei Garrafa, Thiago Rocha Da Cunha, and Camilo Manchola, “Access to Healthcare: A Central Question within Brazilian Bioethics,” Cambridge Quarterly of Healthcare Ethics 27, no. 3 (July 2018): 431–39, https://doi.org/10.1017/S0963180117000810. [31] Jonsen, “Social Responsibilities of Bioethics.” [32] Evans, The History and Future of Bioethics. p. 75-79, 94-96. [33] Julian Savulescu, “Bioethics: Why Philosophy Is Essential for Progress,” Journal of Medical Ethics 41, no. 1 (January 2015): 28–33, https://doi.org/10.1136/medethics-2014-102284. [34] Silvia Camporesi and Giulia Cavaliere, “Can Bioethics Be an Honest Way of Making a Living? A Reflection on Normativity, Governance and Expertise,” Journal of Medical Ethics 47, no. 3 (March 2021): 159–63, https://doi.org/10.1136/medethics-2019-105954; Jackie Leach Scully, “The Responsibilities of the Engaged Bioethicist: Scholar, Advocate, Activist,” Bioethics 33, no. 8 (October 2019): 872–80, https://doi.org/10.1111/bioe.12659. [35] Philip Mirowski, “The Philosophical Bases of Institutionalist Economics,” Journal of Economic Issues, Evolutionary Economics I: Foundations of Institutional Thought, 21, no. 3 (September 1987): 1001–38. [36] David Kennedy, “The International Human Rights Movement: Part of the Problem?,” Harvard Human Rights Journal 15 (2002): 101–25. [37] Richard Rorty, “Pragmatism, Relativism, and Irrationalism,” Proceedings and Addresses of the American Philosophical Association 53, no. 6 (August 1980): 717+719-738. [38]. Mirowski, “The Philosophical Bases of Institutionalist Economics.” [39]. Glenn McGee, ed., Pragmatic Bioethics, 2nd ed, Basic Bioethics (Cambridge, Mass: MIT Press, 2003). [40]. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 7th ed (New York: Oxford University Press, 2013). [41]. Montgomery, “Bioethics as a Governance Practice.” [42]. Debora Diniz and Giselle Carino, “What Can Be Learned from the Global South on Abortion and How We Can Learn?,” Developing World Bioethics 23, no. 1 (March 2023): 3–4, https://doi.org/10.1111/dewb.12385. [43]. International Bioethics Committee, On Social Responsibility and Health Report (Paris: Unesco, 2010). [44]. Cristina Brandão et al., “Social Responsibility: A New Paradigm of Hospital Governance?,” Health Care Analysis 21, no. 4 (December 2013): 390–402, https://doi.org/10.1007/s10728-012-0206-3. [45] Intissar Haddiya, Taha Janfi, and Mohamed Guedira, “Application of the Concepts of Social Responsibility, Sustainability, and Ethics to Healthcare Organizations,” Risk Management and Healthcare Policy Volume 13 (August 2020): 1029–33, https://doi.org/10.2147/RMHP.S258984. [46]The Biopharmaceutical Bioethics Working Group et al., “Considerations for Applying Bioethics Norms to a Biopharmaceutical Industry Setting,” BMC Medical Ethics 22, no. 1 (December 2021): 31–41, https://doi.org/10.1186/s12910-021-00600-y. [47] Anne Van Aaken and Betül Simsek, “Rewarding in International Law,” American Journal of International Law 115, no. 2 (April 2021): 195–241, https://doi.org/10.1017/ajil.2021.2. [48] Jennifer E. Miller, “Bioethical Accreditation or Rating Needed to Restore Trust in Pharma,” Nature Medicine 19, no. 3 (March 2013): 261–261, https://doi.org/10.1038/nm0313-261. [49] John Hardwig, “The Stockholder – A Lesson for Business Ethics from Bioethics?,” Journal of Business Ethics 91, no. 3 (February 2010): 329–41, https://doi.org/10.1007/s10551-009-0086-0. [50] Stefan van Uden, “Taking up Bioethical Responsibility?: The Role of Global Bioethics in the Social Responsibility of Pharmaceutical Corporations Operating in Developing Countries” (Mestrado, Coimbra, Coimbra University, 2012). [51] María Peana Chivite and Sara Gallardo, “La bioética en la empresa: el caso particular de la Responsabilidad Social Corporativa,” Revista Internacional de Organizaciones, no. 13 (January 12, 2015): 55–81, https://doi.org/10.17345/rio13.55-81. [52] Teubner argues that social spheres tend to develop solutions autonomously, but one sphere interfering in the way other spheres govern themselves tends to result in ineffective regulation and demobilization of their autonomous rule-making capabilities. These spheres should develop “reflexion mechanisms” that enable the exchange of their social knowledge and provide effective, non-damaging solutions to social issues. See Gunther Teubner, “Substantive and Reflexive Elements in Modern Law,” Law & Society Review 17, no. 2 (1983): 239–85, https://doi.org/10.2307/3053348.

Postmodernism is supposed to identify the conditions of contemporary cultural production when human affairs in general, and the dissemination of prevailing ideas in particular, have become fully enmeshed in relations of commodity exchange. (Martin 2002, p. 30) The accumulation of capital within industrial economies keyed on the surplus value derived from the production of raw materials into mass manufactured products, and their subsequent exchange in the capitalist marketplace. Within what Poster (1990) described as the contemporary mode of information , surplus capital is generated from the manufacturing of product’s symbolic values, which in turn substantiate their use and ultimately exchange values within the consumer market. This, in essence, is the centrifugal process undermining the brand (Klein 1999), promotional (Wernick 1991), or commodity sign (Goldman and Papson 1996), culture that characterizes contemporary capitalism: Through the creative outpourings of “cultural intermediaries” (Bourdieu 1984) working within the advertising, marketing, public relations, and media industries, commodities—routinely produced within low wage industrializing economies—are symbolically constituted to global consuming publics. This postmodern regime of cultural production is graphically illustrated within the sporting goods industry (Miles 1998) where, in regard to their use value, highly non-differentiated material products such as sport shoes are differentiated in symbolic terms through innovative advertising and marketing initiatives. In this way, oftentimes gaudy concoctions of leather, nylon, and rubber become transformed into prized cultural commodities possessing an inflated economic value within today’s informational-symbolic order (Castells 1996). Arguably, the globally ubiquitous Nike Inc. is the sporting brand that has most aggressively and effectively capitalized upon what Rowe described as the “culturalization of economics” in the latter twentieth century (1999, p. 70). Indeed, as Nike Chairman and CEO Phil Knight enthusiastically declared: For years, we thought of ourselves as a production-oriented company, meaning we put all our emphasis on designing and manufacturing the product. But now we understand that the most important thing we do is market the product. We’ve come around to saying that Nike is a marketing-oriented company, and the product is our most important marketing tool. What I mean is that marketing knits the whole organization together. The design elements and functional characteristics of the product itself are just part of the overall marketing process. (Quoted in (Willigan 1992, p. 92) This commercial culturalization of Nike has certainly sparked considerable academic interest, as evidenced by the voluminous literature pertaining to the various dimensions of its practices of cultural production (Donaghu and Barff 1990; Ind 1993; Korzeniewicz 1994; Cole and Hribar 1995; Boje 1998; Goldman and Papson 1998; Lafrance 1998; Armstrong 1999; Denzin 1999; Penaloza 1999; Sage 1999; Lucas 2000; Stabile 2000). Rather than contribute to this body of work, our aim is to engage a sporting shoe company attempting to establish itself within the brand universe defined and dominated by Nike. For this reason we turn to German-based Puma AG: a dynamic brand-in-process, seeking to differentiate itself within the cluttered sporting landscape, through the assertion of a consciously fractured brand identity designed to address a diverse range of clearly-defined consumer subjectivities. Puma’s history can be traced to post-war Germany when, in 1948, a fraternal dispute compelled Rudolf Dassler to leave Adidas (the company he founded with his brother Adi) and set up a rival sports shoe business on the opposite bank of the Moselle river in Herzogenaurach. Over the next three decades the two companies vied for the leadership in the global sports shoe industry. However, the emergence of Nike and Reebok in the 1980s, and particularly their adoption of aggressive marketing strategies, saw both Adidas and Puma succumbing to what was a new world sneaker order (Strasser and Becklund 1991). Of the two, Puma’s plight was the more chronic, with expenditures regularly exceeding moribund revenues. For instance, in 1993, Puma lost US$32 million on sales of just US$190 million (Saddleton 2002, p. 2). At this time, Puma’s brand presence and identity was negligible quite simply because it failed to operate according to the rhythms and regimes of the commodity sign economy that the sport shoe industry had become (Goldman and Papson 1994; 1996; 1998). Remarkably, from this position of seemingly terminal decline, in recent years, Puma has “successfully turned its image around” (Saddleton 2002, p. 2) through the adoption of a branding strategy perhaps even more radical than that of Nike’s. Led by the company’s global director of brand management, Antonio Bertone, Puma positioned itself as “the brand that mixes the influence of sport, lifestyle and fashion” (quoted in (Davis 2002, p. 41). Hence, Puma eschewed the sport performance mantra which defined the company (and indeed its rivals) for so long, in favour of a strategy centered on the aestheticization of the sport shoe as an important component of the commodity based lifestyle assemblages, through which individuals are encouraged to constitute their very being (Featherstone 1991; Lury 1996). According to Bertone, Puma is now “targeting the sneaker enthusiast, not the guy who buys shoes for running” (quoted in (Davis 2002, p. 41). While its efforts to “blur the lines between sport and lifestyle” (Anon 2002, p. 30) may explain part of Puma’s recent success, at the core of the company’s turnaround was its move to diversify the brand into a plethora of lifestyle and fashion options. Puma has essentially splintered into a range of seemingly disparate sub-brands each directed at a very definite target consumer (or perceptions thereof). Amongst other options, Puma can presently be consumed in, and through: the upscale pseudo-Prada Platinum range; collections by fashion designers such as Jil Sander and Yasuhiro Mihara; Pumaville, a range clearly directed at the “alternative sport” market, and endorsed by athletes such as motocross rider Travis Pastrana; and, the H Street range designed to capture “the carefree spirit of athletics” (http://www.puma.com). However, Puma’s attempts to interpellate (Althusser 1971) a diverse array of sporting subjectivies is perhaps best illustrated in the “Nuala” collection, a yoga-inspired “lifestyle” collection resulting from a collaboration with supermodel Christy Turlington, the inspiration for which is expressed in suitably flowery terms: What is Nuala? NUALA is an acronym representing: Natural-Universal-Altruistic-Limitless-Authentic. Often defined as "meditation in motion", Nuala is the product of an organic partnership that reflects Christy Turlington's passion for the ancient discipline of Yoga and PUMA's commitment to create a superior mix of sport and lifestyle products. Having studied comparative religion and philosophy at New York University, model turned entrepreneur Christy Turlington sought to merge her interest in eastern practices with her real-life experience in the fashion industry and create an elegant, concise, fashion collection to complement her busy work, travel, and exercise schedule. The goal of Nuala is to create a symbiosis between the outer and inner being, the individual and collective experience, using yoga as a