Статті в журналах з теми "Insurance (Widows')"

This paper is a preliminary attempt to examine demographic and economic aspects of widowhood in 19th-century Montreal and the ways working-class widows in particular could survive. Although men and women lost spouses in roughly equal proportions, widows remarried much less frequently than widowers. In the reconstruction of their family economy that followed the loss of the main wage earner, some of these women sought work themselves, mostly in the sewing trades or as domestics or washerwomen. A few had already been involved in small shops, and some used their dower, inheritance, or insurance policies to set up a shop, a saloon, or a boarding-house. Children were the most valuable asset of a widow, and they were more likely to work and to stay at home through their teens and twenties than in father-headed families. Additional strategies, including sharing housing with other families, raising animals, or trading on the streets, were drawn upon; they established an economy of makeshift arrangements that characterized the world of many working-class widows.

The aim of this article is to explore the economic status and the quality of life of widows in the Nordic past, based on the evidence contained in retirement contracts. Analysis of these contracts also shows the ways in which, and when, land and the authority invested in the headship of the household were transferred between generations in the Nordic countryside. After the early eighteenth century, retirement contracts became more detailed but these should be viewed not as a sign of tension between the retirees and their successors but as a family insurance strategy designed to protect the interests of younger siblings of the heir and his or her old parents, particularly if there was a danger of the property being acquired by a non-relative. Both the retirement contracts made by couples and those made by a widow alone generally guaranteed them an adequate standard of living in retirement. Widows were assured of an adequately heated room of their own, more generous provision of food than was available to many families, clothing and the right to continue to work, for example at spinning and milking, but to be excused heavy labour. However, when the land was to be retained by the family, in many cases there was no intention of establishing a separate household.

This study is a part of a larger research project on the coping of widows. The study reported here investigated the effects of widowhood-related needs along the life-cycle and variables hypothesized to be related to it, using a multivariate hierarchical regression model. The participants were 246 widows who were sampled by stratified-random sampling, according to age groups, from the population of social insurance recipient Israeli urban widows. The findings indicate that personal resource variables—age and locus of control orientation—were directly related to the four need constellations studied. Two of the three social support variables studied—size of the network and likelihood of seeking help from network members—were related to the needs only when interacting with the personal variables. The findings support previous research regarding the role of locus of control as a support mobilizer, and point to the importance of including personal as well as environmental resources, such as social support, in the study of bereavement and coping.

In this paper, we examine whether access to treatment for major morbidity conditions is determined by the social class of the person who needs treatment. Secondly, we assess whether health insurance coverage and the presence of a PHC have any significant impact on the utilisation of health services, either public or private, for treatment and, more importantly, whether the presence of health insurance and PHC modify the treatment use behaviour for the two excluded communities of interest namely Indigenous communities and older widows using data from two rounds (2005 and 2012) of the nationally representative India Human Development Survey (IHDS). We estimated a multilevel mixed effects model with treatment for major morbidity as the outcome variable and social groups, older widows, the presence of a PHC and the survey wave as the main explanatory variables. The results confirmed access to treatment for major morbidity was affected by social class with Indigenous communities and older widows less likely to access treatment. Health insurance coverage did not have an effect that was large enough to induce a positive change in the likelihood of accessing treatment. The presence of a functional PHC increased the likelihood of treatment for all social groups except Indigenous communities. This is not surprising as Indigenous communities generally live in locations where the terrain is more challenging and decentralised healthcare up to the PHC might not work as effectively as it does for others. The social class to which one belongs has a significant impact on the ability of a person to access healthcare. Efforts to address inequity needs to take this into account and design interventions that are decentralised and planned with the involvement of local communities to be effective. Merely addressing one or two barriers to access in an isolated fashion will not lead to equitable access.

We combine quasi-experimental variation in spousal death and age eligibility for survivors benefits using US tax records to study the effects on American households’ labor supply and the design of social security’s survivors insurance. Benefit eligibility at the exact age of 60 induces sharp reductions in the labor supply of newly widowed households, highlighting the value of survivors benefits and the liquidity they provide following the shock. Among eligible widows, the spousal death event induces no increases in labor supply, suggesting little residual need to self-insure. Using theory, we underscore the program’s protective insurance role and its high valuation among survivors. (JEL D12, D91, G22, G51, H55, J16, J22)

Past studies of the economic status of widowed and divorced elderly women have focused mostly on the timing, incidence, and duration of their poverty but have neglected the analysis of the correlates of their economic status. The ordinary least squares regression analysis in this article shows that their economic status is commonly associated with such factors as the level of education, work history, and the Social Security primary insurance amount. The article also analyzes the differences between widows and divorcees and between those with substantial work histories and those with less substantial work histories.

They helped every one his neighbor; and every one said to his brother, Be of good courage.—Isaiah 41:6By the end of the nineteenth century most of the economically advanced European nations had adopted some form of public social insurance. In the world’s richest nation, however, widows and the aged, sick, and injured received little support from the state. Without the help of the state, how did American workers and their families survive in the face of sickness, accidents, old age, or the death of the primary earner? The traditional answer is that they survived rather badly, if at all. Social reformers of the early twentieth century and most modern historians argue that voluntarism was a failure, that it was not suited to the needs of an increasingly industrialized, urbanized populace.

AbstractWe analyze the mortality of couples by fitting a multiple state model to a large insurance data set. We find evidence that mortality rates increase after the death of a partner and, in addition, that this phenomenon diminishes over time. This is popularly known as a “broken-heart” effect and we find that it affects widowers more than widows. Remaining lifetimes of joint lives therefore exhibit short-term dependence. We carry out numerical work involving the pricing and valuation of typical contingent assurance contracts and of a joint life and survivor annuity. If insurers ignore dependence, or mis-specify it as long-term dependence, then significant mis-pricing and inappropriate provisioning can result. Detailed numerical results are presented.

Despite the utility of applying mixed methods research to understand complex phenomenon, few studies have applied this approach to health policy and in Africa. This article illustrates the application of mixed methods research to inform health policy in Ghana with the intent of complementarity. Through an exploratory sequential mixed methods research design involving 24 focus group interviews and 417 household surveys, we developed criteria for identifying very poor households for health insurance premium exemptions in Ghana. The qualitative procedures identified communities’ concerns regarding being very poor: food insecurity, lack of seeds to sow, compromised access to education, financial insecurity, and status as unemployed widows with children. The survey findings illustrated the distribution and predictors of poverty in the Kassena-Nankana District. Based on these findings, the authors proposed a four-question survey for the Kassena-Nankana District Health Insurance Scheme to administer to determine extreme poverty. Based on these recommendations, the local government has a unique opportunity to increase the very poor’s access to and utilization of health care services.

Kerala is a state that is incomparable with many other states in India in matters of literacy, employment, social security, health, and many other social welfare initiatives. Social Security is the sum of all government regulations and provisions that aim at enhancing the people’s living conditions, including legislation/acts/laws, regulation, and planning in the fields of old age, wage, unemployment, social exclusion, sickness, and health care, and income security measures such as food security, employment, education and health, housing, social insurance, and social assistance. Financial assistance provided by the Government towards various pension schemes exhibits its concern for the privileged group in society. Various social welfare pension Schemes offered by Govt of Kerala include 1) Agriculture Labour Pension, 2) Indira Gandhi National Old Age Pension, 3) Indira Gandhi Nation Disabled Pension Scheme for Physically & Mentally Challenged Persons, 4) Pension to Unmarried Women above 50 Years and 5) Indira Gandhi National Widow Pension Scheme. Social security protects people living in economic and social distress. It can "protect'' people against a fall in living standards and living conditions through ill-health, unemployment, and accidents, and also "promote" enhanced living conditions, helping the poor to overcome persistent deprivations. There has been a growing demand that the approach to social security programmers and schemes should progressively shift to a rights-based framework and should not be viewed merely from a welfare prism. Welfare scheme aims to support the vulnerable section of society. The present study aims to 1) understand various social welfare schemes adopted by Govt of Kerala, and 2) Assess the benefits and Woes of Widows who avails Indira Gandhi National Widow Pension. The present study is based on data collected from primary and secondary sources and suitable statistical tools will be used to analyse the collected data. The study reveals that even though it is one of the flagship initiatives of the Government of Kerala, it has many flaws. A better understanding of the woes of pension beneficiaries will help in better implementation of the project.

When Adam Smith – author of Wealth of Nations (1776) and Theory of Moral Sentiments (1759) – was elected a professor at the University of Glasgow in 1751, he also joined an annuity ‘scheme’ that was unique for its time. The Scottish Ministers’ Widows’ Fund, as it was known, offered members of the Presbyterian Church as well as the university a choice of levels at which to contribute investment savings, ranging from 2 to 10 percent of their wages. The life-contingent benefits were in the form of a reversionary annuity to a spouse and/or lump sum death benefit to children. This article (i) describes the scheme in financial and actuarial terms, (ii) values Smith's reversionary annuity and (iii) examines the choices made by individual participants. The specific research contribution is to compile the archival data to measure the extent of insurance anti-selection and to demonstrate that debates around choice architecture, default options and auto-enrollment, which infuse the literature in the twenty-first century, were prevalent in the mid eighteenth. For the record, Adam Smith actively contributed at the highest allowed rate, but it wasn't a ‘good’ investment for him, either ex ante or ex post. As for why, one must read the article.

Th e focus of this study is on the retirement of officers of large estates and pension regulations. The pensions have increasingly become part of the career path and employer commitment. At the same time, pensions provided an economic incentive for officers to stay in offi ce, on the other hand, ensured their loyalty to the landlords and their lifelong service. The social side of these measures is also evident, as they imply the provision of care for officers in case of illness or old age. In fact, the insurance also extended to the families of officers, as financial support was available to their surviving widows and orphans, even as the provisions became tighter and more restrictive. I based my analysis on the pension regulations issued by the Károlyi family at different times, and then analysed the evolution of pension payments on the basis of the family’s joint treasury statements. It is clear that the maintenance and payment of pensions was, if not the largest, then a signifi cant investment for the estate government. In later years, the landlords tightened the scope of eligibility precisely on the basis of the size of this expense, until by the second half of the 19th century the landlord had created a pension fund, obliging officers to contribute. Further afield, the employment relationship between large landowners and officers was now a regulated model between worker and employer, established and maintained by the estate government under private law.