metaphor to make this balance possible. At Nuala, we believe that everything in life should serve more than one purpose. Nuala is more than a line of yoga-inspired activewear; it is a building block for limitless living aimed at providing fashion-conscious, independant women comfort for everyday life. The line allows flexibility and transition, from technical yoga pieces to fashionable apparel one can live in. Celebrating women for their intuition, intelligence, and individuality, Nuala bridges the spacious gap between one's public and private life. Thus, Puma seeks to hail the female subject of consumption (Andrews 1998), through design and marketing rhetorics (couched in a spurious Eastern mysticism) which contemporary manifestations of what are traditionally feminine experiences and sensibilities. In seeking to engage, at one at the same time, a variety of class, ethnic, and gender based constituencies through the symbolic advancement of a range of lifestyle niches (hi-fashion, sports, casual, organic, retro etc.) Puma evokes Toffler’s prophetic vision regarding the rise of a “de-massified society” and “a profusion of life-styles and more highly individualized personalities” (Toffler 1980, pp. 231, 255-256). In this manner, Puma identified how the nurturing of an ever-expanding array of consumer subjectivities has become perhaps the most pertinent feature of present-day market relations. Such an approach to sub-branding is, of course, hardly anything new (Gartman 1998). Indeed, even the sports shoe giants have long-since diversified into a range of product lines. Yet it is our contention that even in the process of sub-branding, companies such as Nike nonetheless retain a tangible sense of a core brand identity. So, for instance, Nike imbues a sentiment of performative authenticity, cultural irreverence and personal empowerment throughout all its sub-brands, from its running shoes to its outdoor wear (arguably, Nike commercials have a distinctive “look” or “feel”) (Cole and Hribar 1995). By contrast, Puma’s sub-branding suggests a greater polyvalence: the brand engages divergent consumer subjectivities in much more definite and explicit ways. As Davis (2002, p. 41) emphasis added) suggested, Puma “has done a good job of effectively meeting the demands of disparate groups of consumers.” Perhaps more accurately, it could be asserted that Puma has been effective in constituting the market as an aggregate of disparate consumer groups (Solomon and Englis 1997). Goldman and Papson have suggested the decline of Reebok in the early 1990s owed much to the “inconsistency in the image they projected” (1996, p. 38). Following the logic of this assertion, the Puma brand’s lack of coherence or consistency would seem to foretell and impending decline. Yet, recent evidence suggests such a prediction as being wholly erroneous: Puma is a company, and (sub)brand system, on the rise. Recent market performance would certainly suggest so. For instance, in the first quarter of 2003 (a period in which many of its competitors experienced meager growth rates), Puma’s consolidated sales increased 47% resulting in a share price jump from ?1.43 to ?3.08 (Puma.com 2003). Moreover, as one trade magazine suggested: “Puma is one brand that has successfully turned its image around in recent years…and if analysts predictions are accurate, Puma’s sales will almost double by 2005” (Saddleton 2002, p. 2). So, within a postmodern cultural economy characterized by fragmentation and instability (Jameson 1991; Firat and Venkatesh 1995; Gartman 1998), brand flexibility and eclecticism has proven to be an effective stratagem for, however temporally, engaging the consciousness of decentered consuming subjects. Perhaps it’s a Puma culture, as opposed to a Nike one (Goldman and Papson 1998) that best characterizes the contemporary condition after all? Works Cited Althusser, L. (1971). Lenin and philosophy and other essays. London: New Left Books. Andrews, D. L. (1998). Feminizing Olympic reality: Preliminary dispatches from Baudrillard's Atlanta. International Review for the Sociology of Sport, 33(1), 5-18. Anon. (2002, December 9). The Midas touch. Business and Industry, 30. Armstrong, K. L. (1999). Nike's communication with black audiences: A sociological analysis of advertising effectiveness via symbolic interactionism. Journal of Sport & Social Issues, 23(3), 266-286. Boje, D. M. (1998). Nike, Greek goddess of victory or cruelty? Women's stories of Asian factory life. Journal of Organizational Change Management, 11(6), 461-480. Bourdieu, P. (1984). Distinction: A social critique of the judgement of taste. Cambridge: Harvard University Press. Castells, M. (1996). The rise of the network society: Blackwell Publishers. Cole, C. L., & Hribar, A. S. (1995). Celebrity feminism: Nike Style - Post-fordism, transcendence, and consumer power. Sociology of Sport Journal, 12(4), 347-369. Davis, J. (2002, October 13). Sneaker pimp. The Independent, pp. 41-42. Denzin, N. (1999). Dennis Hopper, McDonald's and Nike. In B. Smart (Ed.), Resisting McDonalidization (pp. 163-185). London: Sage. Donaghu, M. T., & Barff, R. (1990). Nike just did it: International subcontracting and flexibility in athletic footwear production. Regional Studies, 24(6), 537-552. Featherstone, M. (1991). Consumer culture and postmodernism. London: Sage. Firat, A. F., & Venkatesh, A. (1995). Postmodern perspectives on consumption. In R. W. Belk, N. Dholakia & A. Venkatesh (Eds.), Consumption and Marketing: Macro dimensions (pp. 234-265). Cincinnati: South-Western College Publishing. Gartman, D. (1998). Postmodernism: Or, the cultural logic of post-Fordism. Sociological Quarterly, 39(1), 119-137. Goldman, R., & Papson, S. (1994). Advertising in the age of hypersignification. Theory, Culture & Society, 11(3), 23-53. Goldman, R., & Papson, S. (1996). Sign wars: The cluttered landscape of advertising. Boulder: Westview Press. Goldman, R., & Papson, S. (1998). Nike culture. London: Sage. Ind, N. (1993). Nike: Communicating a corporate culture. In Great advertising campaigns: Goals and accomplishments (pp. 171-186). Lincolnwood: NTC Business Books. Jameson, F. (1991). Postmodernism, or, the cultural logic of late capitalism. Durham: Duke University Press. Klein, N. (1999). No Logo: Taking aim at brand bullies. New York: Picador. Korzeniewicz, M. (1994). "Commodity chains and marketing strategies: Nike and the global athletic footwear industry." In G. Gereffi & M. Korzeniewicz (Eds.), Commodity chains and global capitalism (pp. 247-265). Westport: Greenwood Press. Lafrance, M. R. (1998). "Colonizing the feminine: Nike's intersections of postfeminism and hyperconsumption." In G. Rail (Ed.), Sport and postmodern times (pp. 117-142). New York: State University of New York Press. Lucas, S. (2000). "Nike's commercial solution: Girls, sneakers, and salvation." International Review for the Sociology of Sport, 35(2), 149-164. Lury, C. (1996). Consumer culture. Cambridge: Polity Press. Martin, R. (2002). On your Marx: Rethinking socialism and the left. Minneapolis: University of Minnesota Press. Miles, S. (1998). Consumerism: As a way of life. London: Sage. Penaloza, L. (1999). "Just doing it: A visual ethnographic study of spectacular consumption behavior at Nike Town." Consumption, Markets and Culture, 2(4), 337-400. Poster, M. (1990). The mode of information: Poststructuralism and social context. Chicago: University of Chicago Press. Puma.com. (2003). Financial results for the 1st quarter 2003. Retrieved 23 April, from http://about.puma.com/ Rowe, D. (1999). Sport, culture and the media: The unruly trinity. Buckingham: Open University Press. Saddleton, L. (2002, May 6). How would you revive a flagging fashion brand? Strategy, 2. Sage, G. H. (1999). Justice do it! The Nike transnational advocacy network: Organization, collective actions, and outcomes. Sociology of Sport Journal, 16(3), 206-235. Solomon, M. R., & Englis, B. G. (1997). Breaking out of the box: Is lifestyle a construct or a construction? In S. Brown & D. Turley (Eds.), Consumer research: Postcards from the edge (pp. 322-349). London: Routledge. Stabile, C. A. (2000). Nike, social responsibility, and the hidden abode of production. Critical Studies in Media Communication, 17(2), 186-204. Strasser, J. B., & Becklund, L. (1991). Swoosh: The unauthorized story of Nike and the men who played there. New York: Harcourt Brace Jovanovich. Toffler, A. (1980). The third wave. New York: William Morrow. Wernick, A. (1991). Promotional culture: Advertising, ideology and symbolic expression. London: Sage. Willigan, G. E. (1992). High performance marketing: An interview with Nike's Phil Knight. Harvard Business Review(July/August), 91-101. Links http://about.puma.com/ http://www.puma.com Citation reference for this article Substitute your date of access for Dn Month Year etc... MLA Style Grainger, Andrew D. and Andrews, David L.. "Postmodern Puma" M/C: A Journal of Media and Culture< http://www.media-culture.org.au/0306/08-postmodernpuma.php>. APA Style Grainger, A. D. & Andrews, D. L. (2003, Jun 19). Postmodern Puma. M/C: A Journal of Media and Culture, 6,< http://www.media-culture.org.au/0306/08-postmodernpuma.php>

I consider that the golden rule requires that if I like a program I must share it with other people who like it. Software sellers want to divide the users and conquer them, making each user agree not to share with others. I refuse to break solidarity with other users in this way. I cannot in good conscience sign a nondisclosure agreement or a software license agreement. Richard Stallman (GNU Manifesto) There is much more to Stallman’s Manifesto […] Suffice it to say that on the surface, it read like a socialist polemic, but I saw something different. I saw a business plan in disguise. Michael Tiemann (72) The current discourse surrounding the rapid development and deployment of “free” and “open source” software and operating systems is framed by an undeniably utopian impulse. The “openness” of open source software is informed by concerns both practical (freedom from oppressive software production and licensing/copyright schemes) and ideological (the valorisation of anarchic organizational forms, communal production, and public property rights). The utopian impulse that underwrites this discourse is important for many reasons, but what I want to trace here is the trajectory from ideological position to practical action as it relates to differing forms of utopianism. The initial anarcho-socialist utopian move initiated by Richard Stallman’s GNU (GNU’s Not UNIX) Project and Free Software Foundation (FSF) is currently being transformed into an organizational utopia in the form of the Open Source Movement (OSM). The purpose here is not to take sides in the philological/philosophical debate over the definitions and relative merits of “free” versus “open source” software or to lament the passing of a missed opportunity, but to address the intimations of hope and deprival (with apologies to Grant) that can be gleaned from the relationship between utopianism and socio-technological practices. The popularity of open source development ideals and practices indicates a certain dissatisfaction with corporate technoculture on the part of some (many?) of those who work in these institutions. This dissatisfaction is clearly evident in Richard Stallman’s GNU Manifesto wherein he critiques the shift from public domain to copyrighted software development that has occurred in the last three decades. Recalling Brian Winston’s theorization of technological development, the move toward copyrighted software appears to have come as a result of the increasing diffusion of computing hardware in the 1980’s and the practical realization of software development as an economically rationalized for-profit enterprise. Prior to the broad commodification of software, programmers shared knowledge and code without worrying about software licenses and copyrights, institutionally commodified intellectual property, and non-disclosure agreements (at least according to Stallman’s experience). Stallman’s heroic effort to create the GNU system is thus not only a direct attack on commodified software production, but a consciously utopian attempt to recapture the “open” communal programming practices that existed during the 1960’s and 70’s. The utopian impulse found in this open form of software development is significant precisely because it underwrites recent efforts to reject current copyright regimes and, by extension, techno-industrial oligarchies. This potential is enabled by newly available forms of grassroots software development (code sharing and development via the Internet being the most obvious example). Stallman introduced and encouraged a licensing system that expressly prohibited the copyrighting of software developed using GNU software protocols and standards (termed “copyleft”). The lag between the initial deployment of Stallman’s early software efforts and their uptake by the wider computing community came as increases in computer literacy, technology markets, affordable personal computing power, and broadband CMC networks came along in the 1990’s. The OSM’s recent mobilization around Linux continues and parallels Stallman’s efforts via the adoption of the GNU license and copyleft. While the hallmarks of Stallman’s communal software production system remain, the overall nature of Open Source software is framed by a rather different notion of utopian openness than is evident in Stallman’s manifesto. This brings me to the broader notion of an anarcho-utopianism framed by what Bookchin has identified as the twin goals of individual liberty and social democracy. Claims are already being made that practices related to open source software development and its emergent virtually interconnected organizational form may provide the basis for (re)imagining systems of social governance while simultaneously providing the practical infrastructure by which these new forms may be manifested: The experience of open source development, or even just the acceptance of its value as a model for others, provides a real-life practice for the deeper change in perspective required if we are to move into a more networked and emergent understanding of our world. The local community must be experienced as a place to implement policies, incrementally, that will eventually have an effect on the whole. (Rushkoff 61) Suggestions that the FSF’s and OSM’s methods of software development may serve as a model for more open and democratic policy making resonates with political theory in general, and social democracy and anarchism in particular. But neither the OSM nor the FSF is a political platform. They are simply modalities of software production which find their foundations in communal forms of decision making, intellectual labour, and dissemination. A utopian impulse is nonetheless revealed in the typically vague invocations of political anarchism and social democratic ideals that accompany the discursive promotion and legitimization of these modalities. The FSF advocates a broadly social anarchistic approach allied with a desire to overturn entirely commodified software production. The OSM, on the other hand, is more concerned with a kind of lifestyle anarchism that focuses on increasing programmer and user freedom within existing frameworks of software production and use. For Bookchin, the latter form of anarchism is positive insofar it advocates individual liberty, but it ultimately undermines the broader goals of anarchism by focusing on transient notions of individualism. The result is a situation wherein “the word anarchy will become part of the chic bourgeois vocabulary of the coming century — naughty, rebellious, insouciant, but deliciously safe” (3). It is interesting to note in passim the various discursive entanglements of anarchism and the Internet that have occurred since 1995, the time of Bookchin’s statement. The utopian discourse that weaves its way through the non-technical discussions surrounding GNU, Linux, and other Open Source projects is certainly strong, but it begs the question of exactly what kinds of utopias are being offered ? Henri Lefebvre was rather suspicious of utopian thought because it is so frequently allied with efforts to legitimize nationalistic and totalitarian organizational practices. While suggesting that utopian thought was useful, he would only go so far as to warn that any such thought must avoid notions of a revolution that would simply substitute one state-sanctioned form of organized production with another, arguing instead for a “transformation of society [that] presupposes a collective ownership and management of space [we could say “society’ or even “software” here in place of “space] founded on the permanent participation of the ‘interested parties’, with their multiple, varied and even contradictory interests” (422). For Lefebvre, any useful form of utopianism is not a matter of coming up with alternative state apparatuses, but of somehow creating the conditions through which an open orientation to future possibilities might allow for the foundation of a more socially democratic society. The FSF comes closest to fulfilling this ideal—at least within the realm of computing—insofar its attendant communities are involved less in the creation of a new institutional form than in the propagation of practices and desires for more open forms of software development. As such, the FSF seems to deploy the kind of utopian thinking and practice that Lefebvre finds useful. There is hope (social and computational) in this kind of utopian orientation because its socio-institutional functioning is left forever open-ended by way of its locating productive practices in communal formations. The FSF offers an idealized mode of communally open software development while refusing to provide an overarching and institutionalized organizational form by which it is to be utilized. Borrowing heavily from the FSF’s ideals and practices, the OSM’s efforts to integrate practices of communal software development into contemporary techno-capitalism is not simply an intimation of deprival — a moment to lament the passing of the FSF’s utopian ideals — rather, the OSM constitutes what Deleuze and Guattari refer to as a moment of actualization whereby the virtual (and utopian) potential future(s) of communal software development cross the practico-material threshold to become manifest practices. Stallman’s GNU existed in the rather rarefied realm of hardcore coders for years before Torvald’s Linux took open/free software principles into the mainstream. The moment of actualization was not simply technical (available hardware, software, programmers, networks, etc.): it was the recognition that communal “copylefted” programming could “find a place” in the everyday structures of IT industries, services, and markets. It is the moment when Tiemann sees a business plan in Stallman’s “socialist polemic”. At this point that the utopian orientation and ideals promoted by the FSF transforms into an organizational utopia spearheaded by the OSM. The debate over this transformation shows few signs of abating any time soon. Stallman feels that Eric Raymond’s (the spiritual “leader” of the OSM) promotion of a potentially massive, and certainly for-profit, industry founded on the implementation and support of open source software defeats the basic (utopian) principles of free software. Echoing Bookchin’s concerns about lifestyle anarchism, Stallman worries that the OSM will simply result in the re-introduction of all of those things that drove him out of institutional software development in the first place: “the rhetoric of ‘open source’ focuses on the potential to make high quality, powerful software, but shuns the ideas of freedom, community and principle” (1999:70) . The FSF’s social utopianism thus appears to provide the productive content, but not the political form, for the more practically minded utopianism of the OSM, which offers an organizational utopia more akin to the “substitutive” utopias disavowed by Lefebvre. As Martin Parker argues, utopian thought and practice tends to be organizational in nature: “most, if not all, fictional and actual utopias rely on a re-formulation of principles of social order. They are in that sense organized, though often on different principles to the market managerial hegemony” (217-218). Stallman’s open anarcho-utopianism commits to an avoidance of market managerial hegemony. The OSM, however, not only cooperates with market hegemony, it seeks to find a place within it. This is a crucial difference. The openness introduced by the FSF is incorporated by the OSM only at the level of software production itself, thus containing and integrating its communal practices in the service of existing market needs and structures. The OSM is thus likely only a threat to Microsoft, and this only because it proffers a new business model. Indeed, the popular appeal of the OSM’s version of open source as a metaphor and model for businesses suggests that it may be an easily, and safely, appropriated set of practices. On the other hand, the FSF’s promotion of a more “socialist” approach to software production and use is based on the same basic programming practices and it will therefore be rather difficult to exact some sort of industrial control of copyright and/or intellectual property where open source software is concerned. Whether or not these two approaches are compatible, or if users will push their development into as yet unseen directions, is by no means clear at this point. With open source development poised on the verge of being the “next big thing”, the manifest expression of its anarchic utopian impulse in the form of treatises and essays is somewhat limited insofar as the community is primarily composed of programmers rather than social theorists. Nevertheless, the utopian impulse is becoming more clearly expressed where it perhaps matters most: as an emergent set of practices in the domain of software production and use. The “kernel” of openness introduced by both the FSF and the OSM thus needs to be addressed in detail, and sooner rather than later, because it is in the struggle between these two forms of anarchic utopianism that the broader sociopolitical implications of a radically different form of software production will be played out. About the Author Dale Bradley is an Assistant Professor in the Dept. of Communications, Popular Culture, and Film at Brock University, Canada. His research interests include the discursive analysis of contemporary technoculture and the historical emergence of cybersociety. Email: dbradley@brocku.ca Works Cited Bookchin, Murray. Social Anarchism or Lifestyle Anarchism. San Francisco: AK Press, 1995. Deleuze, Gilles & Felix Guattari. A Thousand Plateaus. Minneapolis: U of Minnesota Press, 1987. Grant, George. Technology and Empire: Perspectives on North America. Toronto: House of Anansi, 1969. Lefebvre, Henri. The Production of Space. Trans. Donald Nicholson-Smith. Oxford UK: Blackwell, 1991. Parker, Martin. ‘Utopia and the Organizational Imagination: Eutopia’. Utopia and Organization. Ed. Martin Parker. Oxford UK: Blackwell, 2002. Rushkoff, Douglas. Open Source Democracy. London: Demos, 2003. Full text available under open source licensing at: http://www.demos.co.uk/catalogue/opensourcedemocracy_page292.aspx http://www.gnu.org/gnu/manifesto.html Stallman, Richard. ‘The GNU Operating System and the Free Software Movement’. Open Sources: Voices from the Open Source Revolution. Eds. Chris DiBona, Sam Ockman & Mark Stone. Sebastopol CA: O’Reilly & Associates,1999. Tiemann, Michael. ‘Future of Cygnus Solutions: An Entrepreneur’s Account’. Open Sources: Voices from the Open Source Revolution. Eds. Chris DiBona, Sam Ockman & Mark Stone. O’Reilly & Associates, Sebastopol CA: 1999 Winston, Brian. Misunderstanding Media. Harvard U Press, Cambridge MA: 1986 For a brief overview of the debate between Stallman and Raymond, see ‘Whence the Source: Untangling the Open Source/Free Software Debate’ at: http://opensource.oreilly.com/news/scoville_0399.html) Citation reference for this article MLA Style Bradley, Dale. "Open Source, Anarchy, and the Utopian Impulse" M/C: A Journal of Media and Culture <http://www.media-culture.org.au/0406/03_Bradley.php>. APA Style Bradley, D. (2004, Jul1). Open Source, Anarchy, and the Utopian Impulse. M/C: A Journal of Media and Culture, 7, <http://www.media-culture.org.au/0406/03_Bradley.php>