In this article, we use an advanced microsimulation model to study the distributional effects of the reformed Norwegian pension system with a particular focus on gender equality. The reformed Norwegian system is based on the notional defined contribution (NDC)-formula with fixed contribution/accrual rates over the active life-phase and with accumulated pension wealth being transformed into an annuity upon retirement. A number of redistributive components are built into the system: a unisex annuity divisor, a ceiling on annual earnings, generous child credits, a possibility for widows/widowers to inherit pension rights from a deceased spouse, a targeted guarantee pensions with higher benefit rates to single pensioners compared to married/cohabitating pensioners, and finally a tax system that is particularly progressive in its treatment of pensioners and pension income. Taking complete actuarial fairness as the point of departure, we conduct a stepwise analysis to investigate how these different components of the National Insurance pension system impact on the gender gap in pensions and on general (Gini) inequality in the distribution of pension income within a cohort of pensioners. Our analysis concentrates on one birth cohort – individuals born in 1963 – and we study three different outcomes: the distribution of annual pensions early in retirement (at age 70), the distribution of the total sum of pension benefits received over retirement, and the distribution of the average annual pension benefits received over the retirement phase. In addition, we look at three alternative income concepts. These are personal income, equivalised household income, and finally an original income concept developed for this study: personal income adjusted for the economies of scale enjoyed by couple households.

One of the most important objectives of development planning in India is poverty alleviation. Various approaches to alleviate poverty have been undertaken by the Government of India. The agenda for financial inclusion involves creating specific environment through which the poor across the country have open, safe, secure and affordable access to various financial products. Microfinanceis one such strategy for inclusive growth, which can be explained as provision of financial services such as loans, savings, insurance, financial literacy, etc. Those who promote the concept of microfinance as an inclusive development tool believe that such unrestricted access will help in poverty alleviation and uniform growth. Various steps have been taken in this direction since Independence by Government, Financial Institutions, Microfinance Institutions, and NGOs which include SHG-Bank Linkage Programme as one such initiative.Microfinance in J&K is still in its initial stage; from the formal sources like Public Sector Commercial Banks, District Cooperative Societies, Regional Rural Banks and Private Sector Commercial Banks, which provide microfinance services to few thousand SHGs formed in theState and it is in this direction that the present study has been undertaken in Kashmir. Jammu and Kashmir accounts for 1.04 percent of the total population of India but its contribution to the national income is mere 0.7 percent. In this backdrop, micro finance has emerged as one of the tools in Jammu and Kashmir State for poverty mitigation against economic backwardness and political turmoil being witnessed over two decades now. The study attempts to assess the role of microfinance in Kashmir with emphasis on analyzing the performance of Self Help Groups in terms of growth, employment, improvement in living standards and so on. The study shows that microfinance has played a positive role in the valley. In Jammu and Kashmir, microfinance plays an important role in women empowerment of the poor and widows but a lot more needs to be done in this direction

Abstract A search of the forensic economic literature fails to disclose any discussion of the proper methodology for valuing the loss of survivor benefits in a defined benefit retirement plan when a wrongful death event occurs. A first approximation, which might be used to calculate a widow's loss of retirement benefits resulting from the wrongful death of her spouse, is the retiree's benefit payments minus his personal consumption (or maintenance allowance) minus the widow's survivor benefit, if there is one. Economic analysis reveals that while the actual payment to the retiree includes the spouse's benefit if the retiree does survive, it fails to include the spouse's expected survivor benefit in the event that the retiree does not survive. This omitted benefit is significant and should be included in valuing the spouse's expected benefit from the total retirement plan and the widow's loss. Legal analysis reveals that the widow's benefit is essentially the same as proceeds from privately purchased life insurance, which in common law would be considered a collateral source and protected from disclosure at trial or offset against an award. However, tort reform efforts over the past 30 years have led many states to modify or even repeal the traditional collateral source rules. Therefore, the widow's benefit may or may not be considered in valuing the loss of retirement, depending on the jurisdiction, the cause of death (e.g., medical malpractice), and even the interpretation of the collateral source rules by the trial judge. If it is determined that the collateral source rule excludes introduction of the survivor benefit, a reasonable alternative for the plaintiff would be to claim the loss as the retiree's gross benefit minus his personal consumption weighted by the joint probability of survival.

The judgment in Maqubela v The Master leaves room to revisit some established norms in private law that define under what circumstances a subject may be disqualified and found to be unworthy to benefit financially from his/her behaviour against another – including the deceased. The deceased Maqubela AJ took out a significant life policy (R20 million) on his own life two weeks before his death. At the time of his death he was still married in community of property to his wife but was seriously contemplating divorce. His wife was not only aware of the significant life insurance that had just been taken out, but also of his contemplation of divorce. She was much annoyed about his multiple adulterous affairs over many years and even mentioned as much to the minister of justice the day before his sudden death in a deliberate way so as to discredit him in the eyes of the minister. After the sudden demise of the insured life under suspicious circumstances, the widow was originally found guilty of premeditated murder of her husband and of the fraudulent production of a document presented to the master of the high court as the last will of the deceased that was proven to be a falsification in every respect. For the second offence she was sentenced by the court of first instance to prison for three years. On appeal the supreme court of appeal upheld her appeal regarding the conviction on the murder charge, but the other conviction remained intact. In the civil case under discussion the court had to decide whether the widow as claimant was entitled to half of the common estate with inclusion of the R20 million insurance benefit as well as to lay claim as beneficiary under the norms of intestate succession to the widow’s part of the deceased’s estate. It is submitted that the well-known “bloedige hand” rule, which excludes the person responsible for the death of the deceased from benefiting under the law of succession from the estate of the deceased, is merely an example of the underlying broader principle encapsulated in the text from Roman law “nemo ex suo delicto meliorem suam condicionem facere potest” (D 50 17 134 1): “No one is allowed to improve his own condition by his own wrongdoing” or “no woman should profit from her own wrong”. This principle can be found not merely in every civil law legal system but is also recognized in all common-law jurisdictions as can be deduced inter alia from the judgment in Karen L Postlewait v Ohio Valley Medical Center, Inc, a Corporation, et al, and Ohio Valley Medical Center, Inc, a Corporation, and The Estate of Robert L Postlewait, where Maynard JA on 8 Dec 2003 in the appeal to the supreme court of appeal of West Virginia held: “However, the majority equally fails to consider the possibility that Mrs Postlewait’s misconduct in pushing her husband off the porch played a significant role in her husband’s death. Clearly, the chain of events that led to Mr Postlewait’s death were directly put in motion by Mrs Postlewait. Mrs Postlewait filed a medical malpractice/wrongful death action against her husband’s medical providers and successfully negotiated a settlement netting herself more than half a million dollars! Given these circumstances, I am unable to find that Mrs Postlewait is entitled to profit from her husband’s death. Accordingly, I respectfully dissent” (31406). Clearly the claim of Mrs Postlewait to the resulting benefit of more than half a million dollars was unrelated to any claim founded on the law of succession. The quoted Latin maxim is a venerable old maxim in equity and should have been at the root of the judgment in the Maqubela case where there is room to suspect that the old adage still applies: the love of money is the root of all evil. In light of the proven circumstances surrounding the demise of the late acting judge and the fraudulent attempt by his widow Maqubela to pass herself off as the primary testamentary beneficiary of his estate, reasonableness and equity prescribed that the erstwhile wife may neither lay claim to the significantly enhanced half of the common estate thanks to the life insurance benefit nor claim a child’s share as the widow’s portion of the estate of the deceased as governed by the law of intestate succession. Her conduct regarding the proven crime of the falsification of the will should have excluded her as unworthy beneficiary from any form of financial benefit from her marriage to the deceased including the claim to half of the common estate. Matthaeus, the most prominent Old Authority on the implications of this principle in Roman-Dutch law, clearly states in Zinspreuken 6:4 that the disqualified unworthy spouse is also excluded from benefitting from the enhanced half of the common estate under the guise of the default principle of a rightful holder of half of the common estate. Modern Dutch law applies the same underlying principle to prevent unjustified enrichment of the wrongdoer. The principle of legal certainty in South African law did not benefit by this judgment. Not merely does it ignore the standing principles of Roman-Dutch law, but it also compares unfavourably with the outcome in related scenarios in comparable other legal systems.

This research is based on the problems in the distribution of common property. First, the emerging of differences in the system of distributing of common property in talak raj'i and talak ba'in. Second, the occurrence of expansion in terms of income during marriage such as the existence of insurance. Third, the existence of the agreement in marriage before the joint property is shared. The result of the research shows that in the sociology perspective of Islamic law the effort to share the common property: first, in the case of divorce because the situation is still in the iddah period of talak raj'i, property should not be divided because it minimizes the possibility of reunification. Unlike the case if talak ba'in, property should be devidedd soon because it certainly will not be reunited. Second, in response to the expansion of common property such as the existence of insurance money, all Indonesian Judge agreed that all property acquired during marriage is related to Taspen Insurance, Asabri Fund, Labor Insurance, Traffic Accident Fund, Passenger Accident Fund, Life Insurance Fund, Property of Luggage, Credit that has not paid off. Third, the agreement in marriage greatly affects the distribution of common property given the existence of Article 45, 52, and 97 Compilation of Islamic Law "divorced or divorced widow respectively entitled to two joint property as long as not specified in the marriage agreement.

China implements different social endowment insurance policies between urban and rural areas which may cause differences in investment decisions of urban and rural households. Based on the 2013 to 2017 China Household Finance Survey (CHFS) data and the two-way fixed effect panel model, this study aims to investigate the effect of social endowment insurance on the inequality of household portfolio between China’s urban and rural areas and the moderating effect of financial literacy on the relationship between social endowment insurance and household portfolio. The empirical results show that (1) the participation of social endowment insurance is positively related to the possibility of holding risky financial assets and the ratio of risky financial assets; (2) the effect of social endowment insurance is strong and significant in urban areas but weak and not significant in rural areas; (3) the moderating effect of financial literacy on the relationship between social endowment insurance and household portfolio widens the gap of the household portfolio between the urban and rural areas. This paper indicates that the social endowment insurance would affect the household portfolio decisions positively and the financial literacy positively moderates the relationship between social endowment insurance and household portfolio, which just can be applied to urban households. This paper provides evidence of the inequality between the urban and rural households in China and discusses the possible causes of the urban-rural income gap.