Photo by National Cancer Institute on Unsplash INTRODUCTION Gift-giving by patients or their families to physicians has happened since there were patients and physicians, and in many places, it’s still quite common. It’s also potentially problematic, and the why and how of it offer important insight into the physician-patient relationship and human relationships more broadly. Yet ethicists, regulators, and the public have not paid much systematic attention. In the United States, no federal or state legislation directly addresses it. Only in the past two decades did the American Medical Association (AMA) release guidance to physicians about it. That guidance, which permits physicians to accept certain gifts by certain patients under certain circumstances, namely, when it will not influence their medical judgment or cause hardship to the gift-giver, is vague and incomplete – indeed, it’s all of 200 words.[1] Other physician professional organizations have little to add.[2] A few academics and opinion columnists have studied or reflected on the psychology of gift-giving and -receiving and recommended everything from categorical rejection of patient gifts[3] to erring on the side of accepting them, provided they are of modest value, and the motivation behind them can be discerned.[4] However, insufficient attention has been paid to the when and where of those gifts or the significance of clinic-, hospital- or other systems-level ethical safeguards. ANALYSIS When deciding whether they will accept a gift from a patient or their family, physicians must balance the possibility that the gift could cloud medical judgment, lead to favoritism, exploitation, and slippery slopes, or pressure other patients to give, and perhaps even debase the meaning of medical treatment, against the prospect that gift-giving could increase patient trust and satisfaction, as well as empower patients and respect their autonomy and culture.[5] Performing this harm-benefit calculation case by case is challenging and time-consuming. Unsurprisingly, many physicians opt simply to tell would-be gift-giving patients that they appreciate the sentiment, but, as a rule, they accept no gifts. I submit many physicians do this also because they are unaware of how meaningful giving a gift can be for patients or anyone in a disadvantaged position with respect to the gift recipient. They may also not know that there are simple accountability mechanisms they can institute that may prevent many of the possible adverse consequences of gift-giving and -receiving in the context of the physician-patient or physician-patient-family relationship. Unfortunately, many instances in which accepting a gift would have led to net benefit are foregone. It is my belief a consensus could quickly be formed about which types of gifts would clearly be wrong to accept. Few would defend the physician who agrees to use a patient’s villa in the Bahamas or welcomes expensive jewelry or lewd photos. The timing and intent of a gift also matter. Few would forgive the physician who accepted even a modestly valuable voucher to eat at a patient’s restaurant while their eligibility for transplant was being debated or after they had run out of opioid painkillers and were denied a prescription renewal. On the other hand, I doubt even Charles Weijer or the College of Physicians and Surgeons of Prince Edward Island, which views accepting gifts from patients as “boundary crossing,”[6] would demand an orthopedic surgeon turn down the happy picture a pediatric patient drew after recovering from a hip injury and resuming sports. They are also unlikely to criticize an oncology team that graciously receives a fruitcake baked by the sister of an elderly cancer patient after the decision was made and agreed to, around Christmastime, not to initiate another round of chemotherapy. These unlikely refusals may be because rejecting those gifts, all things considered, would seem cruel. But it might also be because there is disagreement about what constitutes a gift: whether it must be a tangible object (are heartfelt thank-yous and hugs not also “gifts”?) or whether it must be something that requires the physician actively do something, e.g., get on a plane. These disagreements about definitions may also partially underlie disagreements about practice. Suppose a patient in a sparsely populated, heavily wooded part of Maine takes it upon himself to offer a sack of apples from his orchard to his internist, who regularly waives fees for those who cannot pay them or will make a house call at any time of the night. In that case, the internist may not consider the apples a gift. He may not think of them as payment or re-payment either. They may exist in some in-between category, much like the knitted slippers brought in by a patient in whose culture “thank you” is seldom said. But clearly, some things are widely perceived as gifts or to have substantial gift-like character. Should they, at least, be rejected? I don’t think so. The act of gift-giving and -receiving can be a sort of ritual and gradually lead to trust and closeness.[7] Perhaps a shy patient whose wife previously sent chocolates to his physician around Christmastime will come to see the physician as a part of his extended family. Perhaps he needs to do so to feel comfortable talking about his erectile dysfunction. Gifts can be expressions of caring.[8] Perhaps an elderly Texan patient imagines her younger physician, whom she has known for thirty years and often sees at the grocery store, as her son and asks to prepare a homecoming mum (traditionally a chrysanthemum flower corsage) for his children’s school dance. Perhaps doing so will give her purpose, make her feel useful, as all her own children have moved away. Giving gifts may also provide patients with a sense of control and help them feel as if less of a power imbalance exists between them and their physician. Perhaps a young judge, who is not used to not being in control, and was previously misdiagnosed with rheumatoid arthritis, is now struggling to come to terms with his Lupus. Perhaps giving the physician who made the correct diagnosis a moderately-priced bottle of scotch restores his confidence or sense of pride to. Gifts are also undoubtedly important to the recipient. When medical providers receive a gift, they may interpret it as a sign that they are valued. While it would be wrong to practice medicine to receive gifts or expect them, there are times, like when ERs and ICUs are overwhelmed because of a viral pandemic,[9] which threatens the will to continue working, and most anything (within reason) that bolsters resolve can be considered good. There is also no obvious distinction between the satisfaction physicians normally receive on seeing their patients recover or being thanked or smiled at and what they feel when they receive a small or “token” gift, like a plate of homemade cookies. The point is that the physician-patient relationship is a human one. Many advocate it should be personal, that physicians should be emotionally invested in their patients, care about and have compassion for them in ways that professional oaths do not fully capture.[10] This dynamic is particularly important in primary care or when the physician-patient relationship continues for long periods. According to one Israeli study, many patients even wish for a relationship with their physician akin to friendship. Those who felt they had such a relationship were more satisfied with their care than those who believed the relationship was business-like.[11] The precedent for this “friendship between unequals” goes back at least to the time of Erasmus, some five hundred years ago.[12] There may be good reasons for physicians to draw the line before friendship, but if accepting certain gifts builds intimacy, and that intimacy does not cross over into an inappropriate relationship, e.g., a sexual or romantic relationship, and if it has the chance to improve healthcare outcomes through improved mood or early disclosure of problems, I think it should be done. Physicians have a prima facie duty to do good for their patients.[13] Most physicians want to do good for their patients and respect their traditions and preferences. I suspect that accepting the gifts from the patients in the examples above would do a lot of good, or at least that rejecting them could do significant harm, including making them or their families feel estranged from the medical community, impeding future care. Physicians might be more comfortable accepting gifts if receiving gifts would not subject them to scrutiny or penalty. They also may feel better if they knew that receiving gifts would not harm their patients and that rejecting gifts might. They should document all gifts they receive.[14] This will enable them to detect if gifts from a particular patient are increasing in frequency or lavishness or changing markedly in character, which could warrant attention. I maintain this “Gift Log” should be maintained in common with everyone at the clinic or in the relevant hospital department and potentially made available to hospital administration for audit. Investigation might be necessary if a gift is given (and accepted) with no explicable context, e.g., not near holiday season or after a treatment milestone is achieved. When possible, gifts should be shared communally, such as placing fruit baskets or chocolates in the staff room. Other gifts, like artwork, can be displayed on the walls. Others should be encouraged to hold physicians accountable if they feel patients who have given gifts receive preferential treatment, including something as seemingly small as priority for appointment bookings. Appearances matter and even the appearance of impropriety can affect the public’s trust in medicine. The culture of medicine has already changed such that nurses now reproach physicians they feel violate the standard of care,[15] and this would be an extension of that trend. Depending on the set-up of the practice, a staff member can be designated for receiving gifts and politely declining those that ought to be declined. Staff members should tell patients, who give gifts in full view of other patients, that they cannot do so in the future. Physicians can politely rebuff patients who wish to give inappropriate gifts, or gifts at inappropriate times and suggest they donate to charity instead. Medical practices and hospitals should develop a gift policy in consultation with staff and patients to avoid needlessly rejecting gifts that benefit both doctor and patient and to avoid pressuring patients into giving gifts. The policy should be flexible to account for the crucial human element in any provider-patient relationship and the cultural nuances of any practice setting. Psychiatrists, who work with particularly vulnerable patients, may need to be more vigilant when accepting gifts.[16] CONCLUSION Though we tend to think health innovation occurs in urban medical centers and spreads outward, there may be something big-city physicians can learn from their rural colleagues about personalized patient-physician relationships. The value of gifts is only one example. Normalizing the acceptance of patient gifts in appropriate restricted circumstances has the added benefit of shining a spotlight on the acceptance of patient gifts in dubious ones. By bringing an already fairly common practice into the open and talking about it, we can create policies that respect patients as persons, prevent abuse, and deconstruct the stereotype of the austere and detached physician. While there is no reason to think that gift-giving would get out of control if appropriate safeguards are put in place, the medical community can always re-evaluate after a period, or an individual medical practice can re-evaluate based on the circumstances of their practice environment. Gift-giving, especially when gifts are of small monetary value, should be recognized as a culturally appropriate gesture with meaning far beyond that monetary value. It is best governed by reasonable gift-giving policies, not banned altogether. - [1] Council on Ethical and Judicial Affairs. “Ethics of Patient-Physician Relationships.” In AMA Code of Medical Ethics, 11. Chicago: American Medical Association, 2021. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/code-of-medical-ethics-chapter-1.pdf. [2] Sulmasy, Lois Snyder, and Thomas A. Bledsoe. “American College of Physicians Ethics Manual.” Annals of Internal Medicine 170, no. 2_Supplement (January 15, 2019): S1–32. https://doi.org/10.7326/M18-2160; Committee on Bioethics. “Pediatrician-Family-Patient Relationships: Managing the Boundaries.” Pediatrics 124, no. 6 (December 1, 2009): 1685–88. https://doi.org/10.1542/peds.2009-2147. [3] Weijer, Charles. “No: Gifts Debase the True Value of Care.” Western Journal of Medicine 175, no. 2 (August 2001): 77. [4] Lyckholm, Laurie J. “Should Physicians Accept Gifts From Patients?” JAMA 280, no. 22 (December 9, 1998): 1944–46. https://doi.org/10.1001/jama.280.22.1944; Spence, Sean A. “Patients Bearing Gifts: Are There Strings Attached?” BMJ 331, no. 7531 (December 22, 2005): 1527–29. https://doi.org/10.1136/bmj.331.7531.1527; Gaufberg, Elizabeth. “Should Physicians Accept Gifts from Patients?” American Family Physician 76, no. 3 (August 1, 2007): 437; Caddell, Andrew, and Lara Hazelton. “Accepting Gifts from Patients.” Canadian Family Physician 59, no. 12 (December 2013): 1259–60. [5] See above commentators and Drew, Jennifer, John D. Stoeckle, and J. Andrew Billings. “Tips, Status and Sacrifice: Gift Giving in the Doctor-Patient Relationship.” Social Science & Medicine 17, no. 7 (January 1, 1983): 399–404. https://doi.org/10.1016/0277-9536(83)90343-X. [6] College of Physicians and Surgeons of Prince Edward Island. “Respecting Boundaries.” Accessed April 4, 2021. https://cpspei.ca/respecting-boundaries/. [7] The Atlantic’s Marketing Team. “What Gifting Rituals from Around the Globe Reveal About Human Nature.” The Atlantic, 2018. https://www.theatlantic.com/sponsored/hennessy-2018/what-gifting-rituals-around-globe-reveal-about-human-nature/2044/. [8] Parker-Pope, Tara. “A Gift That Gives Right Back? The Giving Itself.” The New York Times, December 11, 2007, sec. Health. https://www.nytimes.com/2007/12/11/health/11well.html. [9] Harlan, Chico, and Stefano Pitrelli. “As Coronavirus Cases Grow, Hospitals in Northern Italy Are Running out of Beds.” Washington Post. Accessed April 4, 2021. https://www.washingtonpost.com/world/europe/italy-coronavirus-patients-lombardy-hospitals/2020/03/12/36041dc6-63ce-11ea-8a8e-5c5336b32760_story.html. [10] Frankel, Richard M. “Emotion and the Physician-Patient Relationship.” Motivation and Emotion 19, no. 3 (September 1, 1995): 163–73. https://doi.org/10.1007/BF02250509. [11] Magnezi, Racheli, Lisa Carroll Bergman, and Sara Urowitz. “Would Your Patient Prefer to Be Considered Your Friend? Patient Preferences in Physician Relationships.” Health Education & Behavior 42, no. 2 (April 1, 2015): 210–19. https://doi.org/10.1177/1090198114547814. [12] Albury, W. R., and G. M. Weisz. “The Medical Ethics of Erasmus and the Physician-Patient Relationship.” Medical Humanities 27, no. 1 (June 2001): 35–41. https://doi.org/10.1136/mh.27.1.35. [13] Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th edition. New York: Oxford University Press, 2012. [14] Caddell and Hazelton, 2013. [15] See, e.g. Peplau, Hildegard E. “A Glance Back in Time: Nurse-Doctor Relationships.” Nursing Forum 34, no. 3 (1999): 31–35. https://doi.org/10.1111/j.1744-6198.1999.tb00991.x and Ahmad, Ahmir. “The Doctor-Nurse Relationship: Time for Change?” British Journal of Hospital Medicine (2005), September 27, 2013. https://doi.org/10.12968/hmed.2009.70.Sup4.41642. [16] Hundert, Edward M. “Looking a Gift Horse in the Mouth: The Ethics of Gift-Giving in Psychiatry.” Harvard Review of Psychiatry 6, no. 2 (January 1, 1998): 114–17. https://doi.org/10.3109/10673229809000319.

Photo by niu niu on Unsplash ABSTRACT Shackling prisoners has been implemented as standard procedure when transporting prisoners in labor and during childbirth. This procedure ensures the protection of both the public and healthcare workers. However, the act of shackling pregnant prisoners violates the principles of ethics that physicians are supposed to uphold. This paper will explore how shackling pregnant prisoners violates the principle of justice and beneficence, making the practice unethical. INTRODUCTION Some states allow shackling of incarcerated pregnant women during transport and while in the hospital for labor and delivery. Currently, only 22 states have legislation prohibiting the shackling of pregnant women.[1] Although many states have anti-shackling laws prohibiting restraints, these laws also contain an “extraordinary circumstances” loophole.[2] Under this exception, officers shackle prisoners if they pose a flight risk, have any history of violence, and are a threat to themselves or others.[3] Determining as to whether a prisoner is shackled is left solely to the correctional officer.[4] Yet even state restrictions on shackling are often disregarded. In shackling pregnant prisoners during childbirth, officers and institutions are interfering with the ability of incarcerated women to have safe childbirth experiences and fair treatment. Moreover, physicians cannot exercise various ethical duties as the law constrains them. In this article, I will discuss the physical and mental harms that result from the use of restraints under the backdrop of slavery and discrimination against women of color particularly. I argue that stereotypes feed into the phenomenon of shackling pregnant women, especially pregnant women of color. I further assert that shackling makes it difficult for medical professionals to be beneficent and promote justice. BACKGROUND Female incarceration rates in the United States have been fast growing since the 1980s.[5] With a 498 percent increase in the female incarceration population between 1981 and 2021, the rates of pregnancy and childbirth by incarcerated people have also climbed.[6],[7] In 2021, over 1.2 million women were incarcerated in the United States.[8] An estimated 55,000 pregnant women are admitted to jails each year.[9],[10] Many remain incarcerated throughout pregnancy and are transported to a hospital for labor and delivery. Although the exact number of restrained pregnant inmates is unclear, a study found that 83 percent of hospital prenatal nurses reported that their incarcerated patients were shackled.[11] I. Harms Caused by Shackling Shackling has caused many instances of physical and psychological harm. In the period before childbirth, shackled pregnant women are at high risk for falling.[12] The restraints shift pregnant women’s center of gravity, and wrist restraints prevent them from breaking a fall, increasing the risk of falling on their stomach and harming the fetus.[13] Another aspect inhibited by using restraints is testing and treating pregnancy complications. Delays in identifying and treating conditions such as hypertension, pre-eclampsia, appendicitis, kidney infection, preterm labor, and especially vaginal bleeding can threaten the lives of the mother and the fetus.[14] During labor and delivery, shackling prevents methods of alleviating severe labor pains and giving birth.[15] Usually, physicians recommend that women in labor walk or assume various positions to relieve labor pains and accelerate labor.[16] However, shackling prevents both solutions.[17] Shackling these women limits their mobility during labor, which may compromise the health of both the mother and the fetus.[18] Tracy Edwards, a former prisoner who filed a lawsuit for unlawful use of restraints during her pregnancy, was in labor for twelve hours. She was unable to move or adjust her position to lessen the pain and discomfort of labor.[19] The shackles also left the skin on her ankles red and bruised. Continued use of restraints also increases the risk of potentially life-threatening health issues associated with childbirth, such as blood clots.[20] It is imperative that pregnant women get treated rapidly, especially with the unpredictability of labor. Epidural administration can also become difficult, and in some cases, be denied due to the shackled woman’s inability to assume the proper position.[21] Time-sensitive medical care, including C-sections, could be delayed if permission from an officer is required, risking major health complications for both the fetus and the mother.[22] After childbirth, shackling impedes the recovery process. Shackling can result in post-delivery complications such as deep vein thrombosis.[23] Walking prevents such complications but is not an option for mothers shackled to their hospital beds.[24] Restraints also prevent bonding with the baby post-delivery and the safe handling of the baby while breast feeding.[25] The use of restraints can also result in psychological harm. Many prisoners feel as though care workers treat them like “animals,” with some women having multiple restraints at once— including ankles, wrists, and even waist restraints.[26] Benidalys Rivera describes the feeling of embarrassment as she was walking while handcuffed, with nurses and patients looking on, “Being in shackles, that make you be in stress…I about to have this baby, and I’m going to go back to jail. So it’s too much.”[27] Depression among pregnant prisoners is highly prevalent. The stress of imprisonment and the anticipation of being separated from their child is often overwhelming for these mothers.[28] The inhumane action has the potential to add more stress, anxiety, and sadness to the already emotionally demanding process of giving birth. Shackling pregnant prisoners displays indifference to the medical needs of the prisoner.[29] II. Safety as a Pretense While public safety is an argument for using shackles, several factors make escape or violence extremely unlikely and even impossible.[30] For example, administering epidural anesthesia causes numbness and eliminates flight risk.[31] Although cited as the main reason for using shackles, public safety is likely just an excuse and not the main motivator for shackling prisoners. I argue that underlying the shackling exemplifies the idea that these women should not have become pregnant. The shackling reflects a distinct discrimination: the lawmakers allowing it perhaps thought that people guilty of crimes would make bad mothers. Public safety is just a pretense. The language used to justify the use of restraint of Shawanna Nelson, the plaintiff in Nelson v. Correctional Medical Services, discussed below, included the word “aggressive.”[32] In her case, there was no evidence that she posed any danger or was objectively aggressive. Officer Turnesky, who supervised Nelson, testified that she never felt threatened by Nelson.[33] The lack of documented attempts of escape and violence from pregnant prisoners suggests that shackling for flight risk is a false pretense and perhaps merely based on stereotypes.[34] In 2011, an Amnesty International report noted that “Around the USA, it is common for restraints to be used on sick and pregnant incarcerated women when they are transported to and kept in hospital, regardless of whether they have a history of violence (which only a minority have) and regardless of whether they have ever absconded or attempted to escape (which few women have).”