Willingness and ability to pay for insurance that would cover primary healthcare services has not been evaluated consistently in different African communities. We conducted a cross-sectional community health survey and examined willingness and ability to pay in 3676 adults in seven communities in four countries: Nigeria, Tanzania, Uganda and Kenya. We used an open-ended contingency valuation method to estimate willingness to pay and examined ability to pay indirectly by calculating the ratio of healthcare expenditure to total household income. Slightly more than three quarters (78.8%) of participants were willing to pay for a health insurance scheme, and just a little above half (54.7%) were willing to pay for all household members. Across sites, median amount willing to pay was $2 per person per month. A little above half (57.6%) of households in Nigeria were able to pay the premium. The main predictors of likelihood of being unwilling to pay for the health insurance scheme were increasing age [aOR 0.99 (95% CI 0.98, 1.00)], being female [0.68 (0.51, 0.92], single [0.32 (0.21, 0.49)], unemployment [0.54 (0.34, 0.85)], being enrolled in another health insurance scheme [0.45 (0.28, 0.74)] and spending more on healthcare [1.00 (0.99, 1.00)]. But being widow [2.31 (1.30, 4.10)] and those with primary and secondary education [2.23 (1.54, 3.22)] had increased likelihood of being willing to pay for health insurance scheme. Retired respondents [adjusted mean difference $-3.79 (-7.56, -0.02)], those with primary or secondary education [$-3.05 (-5.42, -0.68)] and those with high healthcare expenditure [$0.02 (0.00, 0.04)] predicted amount willing to pay for health insurance scheme. The willingness to pay for health insurance scheme is high among the seven communities studied in East and West Africa with socio-demography, economic and healthcare cost as main predictive factors.

Introduction. Attempts to use health insurance in Low and Middle Income Countries (LMICs) are recognized as a powerful tool in achieving Universal Health Coverage (UHC). However, continuous enrolment onto health insurance schemes and utilization of healthcare in these countries remain problematic due to varying factors. Empirical evidence on the influence of household sociodemographic factors on enrolment and subsequent utilization of healthcare is rare. This paper sought to examine how household profile influences the National Health Insurance Scheme (NHIS) status and use of healthcare in a municipality of Ghana. Methods. A cross-sectional design with quantitative methods was conducted among a total of 380 respondents, selected through a multistage cluster sampling. Data were collected using a semistructured questionnaire. Data were analysed using descriptive and multiple logistics regression at 95% CI using STATA 14. Results. Overall, 57.9% of respondents were males, and average age was 34 years. Households’ profiles such as age, gender, education, marital status, ethnicity, and religion were key predictors of NHIS active membership. Compared with other age groups, 38–47 years (AOR 0.06) and 58 years and above (AOR = 0.01), widow, divorced families, Muslims, and minority ethnic groups were less likely to have NHIS active membership. However, females (AOR = 3.92), married couples (AOR = 48.9), and people educated at tertiary level consistently had their NHIS active. Proximate factors such as education, marital status, place of residence, and NHIS status were predictors of healthcare utilization. Conclusion. The study concludes that households’ proximate factors influence the uptake of NHIS policy and subsequent utilization of healthcare. Vulnerable population such as elderly, minority ethnic, and religious groups were less likely to renew their NHIS policy. The NHIS policy should revise the exemption bracket to wholly cover vulnerable groups such as minority ethnic and religious groups and elderly people at retiring age of 60 years.

Large out-of-pocket spending on medical issues can expose households to catastrophic health expenditure, which can result in poverty. This study aimed to estimate the extent of catastrophic health expenditure among households in Benin and to assess the association between household catastrophic health expenditure and household characteristics. We used the 2017 nationally representative household survey for Benin, the “Analyse Globale de la Vulnérabilité et de la Sécurité Alimentaire,” and a logit model to assess the association between catastrophic health expenditure and demographic and socioeconomic household characteristics. The results suggested that 25.49% of households spent 40% of their resources on healthcare. Moreover, households headed by women, the poorest households, those living in rural areas, those headed by a widow, and households with children and elderly members were identified as vulnerable groups that require protection against catastrophic health expenditure. The policy implication of these results is that healthcare financing strategies in Benin should concentrate on finding ways to reduce both out-of-pocket payments and the probability of catastrophic health expenditure. The health insurance policy that is under development in Benin is an opportunity to protect vulnerable groups.

ObjectiveTo investigate the extent and associations of patient/diagnostic delay and other potential factors with catastrophic health expenditure (CHE) for tuberculosis (TB) care in Chongqing municipality, China.DesignA cross-sectional study.SettingFour counties of Chongqing municipality, China.ParticipantsA total of 1199 patients with active pulmonary TB beyond 16 years and without mental disorders were consecutively recruited in the four counties’ designated TB medical institutions.Outcome measuresThe incidence and intensity of CHE for TB care were described. The association between patients’ ‘sociodemographic and clinical characteristics such as patient delay, diagnostic delay, forms of TB, health insurance status and hospitalisation and CHE were analysed using univariate and multivariate logistic regression.ResultsThe incidence of CHE was 52.8% and out-of-pocket (OOP) payments were 93% of the total costs for TB care. Compared with patients without delay, the incidence and intensity of CHE were higher in patients who had patient delay or diagnostic delay. Patients who experienced patient delay or diagnostic delay, who was a male, elderly (≥60 years), an inhabitant, a peasant, divorced/widow, the New Cooperative Medical Scheme membership had greater risks of incurring CHE for TB care. Having a higher educational level appeared to be a protective factor. However, hospitalisation was not associated with CHE after controlling for other variables.ConclusionThe incidence and intensity of CHE for TB care are high, which provides baseline data about catastrophic costs that TB-related households faced in Chongqing of China. Variety of determinants of CHE implicate that it is essential to take effective measures to promote early seeking care and early diagnosis, improve the actual reimbursement rates of health insurance, especially for outpatients, and need more fine-tuned interventions such as precise poverty alleviation to reduce catastrophic costs of the vulnerable population.

As the pace of medical discovery widens the knowledge-to-practice gap, technologies that enable peer-to-peer crowdsourcing have become increasingly common. Crowdsourcing has the potential to help medical providers collaborate to solve patient-specific problems in real time. We recently conducted the first trial of a mobile, medical crowdsourcing application among healthcare providers in a university hospital setting. In addition to acknowledging the benefits, our participants also raised concerns regarding the potential negative consequences of this emerging technology. In this commentary, we consider the legal and ethical implications of the major findings identified in our previous trial including compliance with the Health Insurance Portability and Accountability Act, patient protections, healthcare provider liability, data collection, data retention, distracted doctoring, and multi-directional anonymous posting. We believe the commentary and recommendations raised here will provide a frame of reference for individual providers, provider groups, and institutions to explore the salient legal and ethical issues before they implement these systems into their workflow.

We investigated the association between social support and negative emotions in Chinese people aged 65 years and over, by comparing those who still had a spouse with those who had been widowed. Data were drawn from the 2018 Chinese Longitudinal Health and Longevity Survey of Elders. The results showed that there were significant differences between those who were widowed and those whose spouse was still alive in terms of the negative emotions of uselessness and loneliness, but not anxiety. The more informal and formal social support (excluding economic support and medical insurance) these older adults had, the fewer negative emotions they felt. These findings provide theoretical and practical insights for scholars who are researching the topic of old age, and also offer practical insights for older adults to maintain their health.

294 Background: Insufficient patient-physician cost communication stems in part from limited physician awareness of actionable interventions when cost issues arise. Oncologists report low awareness of resources to help patients with financial toxicity and often feel underprepared to discuss and navigate this issue. Methods: All oncology fellows (n = 19) at the University of California, Los Angeles were invited to participate in QI project during the fall of 2019. As part of the curriculum, fellows were individually paired with an experienced attending and asked to review a hypothetical case of financial toxicity. The case described an elderly widow on Medicare, living hours from the cancer center who was non-adherent to her oral cancer therapy due to high copays. Participants were asked to identify at least four financial toxicity risk factors in the case, and to identify resources and strategies that a physician could use help navigate her financial concerns. A cost-health literacy survey was administered at baseline and at the conclusion of the curriculum to evaluate the impact of the program. Results: Of 19 participants, 16 completed the case based scenario. Nine categories of risk factors were identified (63% of participants identified an insurance issue, 44% lack of social support, 44% drug cost, 50% fixed income, 50% distance from treatment center, 31% logistical transportation concern). Physician directed solutions were primarily focused on three categories: drug cost, insurance issue, and transportation concerns. Together, an institutional specific financial toxicity tip sheet was generated for further dispersal at the cancer center. After participation in the intervention, more fellows agreed/strongly agreed that they could help a patient experiencing financial toxicity (62% v 6%, p = 0.005). Conclusions: A focused intervention can increase awareness of resources and strategies available to physicians in the management of patient financial concerns, which may impact physician engagement with issues of financial toxicity. Standardized education programs to further educate physicians on financial toxicity management strategies is warranted.

This study examines the Management of Public Funds by the Health Social Security Administration (BPJS) (Review of the Concept of Islamic Insurance Against the Existence of Riba and Garar Elements). The problem that will be studied in this research is how is the health management system for public funds (BPJS) and how is the health social fund management system (BPJS) for health, and how is the existence of ribawi and garar elements in the management of public funds at BPJS Kesehatan. In this study, the authors use qualitative research with field research methods by visiting the BPJS Health office and conducting observation and interview techniques, and library research methods by reviewing books, journals and other data that support this research. The conclusions in this study indicate that in the current management of BPJS Health, there are actually many that are in accordance with sharia principles such as the principle of mutual cooperation used by BPJS Health is the same as the ta'awun contract in sharia insurance. In terms of fund management, BPJS has made it clear about public funds by including the registration requirements as suggested by the MUI. Regarding the late penalty which was previously applied by BPJS Kesehatan as much as 2%, this has been abolished since 2016 with the issuance of Presidential Regulation No. 19 of 2016 concerning the Second Amendment to Presidential Regulation No. 12 of 2013. In 2020 President Joko Widodo stipulates Presidential Regulation number 64 of 2020. Article 42 states that BPJS Kesehatan does not apply a penalty system for late payment of contributions. However, regarding investment in public contributions, until now they still use conventional investments and deposit funds also use conventional banks which still contain usury.

Abstract Background: Multiple myeloma (MM) affects predominantly older individuals but approximately 38% of patients are under the age of 65. Younger patients have benefitted the most from high dose chemotherapy with autologous hematopoietic cell support and subsequently from the introduction of novel agents. While outcomes have improved, care has become more complex and cost-prohibitive, potentially creating barriers to access for disadvantaged patients. The impact of socio economic factors potentially affecting care, namely insurance status, marital status, income and level of education in the outcomes of younger patients with MM is unknown. Methods: We analyzed MM cases diagnosed in patients < 65 years of age and reported to the Surveillance Epidemiology and End Results (SEER-18) program between 2007 (year when insurance information became available) and 2012 (most recent year available) and characterized the impact of insurance status, marital status, county-level income and county-level education (proportion of adult individuals with bachelor degree) in addition to age, gender, SEER registry and race-ethnicity on survival of MM patients. Risk and corresponding 95% confidence intervals were calculated using multivariable Cox proportional hazard models adjusted for confounders. Results: The analysis included 10,161 patients with a median follow up of survivors of 22 months (IQR 8-41 months). Median age at diagnosis was 57 (IQR 51-61), 43.5% were female, 56.2% non-Hispanic Whites (NHW), 24.9% non-Hispanic Blacks (NHB), 13.0% Hispanics, 5.9% of other race-ethnicity category (REC). Uninsured patients comprised 6%, Medicaid beneficiary 14.7%, and 79.3% had insurance benefits other than Medicaid. Married patients were 62.9%, 20.7% were single, 12.9% divorced or separated and 3.5% widowed. As shown in Table 1, increased risk of death was associated with older age, male gender, residence in the area of certain SEER-18 registries, low county-level income, marital status other than married, being uninsured or being Medicaid beneficiary (Table 1). The presence of increasing number of the 3 following independent socioeconomic risk factors: county-level income in the lower two quartiles, not married and being uninsured or Medicaid beneficiary, was associated with incremental worsening in survival (Figure 1). Patients with 0, 1, 2 and 3 socioeconomic risk factors had four year estimated survival of 71.1% (95% C.I. 68.9-73.3%), 63.2% (95% C.I. 61.2-65.1%) , 53.4% (95% C.I. 50.7-56.1) and 46.5% (95% C.I. 41.6-51.4%) respectively (P<0.001). Of interest, while NHB and Hispanics had worse survival in univariate analysis, REC did not contribute to the multivariate survival model. Conclusions: Insurance status, marital status and county-level income, but not REC and county-level education have a strong influence on the survival of younger patients with MM after adjustment for SEER registry, age and sex. Advances in MM treatment and outcomes disproportionally benefit patients of different socioeconomic backgrounds. Table. Multivariate Analysis Reference HR 95% CI P SEER registry 0.001 Alaska Greater California 0.58 0.14-2.33 0.4 Atlanta Greater California 0.97 0.80-1.17 0.8 Connecticut Greater California 0.81 0.65-1.00 0.05 Detroit Greater California 0.99 0.84-1.18 0.9 Greater Georgia Greater California 0.85 0.72-0.99 0.04 Hawaii Greater California 1.53 1.14-2.05 0.005 Iowa Greater California 1.14 0.92-1.41 0.2 Kentucky Greater California 1.01 0.84-1.22 0.9 Los Angeles Greater California 0.85 0.73-0.99 0.04 Louisiana Greater California 0.96 0.80-1.15 0.9 New Jersey Greater California 0.86 0.74-1.00 0.05 New Mexico Greater California 0.98 0.73-1.31 0.9 Rural Georgia Greater California 2.06 1.15-3.67 0.01 San Francisco-Oakland Greater California 0.90 0.73-1.11 0.3 San Jose-Monterey Greater California 0.89 0.68-1.18 0.4 Seattle Greater California 1.04 0.86-1.26 0.7 Utah Greater California 1.18 0.90-1.54 0.2 Age Per year 1.03 1.02-1.04 <0.001 Female Male 0.85 0.78-0.91 <0.001 Marital status <0.001 Divorced Married 1.24 1.11-1.39 <0.001 Single Married 1.39 1.27-1.53 <0.001 Widow Married 1.43 1.20-1.71 <0.001 Insurance status <0.001 Medicaid Insured 1.76 1.59-1.94 <0.001 Uninsured Insured 1.43 1.23-1.67 <0.001 County-level income <0.001 Quartile 1 Quartile 4 1.27 1.09-1.49 0.002 Quartile 2 Quartile 4 1.19 1.03-1.37 0.02 Quartile 3 Quartile 4 0.97 0.85-1.10 0.6 Figure 1. Figure 1. Disclosures No relevant conflicts of interest to declare.

In the case under discussion the insured two weeks before his death took out a large life policy on his own life. At the time of his death he was married in community of property to his wife. The Gauteng local division was called upon to decide whether or not the proceeds of the life policy fell into the joint estate of the spouses. The decision of the court was that the proceeds did not fall into the joint estate because it was paid after the joint estate was dissolved by the death of the spouse. The court relied on a few prior decisions to the same effect. After an analysis of the principles involved we suggest that the proceeds should in principle form part of the spouses’ former joint estate. The life insurance policy was concluded during the subsistence of the marriage in community of property. The policy conferred on the insured the right to the sum insured on his death. This right vested on conclusion of the contract, although it was subject to a time clause and it became enforceable only upon the death of the life insured. It is not a fictitious but an existing right which is capable of being ceded. This right falls into the joint estate: it was created by the policy prior to the death of the spouse and consequently prior to the dissolution of the marriage in community of property. There was indeed no other estate into which this right could have fallen. This means that the spouses were equally entitled to and liable under the contract of insurance. It was, so to speak, a debt due to the former joint estate. Hence each spouse must in principle receive one half of the death benefit. The issue involved has not yet been finally laid to rest, although the supreme court of appeal approvingly referred to the decisions on which the court in the Maqubela case relied. The widow of the late insured also claimed that since the deceased left no will, she was entitled to inherit from her late husband’s estate as an intestate heir. The question arose whether she was entitled to benefit from the death of her husband. This aspect is not dealt with in the present discussion but in a separate article (Sonnekus “Gierigheid is die wortel van alle kwaad” 2023 TSAR 175).

Much of the literature on the New Deal over the last fifteen years has sought to extend it in time and scope. The New Deal has become the New Deal Order. More than the legislation and programs of the Great Depression years under President Roosevelt, it encompasses or designates particular political coalitions brought together under a dominant Democratic Party, expanded citizenship rights, Keynesian economic policymaking, rising standards of living through collective bargaining and public investment, checks on the prerogatives of business, and working-class enfranchisement that continued well beyond the Roosevelt years.1 We talk about the New Deal when we refer to the G.I. Bill, Truman's economic and social policies or organized labor's gains in the late 1940s, Republican President Eisenhower's extension of Social Security in the 1950s, Lyndon Johnson's enactment of Medicare, and can even include the passage of the Occupational Safety and Health Administration (OSHA) laws in 1970 as the New Deal's last gasp, under President Nixon. Other historians have extended the New Deal back in time, linking its programs more firmly with social policy and industrial relations experiments in the Progressive Era, the First World War, and the 1920s. Widow's pensions, war labor boards, unemployment insurance, industrial democracy became the basic building blocks of the New Deal.2 Historians have also been revising the histories of later social movements, such as the African-American freedom struggle or the women's movement, and relocating them as New Deal movements.3 So we no longer think in terms of the “interwar period”—which was always more of a European periodization—just as we no longer talk about the New Deal as emerging full-blown from the forehead of Roosevelt and an inner-circle, male Brain Trust and ending with the Supreme Court packing incident.

The relationship of social determinants of health, Appalachian residence, and prostate cancer treatment delay among Tennessee adults is relatively unknown. We used multivariate logistic regression on 2005–2015 Tennessee Cancer Registry data of adults aged ≥18 diagnosed with prostate cancer. The outcome of treatment delay was more than 90 days without surgical or nonsurgical intervention from date of diagnosis. Social determinants in the population-based registry were race (White, Black, Other) and marital status (single, married, divorced/separated, widow/widower). Tennessee residence was classified as Appalachian versus non-Appalachian (urban/rural). Covariates include age at diagnosis (18–54, 54–69, ≥70), health insurance type (none, public, private), derived staging of cancer (localized, regional, distant), and treatment type (non-surgical/surgical). We found that Black and divorced/separated patients had 32% (95% confidence interval [CI]: 1.22–1.42) and 15% (95% CI: 1.01–1.31) increased odds to delay prostate cancer treatment. Patients were at decreased odds of treatment delay when living in an Appalachian county, both urban (odds ratio [OR] = 0.89, 95% CI: 0.82–0.95) and rural (OR = 0.83, 95% CI: 0.78–0.89), diagnosed at ≥70 (OR = 0.59, 95% CI: 0.53–0.66), and received surgical intervention (OR = 0.72, 95% CI: 0.68–0.76). Our study was among the first to comprehensively examine prostate cancer treatment delay in Tennessee, and while we do not make clinical recommendations, there is a critical need to further explore the unique factors that may propagate disparities. Prostate cancer treatment delay in Black patients may be indicative of ongoing health and access disparities in Tennessee, which may further affect quality of life and survivorship among this racial group. Divorced/separated patients may need tailored interventions to improve social support.

In order to improve shipping safety, especially in overcoming potential hazards posed by ship hulls, Indonesia through the Ministry of Transportation ratified the Nairobi International Convention on the Removal of Ship Skeletons, 2007 (Nairobi International Convention on The Removal of Wrecks, 2007) through Presidential Regulation of the Republic of Indonesia Number. 80 of 2020 concerning Ratification of the Nairobi International Convention on The Removal of Wrecks, 2007 (Nairobi International Convention Concerning the Removal of Ship Framework, 2007) which was signed by the President of the Republic of Indonesia, Joko Widodo on 20 July 2020 in Jakarta. This research method uses a normative juridical research type using a comparative study approach by conducting an assessment of laws and regulations, ratification of international conventions, books, journals. The results of research on the ratification of this convention are important for tackling potential hazards posed by ship hulls that threaten shipping safety and the marine environment as well as for providing legal certainty regarding regulation of responsibility and compensation for the removal of ship hulls. "The ratification of the Nairobi International Convention is in line with the commitment of the Ministry of Transportation of the Directorate General of Sea Transportation to continue to improve the safety and security of shipping and protection of the marine environment," the Nairobi International Convention on Removal of Ship Frames, 2007, regulates the obligation to insurance for removal of ship frames (Wreck Removal) which came into effect internationally on 14 April 2015.