[35] In a 2020 survey of correctional officers in select midwestern prisons, 76 percent disagreed or strongly disagreed with restraining pregnant women during labor and delivery.[36] If a correctional officer shackles a pregnant prisoner, it is not because they pose a risk but because of a perception that they do. This mindset is attributed to select law enforcement, who have authority to use restraints.[37] In 2022, the Tennessee legislature passed a bill prohibiting the use of restraints on pregnant inmates. However, legislators amended the bill due to the Tennessee Sherriff Association’s belief that even pregnant inmates could pose a “threat.”[38] Subjecting all prisoners to the same “precautions” because a small percentage of individuals may pose such risks could reflect stereotyping or the assumption that all incarcerated people pose danger and flight risk. To quell the (unjustified) public safety concern, there are other options that do not cause physical or mental harm to pregnant women. For example, San Francisco General Hospital does not use shackles but has deputy sheriffs outside the pregnant women’s doors.[39] III. Historical Context and Race A. Slavery and Post-Civil War The treatment of female prisoners has striking similarities to that of enslaved women. Originally, shackling of female slaves was a mechanism of control and dehumanization.[40] This enabled physical and sexual abuses. During the process of intentionally dehumanizing slaves to facilitate subordination, slave owners stripped slave women of their feminine identity.[41] Slave women were unable to exhibit the Victorian model of “good mothering” and people thought they lacked maternal feelings for their children.[42] In turn, societal perception defeminized slave women, and barred them from utilizing the protections of womanhood and motherhood. During the post-Civil War era, black women were reversely depicted as sexually promiscuous and were arrested for prostitution more often than white women.[43] In turn, society excluded black women; they were seen as lacking what the “acceptable and good” women had.[44] Some argue that the historical act of labeling black women sexually deviant influences today’s perception of black women and may lead to labeling them bad mothers.[45] Over two-thirds of incarcerated women are women of color.[46] Many reports document sexual violence and misconduct against prisoners over the years.[47] Male guards have raped, sexually assaulted, and inappropriately touched female prisoners. Some attribute the physical abuse of black female prisoners to their being depicted or stereotyped as “aggressive, deviant, and domineering.”[48] Some expect black women to express stoicism and if they do not, people label them as dangerous, irresponsible, and aggressive.[49] The treatment of these prisoners mirrors the historical oppression endured by black women during and following the era of slavery. The act of shackling incarcerated pregnant women extends the inhumane treatment of these women from the prison setting into the hospital. One prisoner stated that during her thirty-hour labor, while being shackled, she “felt like a farm animal.”[50] Another pregnant prisoner describes her treatment by a guard stating: “a female guard grabbed me by the hair and was making me get up. She was screaming: ‘B***h, get up.’ Then she said, ‘That is what happens when you are a f***ing junkie. You shouldn’t be using drugs, or you wouldn’t be in here.”[51] Shackling goes beyond punishing by isolation from society – it is an additional punishment that is not justified. B. Reproductive Rights and “Bad Mothers” As with slaves not being seen as maternal, prisoners are not viewed as “real mothers.” A female prison guard said the following: “I’m a mother of two and I know what that impulse, that instinct, that mothering instinct feels like. It just takes over, you would never put your kids in harm’s way. . . . Women in here lack that. Something in their nature is not right, you know?”[52] This comment implies that incarcerated women lack maternal instinct. They are not in line with the standards of what society accepts as a “woman” and “mother” and are thought to have abandoned their roles as caretakers in pursuit of deviant behaviors. Without consideration of racial discrimination, poverty issues, trauma, and restricted access to the child right after delivery, these women are stereotyped as bad mothers simply because they are in prison. Reminiscent of the treatment of female black bodies post-civil war and the use of reproductive interventions (for example, Norplant and forced sterilization) in exchange for shorter sentences, I argue that shackles are a form of reproductive control. Justification for the use of shackles even includes their use as a “punitive instrument to remind the prisoner of their punishment.”[53] However, a prisoner’s pregnancy should have no relevance to their sentence.[54] Using shackles demonstrates to prisoners that society tolerates childbirth but does not support it.[55] The shackling is evidence that women are being punished “for bearing children, not for breaking the law.”[56] Physicians and healthcare workers, as a result, are responsible for providing care for the delivery and rectifying any physical problems associated with the restraints. The issues that arise from the use of restraints place physicians in a position more complex than they experience with regular healthy pregnancies. C. Discrimination In the case of Ferguson v. City of Charleston, a medical university subjected black woman to involuntary drug testing during pregnancy. In doing so, medical professionals collaborated with law enforcement to penalize black women for their use of drugs during pregnancy.[57] The Court held the drug tests were an unreasonable search and violated the Fourth Amendment. Ferguson v. City of Charleston further reveals an unjustified assumption: the medical and legal community seemed suspicious of black women and had perhaps predetermined them more likely to use drugs while pregnant. Their fitness to become mothers needed to be proven, while wealthy, white women were presumed fit.[58] The correctional community similarly denies pregnant prisoners’ medical attention. In the case of Staten v. Lackawanna County, an African American woman whose serious medical needs were treated indifferently by jail staff was forced to give birth in her cell.[59] This woman was punished for being pregnant in prison through the withholding of medical attention and empathy. IV. Failure to Follow Anti-Shackling Laws Despite 22 states having laws against shackling pregnant prisoners, officers do not always follow these laws. In 2015, the Correctional Association of New York reported that of the 27 women who gave birth under state custody, officers shackled 23 women in violation of the anti-shackling laws.[60] The lawyer of Tracy Edwards, an inmate who officers shackled unlawfully during her twelve-hour labor stated, “I don’t think we can assume that just because there’s a law passed, that’s automatically going to trickle down to the prison.”[61] Even with more restrictions on shackling, it may still occur, partly due to the stereotype that incarcerated women are aggressive and dangerous. V. Constitutionality The Eighth Amendment protects people from cruel and unusual punishment. In Brown vs. Plata, the court stated, “Prisoners retain the essence of human dignity inherent in all persons.”[62] In several cases, the legal community has held shackling to be unconstitutional as it violates the Eighth Amendment unless specifically justified. In the case of Nelson v. Correctional Medical Services, a pregnant woman was shackled for 12 hours of labor with a brief respite while she pushed, then re-shackled. The shackling caused her physical and emotional pain, including intense cramping that could not be relieved due to positioning and her inability to get up to use a toilet.[63] The court held that a clear security concern must justify shackling. The court cited a similar DC case and various precedents for using the Eighth Amendment to hold correctional facilities and hospitals accountable.[64] An Arkansas law similarly states that shackling must be justified by safety or risk of escape.[65] If the Thirteenth Amendment applied to those convicted of crimes, shackling pregnant incarcerated people would be unconstitutional under that amendment as well as the Eighth. In the Civil Rights Cases, Congress upheld the right “to enact all necessary and proper laws for the obliteration and prevention of slavery with all its badges and incidents.”[66] Section two of the Thirteenth Amendment condemns any trace or acts comparable to that of slavery. Shackling pregnant prisoners, stripping them of their dignity, and justification based on stereotypes all have origins in the treatment of black female slaves. Viewed through the lens of the Thirteenth Amendment, the act of shackling would be unconstitutional. Nonetheless, the Thirteenth Amendment explicitly excludes people convicted of a crime. VI. Justice As a result of the unconstitutional nature of shackling, physicians should have a legal obligation, in addition to their ethical duty, to protect their patients. The principle of justice requires physicians to take a stand against the discriminatory treatment of their patients, even under the eye of law enforcement.[67],[68] However, “badge and gun intimidation,” threats of noncompliance, and the fear of losing one’s license can impede a physician’s willingness to advocate for their patients. The American College of Obstetricians and Gynecologists (ACOG) finds the use of physical restraints interferes with the ability of clinicians to practice medicine safely.[69] ACOG, The American Medical Association, the National Commission on Correctional Health Care, and other organizations oppose using restraints on pregnant incarcerated people.[70] Yet, legislators can adopt shackling laws without consultation with physicians. The ACOG argues that “State legislators are taking it upon themselves to define complex medical concepts without reference to medical evidence. Some of the penalties [faced by OBGYNs] for violating these vague, unscientific laws include criminal sentences.”[71] Legislation that does not consider medical implications or discourages physicians’ input altogether is unjust. In nullifying the voice of a physician in matters pertaining to the patient’s treatment, physicians are prevented from fulfilling the principle of justice, making the act of shackling patients unethical. VII. Principle of Beneficence The principle of beneficence requires the prevention of harm, the removal of harm, and the promotion of good.[72] Beneficence demands the physician not only avoid harm but benefit patients and promote their welfare.[73] The American Board of Internal Medicine Foundation states that physicians must work with other professionals to increase patient safety and improve the quality of care.[74] In doing so, physicians can adequately treat patients with the goal of prevention and healing. It is difficult to do good when law enforcement imposes on doctors to work around shackles during labor and delivery. Law enforcement leaves physicians and healthcare workers responsible not only to provide care for the delivery, but also rectify any ailments associated with the restraints. The issues arising from using restraints place physicians in a position more complex than they experience with other pregnancies. Doctors cannot prevent the application of the shackles and can only request officers to take them off the patient.