Purpose This study aims to analyze the mediating effect of the open innovation processes of knowledge acquisition and exploitation as external embeddedness strategy on the relationships between strategic orientation toward digitalization and the three dimensions of the innovation capability: client, marketing and technology. Design/methodology/approach The research model was tested using a structural equation modeling design based on survey data from a financial and insurance sector multinational enterprise with direct operations in seven emerging countries. This sector is classified as being highly digitalized. Findings The results show that strategic orientation toward digitalization has an effect on innovation capability, with a greater impact on the client and technology dimensions than on the marketing dimension. However, the relationships with clients and technology are partially mediated by acquisition, while the one with marketing is mediated by exploitation. Originality/value This finding widens the current purpose and theoretical sense of external embeddedness as a type of inter-organizational arrangement key for digitalization in the literature, which is focused on the adaptation of digital technology of the head office to the needs of the subsidiaries and the systems of their local allies. By contrast, the study results show that external embeddedness is key for the multinational to be able, from its global way of creating value through digital technologies, not only to improve operating efficiency, but also to meet costumer experience expectations in each host country and innovate in local commercialization strategies, on account of the knowledge transfer between the multinational and the local players on customer preferences and technology uses in local markets.

Abstract:Deaths from suicide often incur a misclassification. Suicide is in fact subject to stigma and shame; in some countries it is even criminalized. Furthermore, there are situations in which the intentionality of the suicidal behavior is really equivocal or there was a desire to disguise the death by suicide, for example for insurance reasons. In many cases, it can be difficult to ascertain if death was due to a deliberate act (such as not taking life-saving medication or overdosing on them; an accident or a voluntary fall, etc.). Suicide deaths involving older adults are particularly prone to under-reporting. The advanced age of the deceased may imply less investigative interest than a death in childhood or from medical complications. In addition, there are cases in which it is really difficult to classify the type of death. The following story may underline such a difficulty.Angela was 81 years old. A childless widow, sufficiently independent, was a guest in a nursing home for about a year; she was there - she said - mainly to fight her loneliness. However, in the nursing home she felt even lonelier than at home.Her house was sold shortly before entering her residence. She felt very frightened by the pandemic, which she followed for long hours on television: she had begun to say aloud that she didn't want to be intubated, and that there was no more oxygen for anyone anyway. Everybody would have died soon. She was given sedatives to calm her down, but in one occasion a nurse saw her holding the pills in her mouth and then spitting them down the toilet. Her roommate got sick and was taken away. Angela kept asking about her, receiving no answer. She was noticed having difficulties falling asleep and although she showed no signs of infection or disease, she was heard saying that her days were over. One day, she told the nurse that she had finally figured out what to do. A few days later, she was found dead during lunchtime, apparently suffocating on a piece of turkey.

AbstractPoverty among widows has received little empirical attention in Africa despite women's severe vulnerability to death shock. We provided empirical evidence on widow households' transition in and out of poverty and factors influencing their probability of being in poverty. The Markov transition probabilities show moderate but increasing positive transitions for severely poor widows. Non‐poor widows are stayers who primarily sustain their non‐poor class. The ordered logit estimation shows that higher dependency ratio increases the chances of a widow being severely poor. Being an older widow and having literacy skills reduced the probability that a widow household will be severely poor. Household size and dependency ratio are noted to play important roles in the probability of transitions across poverty classes as shown by the estimated multinomial logit model. These findings are robust to alternative poverty measure, estimation method and different set of weights. Generally, the results echo the need for social safety nets to cushion widows' financial strains. Life insurance policy for spouses, increased sensitization of widows of their rights and adult education programmes targeted at widows could mitigate the negative impact of widowhood on women.

This study examines the relationship between three common mental health disorders—anxiety, depression, and post-traumatic stress disorder—in the first year of spousal bereavement and a myriad of social factors—including the security of health insurance and the presence of children at home—among those who have been widowed. We analyzed a novel survey of 503 widows who had participated in the Modern Widows’ Club Widows Empowerment Event. We then used logistic regression to investigate the relationship between these variables, discovering nuance between them. Our findings further elucidate the need for health and mental health providers to be attuned to the unique psychosocial needs of widows, especially among the first year of widowhood.

In Switzerland single mothers, especially from the working class, were rarely able to support themselves and their children as a result of widespread discrimination against women in the labor market throughout the 20th century. Focusing on the case records of the social welfare of the city of Bern from the 1930s to 1950s, the article examines to what extent single mothers benefited from a ‘mixed economy of welfare’. The article points out that after the Second World War, social welfare measures were expanded with the introduction of widows’ and survivors’ insurance and the establishment of family allowances. While these new social insurance schemes undoubtedly brought improvements, the article shows that single mothers continued to experience practices of social exclusions. Especially, the combination of welfare dependency on the one hand, and guardianship measures on the other, often resulted in the out-of-home placement of the children of single mothers.

Abstract Recent work has emphasized the role of colonial state structures in the construction and enforcement of race and gender in the British Empire from the seventeenth century onward, particularly among people of color. But work on the parallel phenomenon of “Whiteness” has focused on White men rather than White women and children, on elites rather than those below them, and on North America rather than the Caribbean. This article, using the records of a “Clergy Fund” established in Jamaica in 1797 as an insurance scheme for the (White) widows and orphans of clergymen, therefore addresses a gap in this literature by providing a case study of how a colonial state in the Caribbean tried—and failed—to construct and enforce race and gender among White women and children from outside the elite, during a period when White society in the region seemed under threat.

In this study, efforts have been made to explore familial and social security for the rural elderly in Naogaon district. The main objective of this study was to learn about the familial and social security they enjoyed in the study area. The social survey method has been employed for data collection in this research. The research area of this study was the Shatoil village of Naogaon district in Bangladesh. Purposive sampling has been used in this research work. The sample size was 100. The findings of the study show that the highest number of the respondents lived in nuclear families. A majority of them were illiterate and poor with an average income of less than 50,000 Taka per year. Most of them could not avail good health services for treatment owing to poverty. Their socio-economic condition was not satisfactory. Familial security was strong. The social security they received in terms of old age allowance was not sufficient. Only 12 percent of the elderly received a monthly allowance. About half of the remaining respondents informed that they did not get any old age allowance because of corruption. Member and Chairman want 3000-4000 taka as a bribe for creating an old age allowance card. None of the widows received widowhood allowance. The government should ensure the access and extend of financial help such as old age allowance, widowhood allowance, and health insurance for the welfare of deprived elderly.

Objective: to describe the satisfaction of service users with the timely detection of cervical cancer through the analysis of indicators and socio-demographic characteristics. Methodology: descriptive study. 101 women participate; they have PAP test in July 2007 in 13 urban health centers from San Luis Potosi Health Department Jurisdiction 1. Socio-demographic characteristics and use of service indicators are measured, including also satisfaction level. Results: the average age is 36 years old. Maximum level of education is ninth grade (42.6%) and 54.5% of the participants have Popular Insurance; 80.2% are married; the women that more attend for the first time are the youngest (18-31 years), and the married ones; and the ones that attend less are those between 51 and 61 years old. Those that are more willing for the first time are the married ones; and the ones with less attendance are the divorced, separated and widows. General knowledge about PAP test and uterine cervix cancer is adequate in 51.5% and 76.2%, respectively, whereas the accessibility is adequate in 67.3%. Satisfaction level was high on waiting time (66.3%); with complete, truthful, opportune, and understandable information (78.2%), as well as an appropriate treatment from health personal (87.1%) and accessibility (80.2%). Conclusions: the users are satisfied with the service. In this article we find that Papanicolaou test is not associated with women satisfaction. Age and marital status are associated to the appointment for the PAP.

AimTo compare differences in life satisfaction between widowed and non-widowed elders based on social support.MethodsA total of 4,560 widowed and 3,655 non-widowed elders were selected from the Chinese Longitudinal Healthy Longevity Survey (CLHLS-2018). Ordinal logistic regression models and t-tests were performed using SPSS v20.ResultsBoth widowed and non-widowed elders had high levels of life satisfaction. Personal characteristics had a significant impact on the life satisfaction of both widowed and non-widowed elders. Endowment insurance, social trust, residence, self-rated health, and living with family had a significant impact on the life satisfaction of widowed elders (p &lt; 0.001), while endowment insurance, government subsidy, and self-rated health significantly impacted non-widowed elders (p &lt; 0.001). Self-rated health had the greatest impact on the life satisfaction of widowed and non-widowed elders (OR = 4.62/4.45), followed by endowment insurance (OR = 1.24/1.32).ConclusionSocial support can significantly improve life satisfaction, but its impact is heterogeneous. Informal social support plays a greater role in improving the life satisfaction of widowed elders, but formal social support plays a greater role in the life satisfaction of non-widowed elders.

BackgroundThe high multimorbidity and lower socioeconomic status (SES) of older adults, can lead to catastrophic health expenditures (CHEs) for older adults’ households. However, whether widowed older adults will bear such a financial burden has yet to be explored. The aim of this study was to investigate the influence of multimorbidity patterns and SES on CHE in Chinese widowed older adults.MethodsData was obtained from the 2018 China Health and Retirement Longitudinal Study (CHARLS). This is a cross-sectional study. A total of 1,721 widowed participants aged 60 years and older were enrolled in the study. Latent class analysis was performed based on 14 self-reported chronic diseases to identify multimorbidity patterns. The logistic model and Tobit model were used to analyze the influence of multimorbidity patterns and SES on the incidence and intensity of CHE, respectively.ResultsAbout 36.72% of widowed older adults generated CHE. The incidence and intensity of CHE were significantly higher in the cardiovascular class and multisystem class than in the minimal disease class in multimorbidity patterns (cardiovascular class, multisystem class, and minimal disease class). Among SES-related indicators (education, occupation and household per capita income), respondents with a middle school and above education level were more likely to generate CHE compared to those who were illiterate. Respondents who were in the unemployed group were more likely to generate CHE compared to agricultural workers. In addition, respondents aged 70–79 years old, geographically located in the east, having other medical insurance, or having fewer family members are more likely to generate CHE and have higher CHE intensity.ConclusionWidowed older adults are at high risk for CHE, especially those in the cardiovascular and multisystem disease classes, and those with low SES. Several mainstream health insurances do not provide significant relief. In addition, attention should be paid to the high-risk characteristics associated with CHE. It is necessary to carry out the popularization of chronic disease knowledge, improve the medical insurance system and medical service level, and provide more policy preferences and social support to widowed older adults.