[75] Physicians who simply go along with shackling are arguably violating the principle of beneficence. However, for most, rather than violating the principle of beneficence overtly, physicians may simply have to compromise. Given the intricate nature of the situation, physicians are tasked with minimizing potential harm to the best of their abilities while adhering to legal obligations.[76] It is difficult to pin an ethics violation on the ones who do not like the shackles but are powerless to remove them. Some do argue that this inability causes physicians to violate the principle of beneficence.[77] However, promoting the well-being of their patients within the boundaries of the law limits their ability to exercise beneficence. For physicians to fulfill the principle of beneficence to the fullest capacity, they must have an influence on law. Protocols and assessments on flight risks made solely by the officers and law enforcement currently undermine the physician’s expertise. These decisions do not consider the health and well-being of the pregnant woman. As a result, law supersedes the influence of medicine and health care. CONCLUSION People expect physicians to uphold the four major principles of bioethics. However, their inability to override restraints compromises their ability to exercise beneficence. Although pledging to enforce these ethical principles, physicians have little opportunity to influence anti-shackling legislation. Instead of being included in conversations regarding medical complexities, legislation silences their voices. Policies must include the physician's voice as they affect their ability to treat patients. Officers should not dismiss a physician's request to remove shackles from a woman if they are causing health complications. A woman's labor should not harm her or her fetus because the officer will not remove her shackles.[78] A federal law could end shackling pregnant incarcerated people. Because other options are available to ensure the safety of the public and the prisoner, there is no ethical justification for shackling pregnant prisoners. An incarcerated person is a human being and must be treated with dignity and respect. To safeguard the well-being of incarcerated women and the public, it is essential for advocates of individual rights to join forces with medical professionals to establish an all-encompassing solution. - [1] Ferszt, G. G., Palmer, M., & McGrane, C. (2018). Where does your state stand on shackling of Pregnant Incarcerated Women? Nursing for Women’s Health, 22(1), 17–23. https://doi.org/10.1016/j.nwh.2017.12.005 [2] S983A, 2015-2016 Regular Sessions (N.Y. 2015). https://legislation.nysenate.gov/pdf/bills/2015/S983A [3] Chris DiNardo, Pregnancy in Confinement, Anti-Shackling Laws and the “Extraordinary Circumstances” Loophole, 25 Duke Journal of Gender Law & Policy 271-295 (2018) https://scholarship.law.duke.edu/djglp/vol25/iss2/5 [4] Chris DiNardo (2018) [5] U.S. Bureau of Justice Statistics. 1980. " Prisoners in 1980 – Statistical Tables”. Retrieved April 20, 2023 (https://bjs.ojp.gov/content/pub/pdf/p80.pdf). [6] U.S. Bureau of Justice Statistics. 2022. " Prisoners in 2021 – Statistical Tables”. Retrieved April 20, 2023 (https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/p21st.pdf). [7] U.S. Bureau of Justice Statistics (1980) [8] Sufrin C, Jones RK, Mosher WD, Beal L. Pregnancy Prevalence and Outcomes in U.S. Jails. Obstet Gynecol. 2020;135(5):1177-1183. doi:10.1097/AOG.0000000000003834 [9] Kramer, C., Thomas, K., Patil, A., Hayes, C. M., & Sufrin, C. B. (2022). Shackling and pregnancy care policies in US prisons and jails. Maternal and Child Health Journal, 27(1), 186–196. https://doi.org/10.1007/s10995-022-03526-y [10] House, K. T., Kelley, S., Sontag, D. N., & King, L. P. (2021). Ending restraint of incarcerated individuals giving birth. AMA Journal of Ethics, 23(4). https://doi.org/10.1001/amajethics.2021.364 [11] Goshin, L. S., Sissoko, D. R., Neumann, G., Sufrin, C., & Byrnes, L. (2019). Perinatal nurses’ experiences with and knowledge of the care of incarcerated women during pregnancy and the postpartum period. Journal of Obstetric, Gynecologic &amp; Neonatal Nursing, 48(1), 27–36. https://doi.org/10.1016/j.jogn.2018.11.002 [12] Shackling and separation: Motherhood in prison. (2013). 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Introduction The Uluru Statement from the Heart (2017) offers an opportunity for the nation to cement the foundation for prosperous Indigenous futures and meaningful reconciliation between Indigenous and non-Indigenous peoples. In this article, we discuss the theme of uniformity in relation to the “From the Heart” campaign which seeks to enact the Uluru Statement by establishing a constitutionally enshrined First Nations’ Voice to Parliament via a referendum. It is important however that we first clarify our use of the word uniform as we do not wish to suggest that all supporters of the Uluru Statement from the Heart are homogenous in their views or positioning. Far from it, the campaign aims to generate support from all walks of life, and with this, it naturally conjures diverse opinions, and at times disagreement (Pearson). Whilst unification corresponds to different persons coming together to form a collective whole – and the From the Heart Campaign can certainly be characterised in this way – uniformity refers to the uncompromising stance needed to enact the reform proposed in the Statement. In this article, we discuss how a constitutionally enshrined First Nations’ Voice to Parliament is the heart of the Uluru Statement and how the push towards a referendum requires not just a unified and united response, but one that is uniformed in its resolve – that is unwavering, steadfast, and determined in delivering its vision of a constitutionally enshrined First Nations’ Voice to Parliament. We therefore consider how images, symbols, icons, and material objects – both digital and tangible – are used to unite the campaigns’ supporters by presenting a uniformed front that advocates for constitutional reform. The Heart as Uniform and Icon Bleiker argues that icons, particularly within the digital space, are effective means of communication due to their ability to quickly disseminate messages in succinct and memorising ways that are relevant and responsive to its users’ needs (Petray; Carlson et al. ‘They Got Filters’; Fredericks and Bradfield ‘Disrupting the Colonial’). The ability of digital media to spread messages over vast distances and in ways that compress time and space, however, also means that the icons communicated through media such as memes (Blackmore; Petray; Fredericks and Bradfield ‘Co-Designing Change’) are in danger of becoming fleeting, empty, or meaningless (Fredericks and Bradfield ‘Disrupting the Colonial’; Petray; Carlson and Frazer ‘Indigenous activism’). Bleiker (9) warns that “when images are produced and circulated with ever greater speed and reach, icons can emerge in a short period. But this very proliferation of images can also lead to a situation where icons are short-lived and soon become superseded from their original setting”. Due to the fluid and often fickle nature of online culture where symbols and images are quickly adopted, transformed, repurposed, disposed, and replaced, icons are most powerful when they reflect a uniformed message, for uniforms demonstrate stability, endurance, and longevity. Uniforms therefore share some affiliation with icons in their ability to transmit messages of social significance. In their sociological study of uniforms, Joseph and Alex (719) argue that the uniform is viewed as a device to resolve certain dilemmas of complex organizations – namely, to define their boundaries, to assure that members will conform to their goals, and to eliminate conflicts in the status sets of their members. The uniform serves several functions: it acts as a totem, reveals and conceals statuses, certifies legitimacy, and suppresses individuality. The interaction of these components and the acceptance or rejection of the uniform and its associated status by the wearer are described. The use of hearts during the Uluru Statement from the Heart campaign can be likened to icons that convey uniformed messages relating to the need for constitutional reform and the creation of a First Nations’ Voice to Parliament. Repeated imagery of hearts, particularly in the colours of the Aboriginal flag – black, red, and yellow – alongside images of Uluru – an unmistakable icon of Aboriginality – has the potential to provoke political and social discussion amongst those who witness them. Online media have provided fora where information and support for the campaign has been shared, creating some uniformity amongst diverse audiences (Fredericks and Bradfield ‘Seeking to be Heard’; ‘More than a thought’). Emoticons, symbols, and hashtags have formed a type of digital uniform that has congealed ideas and helped centralise messages (Grieve-Williams), in this case in relation to the importance of the constitutional enshrinement of a First Nations’ Voice to Parliament. A heart also describes a centralised location that drives action or is seen to represent the underlying ethos of a community, movement, or object. In terms of physiology, the heart is located at the centre of a body and sustains life by pumping blood throughout the cardiovascular system. Similarly, Uluru is physically located in Central Australia, with many considering it as symbolling the geographical and spiritual heart of the nation. Whilst Uluru will always remain a part of the sacred grounds of the Anangu People (Schultz), its iconography resonates with Indigenous and non-Indigenous peoples throughout the nation, acting as a beacon for Indigenous rights and sovereignty. For the Anangu People, Uluru is a site of conflict resolution and great power (Anandakugan), making it an appropriate icon of reconciliation, Makarrata, and healing relationships between Indigenous and non-Indigenous peoples. Wearing Our Hearts on Our Sleeves Amongst other things, jewelry, art, and material objects function as communicative tools which present agreed-upon symbols and codes that represent messages that are collectively decided upon by a particular social group (Geertz; Shaw). Writing on art as a cultural system, Geertz (1488) famously observed how “it is out of participation in the general system of symbolic forms we call culture that participation in the particular we call art, which is in fact but a sector of it, is possible. A theory of art is thus at the same time a theory of culture, not an autonomous enterprise”. Langley writes on how human societies have used beads in jewelry to disseminate social information for at least 100,000 years. Throughout history, jewelry and fashion accessories have been used as visual representations of uniformity amongst activists and protestors (Gulliver). These icons aim to communicate an unwavering front which at times of protest or social upheaval often counter the icons and uniforms of opposing camps, whether the police force, military, or political rivals. The umbrella movement in Hong Kong is one visually striking example of uniformity and civil disobedience where pro-democracy messages were communicated via yellow umbrellas that contrasted the pro-establishment camp who wore blue (Radio Free Asia). The t-shirt for the Uluru campaign depicts an image of Uluru which visibly sits on the land but is also embedded below the surface of Country. Both parts collectively form the shape of a red heart. The shirt reads “We Support the Uluru Statement”, emitting the words “From the Heart”. This clever form of marketing invokes a sense of communitas amongst those who can collectively interpolate and understand its meaning (Turner). It is the shared knowledge that the statement comes “from the heart” (even though it is not written on the t-shirt) amongst those who form the collective “we” that gives the shirt a function that can be likened to a uniform. It is a visual embodiment of the Statement that seeks to “certify its legitimacy” (Joseph and Alex). Brooches and jewelry have also