Objective: Out-of-pocket costs for insured patients have soared in recent years. Medicaid insurance for low-income individuals has minimal cost sharing but private insurance and Medicare have rising levels of cost-sharing that vary widely. We compared cost barriers and out-of-pocket expenditures among a national sample of adults with diabetes. Methods: We used 2018-21 Medical Expenditure Panel Survey data to examine cost barriers. We categorized adults with diabetes into 3 groups: 1) low income (&lt;250% federal poverty level [FPL]) on Medicaid; 2) low income on private insurance or Medicare; 3) high income (&lt;u&gt;&gt;&lt;/u&gt;250% of FPL) on private insurance or Medicare. Logistic regression adjusted for age, sex, race, ethnicity, region, income (% of FPL), number of chronic conditions, self-rated health status, limitation of activities, and insulin use. Results: We included a national sample of 6,219 adults with diabetes. Compared to low-income Medicaid recipients, low income and privately or Medicare-insured adults had higher reporting of delays or forgoing of medical care (OR=1.78, p=0.001) and medications (OR=1.45, p=0.01) due to cost. The high-income group had significantly higher odds of reporting delays and/or forgoing medication use (OR=1.58, p=0.005) but not medical care (OR=1.35, p=0.1). Out-of-pocket expenditures were significantly higher for private and Medicare insured adults compared to those in the low-income Medicaid group (low income, private or Medicare insurance group paid $267 more for medications and $755 more for care; high income group paid $315 and $967 more, respectively). Conclusion: We found most adults with diabetes face cost barriers to care but low-income, privately or Medicare-insured adults are at highest risk of delaying or forgoing care and medication use due to cost. As the gap between rich and poor Americans widens, affordability of diabetes care will be harder to achieve, especially among low income privately or Medicare-insured adults. Disclosure H.A. Torres: None. T. Moin: None.

PurposeAlthough women have advanced in the economic sphere, the gender pay gap (GPG) remains a persisting problem for gender equality. Using Acker's theory of gendered organisations, this study strives to gain a better understanding from a macro and micro approach, how family and work-related policies, especially family-friendly measures (FFMs), and their uptake, contribute and maintain the GPG in Malta and specifically within the Financial and Insurance sector.Design/methodology/approachTwo research instruments were used. National policy documents were analysed through the gender lens, followed by structured interviews with HR managerial participants within this sector.FindingsFindings suggest that at a macro level, family and work-related policies could be divided into two broad categories: A set of family-friendly policies that contribute to the GPG because of their gendered nature, or because the uptake is mostly taken by women. These include make-work pay policies, which initially appear to be gender neutral, but which attracted lower educated inactive women to the Maltese labour market at low pay, contributing to an increase in the GPG. Second, a set of policies that take on a gender-neutral approach and help reduce the GPG. These include policies like the free childcare and after school care scheme that allow mothers to have a better adherence to the labour market. At the micro level within organisations, pay discrepancies between women and men were largely negated and awareness about the issue was low. Here, “ideal worker” values based on masculine norms seemed to lead to covert biases towards mothers who shoulder heavier care responsibilities in the families and make a bigger use of FFMs. Because men are better able to conform to these gendered values and norms, the GPG persists through vertical segregation and glass ceilings, among others.Research limitations/implicationsSince not all the companies in the Eurostat NACE code list participated in this research, results could not be generalised but were indicative to future large-scale studies..Practical implicationsAt the macro and policy level, some FFMs take on a clear gendered approach. For example, the disparity in length between maternity (18 weeks) and paternity leave (1 day) reinforces gender roles and stereotypes, which contribute to the GPG in the long run. While some FFMs like parental leave, career breaks, urgent family leave, telework, flexible and reduced hours seem to take on a more gender-neutral approach, the uptake of FFMs (except childcare) seems to generate discriminatory behaviour that may affect the GPG. When considering the make-work pay policies such as the “in-work benefit” and the “tapering of benefits”, this study showed that these policies attracted lower educated and low-skilled women into the labour market, which in turn may have further contributed to the increasing GPGs. On the other hand, the childcare and after school policies relieve working mothers from caregiving duties, minimising career interruptions, discriminatory behaviour and overall GPGs.Social implicationsThis study confirmed that organisations within the Financial and Insurance sector are gendered and give value to full-time commitment and long working hours, especially in managerial roles. Managerial positions remain associated with men because mothers tend to make more use of FFMs such as parental leave, reduced, flexible hours and teleworking. Mothers are indirectly penalised for doing so, because in gendered organisations, the uptake of FFMs conflict with the demands of work and ideal worker values (Acker, 1990). This maintains the vertical segregation and widens the GPG within the Financial and Insurance sector.Originality/valueBy using the gender lens and taking a wider and more holistic approach from the macro and micro level, this study highlights how interlinking factors lead to and sustain the GPG in the Financial and Insurance sector in Malta.

PurposeThis paper aims to examine the effect of China’s unique household registration system (hukou) on stock market participation.Design/methodology/approachIn an effort to estimate the effect of hukou on households' financial behavior, we draw on data from China Family Panel Studies (CFPS) and use probit model and tobit model to test the effect of hukou on households stock market participation.FindingsThe results are with strong interpretative power over the limited participation of stock market in China-investors living in urban areas with urban hukou are more likely to participate in stock markets and allocate a larger fraction of financial assets to stocks and remarkably robust to a battery of robustness checks. The dual structure of social security caused by the household registration system could explain this result. Furthermore, marriage plays such a role of integrating social resources attached to hukou that only the marriage of individuals with urban hukou could significantly promote households' participation in the stock market. For married families, a household in which both husband and wife have urban hukou has a greater possibility to invest in stocks relative to those with rural hukou.Originality/valueThis paper contributes to the literature in two ways. First, much literature focuses on the stock market limited participation puzzle and gives explanations from the perspectives of individual heterogeneity and financial markets. This paper examines the effect of hukou. Such an idea is instructive to some developing countries where residents are treated differently because of the institutional reason. Second, the effects we find are economically meaningful. Our estimates indicate that medical insurance attached to hukou can explain almost 58% of the impact of hukou, which suggests that the key to reforming China's current household registration system is to make welfare separate from hukou. Moreover, homogamy based on hukou widens the gap of households' risky assets, which provides a new view to understand the income gap in the cities of China and the heterogeneous effect of marriage on stock market participation.

Abstract Background President of Indonesia, Joko Widodo has announced two confirmed CoVid-19 cases who live in Depok, West Java, on Monday, March 2nd, 2020. A rapid assessment of public response toward the new status was conducted, focusing on perceived risk and panic buying. Methodology A cross-sectional survey was conducted within 48 hours after the announcement through an online questionnaire. A demographic data including, sex, age, education, occupation (medical vs nonmedical), income, health insurance, island domicile (Java vs non-Java), mobility, history of contact with a foreigner, and history of overseas travel within a month. Knowledge regarding Covid 19 was determined by the average score of 38 5-Likert scale questions (5 indicates better knowledge). Perceived risk was measured with a 10-scale question, and panic buying was assessed through an average score of 6 5-Likert scale questions (5 indicates panic buying). Mann-Whitney and Linear regression were performed to identify the associated factors. Results As a total of 214 respondents, panic buying was lower (2.28 ± 0.79 on a 5-scale) except for perceived risk (5.91 ± 2.13 on a 10-scale). No difference between medical and nonmedical staff in panic buying (p = 0.619) and perceived risk (p = 0.477) and the domicile of respondents (Java VS nonjava) in panic buying (p = 0.810) and perceived risk (p = 0.101). Younger age, working in a medical field and living in Java are associated with higher perceived risk in the linear model whereas panic buying is solely affected by knowledge (β -1.459. p &lt; 0.001). The respondents agreed that scarcity of single-use components (mean 4.32 out of 5) such as masker and goods inflation particularly groceries (mean 4.31 out of 5) will appear soon Conclusions It is important to disseminate the correct information to the public to reduce panic buying. Collaborative action between the government and medical staff should be done particularly in Java as the first locus of CoVid 19 in Indonesia. Key messages Knowledge regarding corona virus affects the Panic Buying. An intervention to disseminate the correct information should be done. To reduce the perceived risk, a rigorous action should be done in Java and a collaborative work between the government and medical staffs should be established.

Photo by 187929822 © Victor Moussa | Dreamstime.com INTRODUCTION The nonconsensual taking of a human organ to use in transplantation medicine violates ethical principles, including autonomy, informed consent, and human rights, as well as criminal laws. When such an organ harvesting is not just nonconsensual, but performed in a way that causes a death or uses the pretense of brain death without meeting the criteria, it also violates the dead donor[1] rule.[2] The dead donor rule is both ethical and legal. It prevents organ retrieval that would predictably cause the death of the organ donor.[3] Retrieval of a vital organ is permissible only after a declaration of death.[4] Forced organ harvesting may breach the dead donor rule as it stands. A reimagined, broader dead donor rule could consider a larger timeframe in the forced organ harvesting context. In doing so, the broad dead donor rule could cover intent, premeditation, aiding and abetting, and due diligence failures. A broad definition of forced organ harvesting is ‘‘the removal of one or more organs from a person by means of coercion, abduction, deception, fraud, or abuse of power. . .’’[5] A more targeted definition is “[t]he killing of a person so that their organs may be removed without their free, voluntary and informed consent and transplanted into another person.”[6] In the global organ harvesting context, forced organ harvesting violates the World Health Organization (WHO) Guiding Principle 3, which says “live organ donors should be acting willingly, free of any undue influence or coercion.”[7] Furthermore, WHO states live donors should be “genetically, legally, or emotionally” attached to the recipient. Guiding Principle 1 applies to deceased donors, covers consent, and permits donation absent any known objections by the deceased.[8] Principle 7 says, “Physicians and other health professionals should not engage in transplantation procedures, and health insurers and other payers should not cover such procedures if the cells, tissues or organs concerned have been obtained through exploitation or coercion of, or payment to, the donor or the next of kin of a deceased donor.”[9] There are underground markets in which organ hunters prey on the local poor in countries with low wages and widespread poverty[10] and human trafficking that targets migrants for the purpose of organ harvesting.[11] This paper explores forced harvesting under the backdrop of the dead donor rule, arguing that a human rights violation so egregious requires holding even distant participants in the chain of events accountable. By interfering with resources necessary to carry out bad acts, legislation and corporate and institutional policies can act as powerful deterrents. A broader dead donor rule would highlight the premeditation and intent evidenced well before the act of organ retrieval. I. Background and Evidence In China, there is evidence that people incarcerated for religious beliefs and practices (Falun Gong) and ethnic minorities (Uyghurs) have been subjects of forced organ harvesting. A tribunal (the China Tribunal) found beyond a reasonable doubt that China engaged in forced organ harvesting.[12] Additionally, eight UN Special Rapporteurs found a system of subjecting political prisoners and prisoners of conscience to blood tests and radiological examinations to determine the fitness of their organs.[13] As early as 2006, investigators found evidence of forced organ harvesting from Falun Gong practitioners. [14] Over a million Uyghurs are in custody there, and there is ample evidence of biometric data collection.[15] An Uyghur tribunal found evidence of genocide.[16] “China is the only country in the world to have an industrial-scale organ trafficking practice that harvests organs from executed prisoners of conscience.”[17] Witnesses testified to the removal of organs from live people without ample anesthesia,[18] summonses to the execution grounds for organ removal,[19] methods of causing death for the purpose of organ procurement,[20] removing eyes from prisoners who were alive,[21] and forcing live prisoners into operating rooms.[22] The current extent of executions to harvest organs from prisoners of conscience in China is unknown. The Chinese press has suggested surgeons in China will perform 50,000 organ transplants this year.[23] Doctors Against Forced Organ Harvesting (DAFOR) concluded, “[f]orced organ harvesting from living people has occurred and continues to occur unabated in China.”[24] China continues to advertise in multiple languages to attract transplant tourists.[25] Wait times for organs seem to remain in the weeks.[26] In the United States, it is common to wait three to five years.[27] II. The Nascent System of Voluntary Organ Donation in China In China, throughout the 1990s and early 2000s, the supply of organs for transplant was low, and there was not a national system to register as a donor. A 1984 act permitted death row prisoners to donate organs.[28] In 2005, a Vice Minister acknowledged that 95 percent of all organ transplants used organs from death row prisoners.[29] In 2007 the planning of a voluntary system to harvest organs after cardiac death emerged. According to a Chinese publication, China adopted brain death criteria in 2013.[30] There had been public opposition due partly to cultural unfamiliarity with it.[31] Cultural values about death made it more difficult to adopt a universal brain death definition. Both Buddhist and Confucian beliefs contradicted brain death.[32] Circulatory death was traditionally culturally accepted.[33] The Ministry of Health announced that by 2015 organ harvesting would be purely voluntary and that prisoners would not be the source of organs.[34] There are cultural barriers to voluntary donation partly due to a Confucian belief that bodies return to ancestors intact and other cultural and religious beliefs about respect for the dead.[35] An emphasis on family and community over the individual posed another barrier to the Western approach to organ donation. Public awareness and insufficient healthcare professional knowledge about the process of organ donation are also barriers to voluntary donation.[36] Although the Chinese government claims its current system is voluntary and no longer exploits prisoners,[37] vast evidence contradicts the credibility of the voluntary transplant program in China.[38] III. Dead Donor Rule: A Source of Bioethical Debate It seems tedious to apply this ethical foundation to something as glaring as forced organ harvesting. But the dead donor rule is a widely held recognition that it is not right to kill one person to save another.[39] It acts as a prohibition on killing for the sake of organ retrieval and imposes a technical requirement which influences laws on how death is declared. The dead donor rule prevents organ harvesting that causes death by prohibiting harvesting any organ which the donor agreed to donate only after death prior to an official declaration of death. There is an ongoing ethical debate about the dead donor rule. Many in bioethics and transplant medicine would justify removing organs in specific situations prior to a declaration of death, abandoning the rule.[40] Some use utilitarian arguments to justify causing the death of someone who is unconscious and on life support irreversibly. Journal articles suggest that the discussion has moved to one of timing and organ retrieval.[41] Robert Truog and Franklin Miller are critics of the dead donor rule, arguing that, in practice, it is not strictly obeyed: removing organs while a brain-dead donor is still on mechanical ventilation and has a beating heart and removing organs right after life support is removed and cardio-pulmonary death is declared both might not truly meet the requirement of the dead donor rule, making following the rule “a dubious norm.”[42] Miller and Truog question the concept of brain death, citing evidence of whole body integrated functions that continue indefinitely. They challenge cardio-pulmonary death, asserting that the definition includes as dead, those who could be resuscitated. Their hearts could resume beating with medical intervention. Stopping life support causes death only in those whose lives are sustained by it. Some stipulate that the organ retrieval must not itself cause the death. Some would rejigger the cause of death: Daniel Callahan suggests that the underlying condition causes the death despite removal of life support.[43] But logically, a person could continue life support and be alive, so clearly, removing life support does cause death. Something else would have caused brain death or the circumstance that landed the person on mechanical ventilation. To be more accurate, one could say X caused the irreversible coma and removing life support caused the death itself. Miller and Truog take the position that because withdrawal of life support does cause death, the dead donor rule should be defunct as insincere. To them, retrieving vital organs from a technically alive donor should be permissible under limited conditions. They look to the autonomous choices of the donor or the surrogate (an autonomy-based argument). They appreciate the demand for organs and the ability to save lives, drawing attention to those in need of organs. Live donor organ retrieval arguably presents a slippery slope, especially if a potential donor is close to death, but not so close to label it imminent. They say physicians would not be obligated to follow the orders of a healthy person wishing to have vital organs removed, perhaps to save a close friend or relative. Similarly, Radcliffe-Richards, et al. argue that there is no reason to worry about the slippery slope of people choosing death so they can sell their vital organs, whether for money for their decedents or their creditors.[44] The movement toward permissibility and increased acceptance of medical aid in dying also influence the organ donation arena. The slippery slope toward the end of life has potential to become a realistic concern. Older adults or other people close to death may want to donate a vital organ, like their heart, to a young relative in need. That could greatly influence the timing of a decision to end one’s life. IV. Relating the Dead Donor Rule to Forced Organ Harvesting There is well documented evidence that in China organs have been removed before a declaration of death.[45] But one thing the dead donor rule does not explicitly cover is intent and the period prior to the events leading to death. It tends to apply to a near-death situation and is primarily studied in its relationship to organ donation. It is about death more than it is about life. Robertson and Lavee investigated data on transplantation of vital organs in China and they document cases where the declaration of death was a pretense, insincere, and incorrect. Their aim was to investigate whether the prisoners were in fact dead prior to organ harvesting.[46] (The China Tribunal found that organs have been removed from live prisoners and that organ harvesting has been the cause of death.) They are further concerned with the possible role of doctors as executioners, or at least as complicit in the execution as the organ harvesting so closely follows it. V. A Broader Dead Donor Rule A presumed ethical precursor to the dead donor rule may also be an important ethical extension of the rule: the dead donor rule must also prohibit killing a person who is not otherwise near death for the purpose of post-death organ harvesting. In China, extra-judicial killings of prisoners of conscience are premeditated ― there is ample evidence of blood tests and radiology to ensure organ compatibility and health.[47] To have effective ethical force, the dead donor rule should have an obvious application in preventing intentional killing for an organ retrieval, not just killing by way of organ retrieval. When we picture the dead donor rule, bioethicists tend to envision a person on life support who will either be taken off it and stop breathing or who will be declared brain dead. But the dead donor rule should apply to healthy people subject to persecution at the point when the perpetrator lays the ground for the later killing. At that point, many organizations and people may be complicit or unknowingly contributing to forced organ harvesting. In this iteration of the dead donor rule, complicity in its violations would be widespread. The dead donor rule could address the initial action of ordering a blood or radiology test or collecting any biometric data. Trained physicians and healthcare technicians perform such tests. Under my proposed stretch of the dead donor rule, they too would be complicit in the very early steps that eventually lead to killing a person for their organs. I argue these steps are part of forced organ harvesting and violate the dead donor rule. The donor is very much alive in the months and years preceding the killing. A conspiracy of indifference toward life, religious persecution, ethnic discrimination, a desire to expand organ transplant tourism, and intent to kill can violate this broader dead donor rule. The dead donor rule does not usually apply to the timing of the thought of organ removal, nor the beginning of the chain of events that leads to it. It is usually saved for the very detailed determination of what may count as death so that physicians may remove vital and other organs, with the consent of the donor.