been used as means to provoke conversation and add social or political commentary during public engagements; often in satirical and/or ironic ways (Shaw). Former US Secretary of State Madeleine Albright, for example, famously wore a brooch of a snake after being called an “unparalleled serpent” by Iraqi state media under the Saddam Hussein regime (Becker). For Albright, brooches complemented her political agenda and became part of her “diplomatic arsenal” (Becker), which she described as effective mnemic communication that helped generate greater understandings amongst the wider public (Albright). Whilst an expression of her individuality, the jewelry delivers a uniformed statement and commentary that defines boundaries, assures goals, and seeks to eliminate conflicts or ambiguity in the messages she seeks to deliver. In this respect, it functions as part of her uniform. Similarly, when Lady Hale, the president of the UK Supreme Court, claimed Boris Johnson’s decision to prorogue parliament was unlawful in 2019, she strategically wore a spider brooch (Cochrane and Belam). The imagery was quickly seized upon by activists who interpreted it as a symbol of the government’s dysfunction, or venomous nature, and printed the design on t-shirts. The shirts sold out in less than 24 hours and presented a uniformed front that both critiqued the government and raised money for a homeless shelter (Butchart). A Gift Worth Sharing The Uluru Statement was gifted to the Australian people to affirm the campaign as one for and led by the Australian public (Synott; Appleby and Davis). The decision to disseminate the outcomes of the National Convention via a poetic and concise statement, rather than a formalised petition or legal declaration, emphasises its intent to remain accessible to the public (Davis ‘The Long Road’). The fact that it was gifted to the public instead of being “presented” or “submitted” to government signifies that it is a gesture of good faith that invites the Australian people to join the movement, whilst also placing onus on the public to accept or reject the gift that is offered and placing pressure on the government to call a referendum (Mayor). In the spirit of the Uluru Statement’s gifting, heart icons and paraphernalia are often exchanged amongst its supporters with aim of building awareness and provoking conversation. One of the authors of this paper, Professor Bronwyn Fredericks, is known for having accumulated an extensive collection of heart objects, many of which have been gifted to her. These objects range from brooches, earrings, necklaces, and other forms of jewelry to clothes, fabrics, and novelty glasses. Although the medium varies, the heart iconography and messages remain uniform. The Uluru from the Heart Campaign, however, has suffered many arrhythmias, at times speeding up whilst at others becoming really slow. After the reforms were presented to the Australian Government in 2017, the then prime minister Malcom Turnbull rejected them on account that an Indigenous Voice to Parliament was undesirable, too “radical” in nature, and unlikely to pass a referendum (Wahlquist; Brennan). A media release from the government published on 26 October 2017 declared that “the Government does not believe such a radical change to our constitution’s representative institutions has any realistic prospect of being supported by a majority of Australians in a majority of States” (Prime Minister et al.). The chief executive of the Victorian Community Controlled Health Organisation, Jill Gallagher, has commented that many politicians were too preemptive in their dismissal of the reforms; and in doing so, prevented the public from engaging in the critical discussion that is needed before a referendum (Brennan). Public discussion is now increasing after the Albanese-led Labor government announced that a referendum will be held during their first term of their government, which was formed in 2022 (Kunc). Turnbull’s rejection was also premised on the notion that the Uluru Statement, and its call for a First Nations Voice to Parliament, was too uniform in its “take it or leave it” positioning, which the government was unwilling to commit to (Prime Minister et al.). After years of having reforms and recommendations diluted or ignored by governments, and political promises and commitments dismissed (see Fredericks for an example), the Referendum Council were unapologetic in their stance that the Statement remain untouched and unmanipulated by politicians and political agendas (Referendum Council). The proposed reforms are the manifestation of Indigenous peoples’ will and desire as expressed during the regional dialogue (Anderson, Davis, and Pearson; Davis and Williams). The Final Report of the Referendum Council reads that “it is the Council’s view that there is no practical purpose to suggesting changes to the Constitution unless they are what Aboriginal and Torres Strait Islander peoples want” (Referendum Council, 5). It must be remembered that the Referendum Council was established by Malcom Turnbull in 2015, tasked with finding out what Indigenous peoples wanted to see in constitutional reform. Whilst the Turnbull government were willing to provide a forum in which Indigenous views on constitutional reform could be expressed, they were unwilling to honour their aspirations. After sharing deeply personal and at times traumatic stories of colonial harm and violence at the dialogues (Appleby and Davis), along with entertaining the idea of having greater input into parliamentary discussions, the flat-out rejection by the government was heartbreaking. Aboriginal lawyer, activist, and academic Noel Pearson spoke of the anguish caused by Malcolm Turnbull’s rejection in a Radio National interview, describing him as having “broken the hearts of the First Nations people of this country” (Brennan). Constitutional lawyer Megan Davis was with a young Indigenous law student who had participated in the regional dialogues when the interview aired (Davis ‘The Long Road’). Like many, this was the first she had heard of the Statement’s rejection. Davis recalls how “I could see her faith in the rule of law, fairness and equality – all the important characteristics of our public law system – drain from her face” (Davis, 2019). The impact of Turnbull’s rejection was described by some as “mean-spirited bastardry” (Wahlquist) and is articulated in a cartoon depicting a heart being surgically removed from Uluru (Grant). We wear heart icons as uniforms not only in support of the campaign but as a reminder of its fragility. Whilst hearts are prone to break, like all muscles it is through their tearing and growth that they become stronger. A Voice to Parliament The imagery of hearts aims to generate wider public recognition of the need to recognise First Nations’ peoples within Australia’s constitution via Voice, Truth, Treaty, and in that order (Davis and Williams; Fredericks and Bradfield ‘More than a Thought’; Larkin and Galloway). The need for a visible and uniformed campaign towards constitutional reform, however, is challenged when politicians including the former Indigenous Affairs minister Ken Wyatt (Anderson et al.) or former Greens and now independent senator Lidia Thorpe (Larkin and Maguire) question the premise that reforms such as a constitutionally enshrined First Nations’ Voice to Parliament are representative of Indigenous peoples’ will. Thorpe’s objection is based on the premise that Treaty should be sought first. Our criticism is not placed on their oppositional stance but rather on their false characterisation that it does not reflect the desire of the majority of Aboriginal and Torres Strait Islander peoples as expressed through the Uluru Dialogues. Despite seven delegates walking out on the convention in protest that it would hinder Indigenous sovereignty via a treaty (Hobbs), the 13 regional dialogues conducted by the Referendum Council and led by Indigenous leaders such as Megan Davis, Pat Anderson, and numerous others, as well as delegates at Uluru, clearly expressed a near unanimous and uniformed decision to establish an Indigenous representative body that was protected by the constitutional enshrinement (Davis ‘The Long Road’; Davis and Williams; Fredericks and Bradfield ‘We Don’t Want to’). Subsequent polling has shown strong continued majority support amongst the public for a constitutionally enshrined voice (Centre for Governance and Public Policy; Ford and Blumer; Zillman, Wellauer and Brennan; Reconciliation Australia). Past reconciliation movements have centred around the notion of restoring relationships between Indigenous and non-Indigenous peoples (Reynolds). This is problematic as colonisation in Australia was, and in many cases still is, dependent on the denial of Indigenous peoples and cultures, which was accompanied by epistemic and physical acts of violence (Moreton-Robinson; Lee, Richardson, and Ross). In 1999, then prime minister John Howard held a referendum on whether Australia should become a republic. Attached to the question was whether Aboriginal and Torres Strait Islander people should be recognised in the constitution’s preamble (Pearson, Davis, and Appleby ‘The Uluru Statement’). Despite this being rejected by Indigenous land councils and elected representatives, on account of its symbolism, Howard proceeded with the referendum which ultimately failed (Davis ‘The Status Quo’). The Recognise campaign ran from 2012 to 2017 and sought public awareness of questions relating to constitutional recognition of Indigenous peoples. This too was rejected by Indigenous communities (Maddison). Online polling conducted by Indigenous-controlled media forum IndigenousX showed that only 32.3% of its respondents supported the campaign, with many criticising what they saw as a top-down approach tailored towards the appeasement of non-Indigenous sensibilities (Latimore; Fredericks and Bradfield ‘Disrupting the Colonial’). Reconciliation Australia, the organisation that led the campaign, however, stated that it was successful in generating public awareness, which increased from 30% to 75% nationally (Reconciliation Australia). Conclusion What sets the Uluru campaign apart from its predecessors such as Recognise is that it is a grassroots initiative that emerged out of Indigenous-led consultations and dialogues with community members and stakeholders. It was conceived with awareness of the “limitations of the political class” (Davis, ‘The Long Road’) – illustrated by the ineptitude of Turnbull and other critics – and consciously spoke to the hearts of the Australian public. To ensure that different Indigenous perspectives and interest groups were represented during the National Conference, 60% of attendees were traditional owners, 20% came from Aboriginal community organisations, and 20% were individual community members (Lee, Richardson, and Ross; Davis ‘The Long Road'). The reforms of the Uluru Statement, including a First Nations’ Voice to Parliament, aim to create a framework and functioning mechanism that will help build and repair partnerships through which relationships between Indigenous and non-Indigenous peoples can improve, whilst “gaps” across a range of social outcomes can be redressed by policies led and informed by Indigenous people in accordance with national (Coalition of Peaks) and international (Synott ‘The Universal Declaration’) charters. Whilst Indigenous views are diverse, what remains uniform amongst them is that Aboriginal and Torres Strait Islander strength and power, which has always come from their voices, “are the most powerful of all” when they are together (Davis, ‘Together Our Voices’). Despite the campaigns’ critics and setbacks, our hearts continue to beat as one and our uniformed advance towards referendum remains steadfast. References Albright, Madlelaine. Read My Pins: Stories from a Diplomat's Jewel Box. 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