[48] But I argue that declaring death at the time of retrieval may not be enough. Contributing to the death, even by actions months or years in advance, matter too. Perhaps being on the deathbed awaiting a certain death must be distinguished from going about one’s business only to wind up a victim of forced organ harvesting. Both may well be declared dead before organ retrieval, but the likeness stops there. The person targeted for future organ retrieval to satisfy a growing transplant tourism business or local demand is unlike the altruistic person on his deathbed. While it may seem like the dead donor rule is merely a bioethics rule, it does inform the law. And it has ethical heft. It may be worth expanding it to the arena of human trafficking for the sake of organ removal and forced organ harvesting.[49] The dead donor rule is really meant to ensure that death was properly declared to protect life, something that must be protected from an earlier point. VI. Complicity: Meaning and Application Human rights due diligence refers to actions that people or institutions must take to ensure they are not contributing to a human rights violation. To advise on how to mitigate risk of involvement or contribution to human rights violations, Global Rights Compliance published an advisory that describes human rights due diligence as “[t]he proactive conduct of a medical institution and transplant-associated entity to identify and manage human rights risks and adverse human rights impacts along their entire value and supply chain.”[50] Many people and organizations enable forced organ harvesting. They may be unwittingly complicit or knowingly aiding and abetting criminal activity. For example, some suppliers of medical equipment and immunosuppressants may inadvertently contribute to human rights abuses in transplantation in China, or in other countries where organs were harvested without consent, under duress, or during human trafficking. According to Global Rights Compliance, “China in the first half of 2021 alone imported ‘a total value of about 24 billion U.S. dollars’ worth of medical technology equipment’, with the United States and Germany among the top import sources.”[51] The companies supplying the equipment may be able to slow or stop the harm by failing to supply necessary equipment and drugs. Internal due diligence policies would help companies analyze their suppliers and purchasers. Corporations, educational institutions, and other entities in the transplantation supply chain, medical education, insurance, or publishing must engage in human rights due diligence. The Global Rights Compliance advisory suggests that journals should not include any ill-gotten research. Laws should regulate corporations and target the supply chain also. All actors in the chain of supply, etc. are leading to the death of the nonconsenting victim. They are doing so while the victim is alive. The Stop Forced Organ Harvesting Act of 2023, pending in the United States, would hold any person or entity that “funds, sponsors, or otherwise facilitates forced organ harvesting or trafficking in persons for purposes of the removal of organs” responsible. The pending legislation states that: It shall be the policy of the United States—(1) to combat international trafficking in persons for purposes of the removal of organs;(2) to promote the establishment of voluntary organ donation systems with effective enforcement mechanisms in bilateral diplomatic meetings and in international health forums;(3) to promote the dignity and security of human life in accordance with the Universal Declaration of Human Rights, adopted on December 10, 1948; and(4) to hold accountable persons implicated, including members of the Chinese Communist Party, in forced organ harvesting and trafficking in persons for purposes of the removal of organs.[52] The Act calls on the President to provide Congress a list of such people or entities and to sanction them by property blocking, and, in the case of non-US citizens, passport and visa denial or revocation. The Act includes a reporting requirement under the Foreign Assistance Act of 1961 that includes an assessment of entities engaged in or supporting forced organ harvesting.[53] The law may have a meaningful impact on forced organ harvesting. Other countries have taken or are in the process of legal approaches as well.[54] Countries should consider legislation to prevent transplant tourism, criminalize complicity, and require human rights due diligence. An expanded dead donor rule supports legal and policy remedies to prevent enabling people to carry out forced organ harvesting. VII. Do Bioethicists Mention Human Rights Abuses and Forced Organ Harvesting Enough? As a field, bioethics literature often focuses on the need for more organs, the pain and suffering of those on organ transplant waitlists, and fairness in allocating organs or deciding who belongs on which waitlist and why. However, some bioethicists have drawn attention to forced organ harvesting in China. Notably, several articles noted the ethical breaches and called on academic journals to turn away articles on transplantation from China as they are based on the unethical practice of executing prisoners of conscience for their organs.[55] The call for such a boycott was originally published in a Lancet article in 2011.[56] There is some acknowledgement that China cares about how other countries perceive it,[57] which could lead to either improvements in human rights or cover-ups of violations. Ill-gotten research has long been in the bioethics purview with significant commentary on abuses in Tuskegee and the Holocaust.[58] Human research subjects are protected by the Declaration of Helsinki, which requires acting in the best interests of research subjects and informed consent among other protections.[59] The Declaration of Helsinki is directed at physicians and requires subjects enroll in medical research voluntarily. The Declaration does not explicitly cover other healthcare professionals, but its requirements are well accepted broadly in health care. CONCLUSION The dead donor rule in its current form really does not cover the life of a non-injured healthy person at an earlier point. If it could be reimagined, we could highlight the link between persecution for being a member of a group like Falun Gong practitioners or Uyghurs as the start of the process that leads to a nonconsensual organ retrieval whether after a proper declaration of death or not. It is obviously not ethically enough to ensure an execution is complete before the organs are harvested. It is abuse of the dead donor rule to have such a circumstance meet its ethical requirement. And obviously killing people for their beliefs or ethnicity (and extra-judicial killings generally) is not an ethically acceptable action for many reasons. The deaths are intentionally orchestrated, but people and companies who may have no knowledge of their role or the role of physicians they train or equipment they sell are enablers. An expanded dead donor rule helps highlight a longer timeframe and expanded scope of complicity. The organ perfusion equipment or pharmaceuticals manufactured in the United States today must not end up enabling forced organ harvesting. With an expanded ethical rule, the “donor is not dead” may become “the donor would not be dead if not for. . .” the host of illegal acts, arrests without cause, forced detention in labor camps, extra-judicial killings, lacking human rights due diligence, and inattention to this important topic. The expanded dead donor rule may also appeal to the bioethics community and justify more attention to laws and policies like the Stop Forced Organ Harvesting Act of 2023. - [1] The word “donor” in this paper describes any person from whom organs are retrieved regardless of compensation, force, or exploitation in keeping with the bioethics literature and the phrase “dead donor rule.” [2] Robertson, M.P., Lavee J. (2022). Execution by organ procurement: Breaching the dead donor rule in China. Am J Transplant, Vol.22,1804– 1812. doi:10.1111/ajt.16969. [3] Robertson, J. A. (1999). Delimiting the donor: the dead donor rule. Hastings Center Report, 29(6), 6-14. [4] Retrieval of non-vital organs which the donor consents to donate post-death (whether opt-in, opt-out, presumed, or explicit according to local law) also trigger the dead donor rule. [5] The Stop Forced Organ Harvesting Act of 2023, H.R. 1154, 118th Congress (2023), https://www.congress.gov/bill/118th-congress/house-bill/1154. [6] Do No Harm: Mitigating Human Rights Risks when Interacting with International Medical Institutions & Professionals in Transplantation Medicine, Global Rights Compliance, Legal Advisory Report, April 2022, https://globalrightscompliance.com/project/do-no-harm-policy-guidance-and-legal-advisory-report/. [7] WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation, as endorsed by the sixty-third World Health Assembly in May 2010, in Resolution WHA63.22 https://apps.who.int/iris/bitstream/handle/10665/341814/WHO-HTP-EHT-CPR-2010.01-eng.pdf?sequence=1. [8] WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation (2010). [9] WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation (2010). [10] Promchertchoo, Pichayada (Oct. 19, 2019). Kidney for sale: Inside Philippines’ illegal organ trade. https://www.channelnewsasia.com/asia/kidney-for-sale-philippines-illegal-organ-trade-857551; Widodo, W. and Wiwik Utami (2021), The Causes of Indonesian People Selling Covered Kidneys from a Criminology and Economic Perspective: Analysis Based on Rational Choice Theory. European Journal of Political Science Studies, Vol 5, Issue 1. [11] Van Reisen, M., & Mawere, M. (Eds.). (2017). Human trafficking and trauma in the digital era: The ongoing tragedy of the trade in refugees from Eritrea. African Books Collective. [12] The Independent Tribunal into Forced Organ Harvesting from Prisoners of Conscience in China (China Tribunal) (2020). https://chinatribunal.com/wp-content/uploads/2020/03/ChinaTribunal_JUDGMENT_1stMarch_2020.pdf [13] UN Office of the High Commissioner, Press Release, China: UN human Rights experts alarmed by ‘organ harvesting’ allegations (UN OTHCHR, 14 June 2021), https://www.ohchr.org/en/press-releases/2021/06/china-un-human-rights-experts-alarmed-organ-harvesting-allegations. [14] David Matas and David Kilgour, Bloody Harvest. The killing of Falun Gong for their organs (Seraphim Editions 2009). [15] How China is crushing the Uyghurs, The Economist, video documentary, July 9, 2019, https://youtu.be/GRBcP5BrffI. [16] Uyghur Tribunal, Judgment (9 December 2021) (Uyghur Tribunal Judgment) para 1, https://uyghurtribunal.com/wp-content/uploads/2022/01/Uyghur-Tribunal-Judgment-9th-Dec-21.pdf. [17] Ali Iqbal and Aliya Khan, Killing prisoners for transplants: Forced organ harvesting in China, The Conversation Published: July 28, 2022. https://theconversation.com/killing-prisoners-for-transplants-forced-organ-harvesting-in-china-161999 [18] Testimony demonstrated surgeries to remove vital organs from live people, killing them, sometimes without ample anesthesia to prevent wakefulness and pain. China Tribunal (2020), p. 416-417. https://chinatribunal.com/wp-content/uploads/2020/03/ChinaTribunal_JUDGMENT_1stMarch_2020.pdf; Robertson MP, Lavee J. (2022), Execution by organ procurement: Breaching the dead donor rule in China. Am J Transplant, Vol.22,1804– 1812. doi:10.1111/ajt.16969. [19] Doctors reported being summoned to execution grounds and told to harvest organs amid uncertainty that the prisoner was in fact dead. China Tribunal (2020), p. 52-53. [20]In testimony to the China Tribunal, Dr. Huige Li noted four methods of organ harvesting from live prisoners: incomplete execution by shooting, after lethal injection prior to death, execution by removal of the heart, and after a determination of brain death prior to an intubation (pretense of brain death). China Tribunal (2020), pp. 54-55. https://chinatribunal.com/wp-content/uploads/2020/03/ChinaTribunal_JUDGMENT_1stMarch_2020.pdf [21] A former military medical student described removing organs from a live prisoner in the late 1990s. He further described his inability to remove the eyes of a live man and his witnessing another doctor forcefully remove the man’s eyes. China Tribunal (2020), p. 330. [22] In 2006, a nurse testified that her ex-husband, a surgeon, removed the eyes of 2,000 Falun Gong practitioners in one hospital between 2001 and 2003. She described the Falun Gong labor-camp prisoners as being forced into operating rooms where they were given a shot to stop their hearts. Other doctors removed other organs. DAFOH Special Report, 2022. https://epochpage.com/wp-content/uploads/sites/3/2022/12/DAFOH-Special-Report-2022.pdf [23] Robertson MP, Lavee J. (2022), Execution by organ procurement: Breaching the dead donor rule in China. Am J Transplant, Vol.22,1804– 1812. doi:10.1111/ajt.16969. [24] DAFOH Special Report, 2022. https://epochpage.com/wp-content/uploads/sites/3/2022/12/DAFOH-Special-Report-2022.pdf; DAFOH’s physicians were nominated for a Nobel Prize for their work to stop forced organ harvesting. Šućur, A., & Gajović, S. (2016). Nobel Peace Prize nomination for Doctors Against Forced Organ Harvesting (DAFOH) - a recognition of upholding ethical practices in medicine. Croatian medical journal, 57(3), 219–222. https://doi.org/10.3325/cmj.2016.57.219 [25] Robertson and Lavee (2022). [26] Stop Organ Harvesting in China, website (organization of the Falun Dafa). https://www.stoporganharvesting.org/short-waiting-times/ [27] National Kidney Foundation, The Kidney Transplant Waitlist – What You Need to Know, https://www.kidney.org/atoz/content/transplant-waitlist [28] Wu, Y., Elliott, R., Li, L., Yang, T., Bai, Y., & Ma, W. (2018). Cadaveric organ donation in China: a crossroads for ethics and sociocultural factors. Medicine, 97(10). [29] Wu, Elliott, et al., (2018). [30] Su, Y. Y., Chen, W. B., Liu, G., Fan, L. L., Zhang, Y., Ye, H., ... & Jiang, M. D. (2018). An investigation and suggestions for the improvement of brain death determination in China. Chinese Medical Journal, 131(24), 2910-2914. [31] Huang, J., Millis, J. M., Mao, Y., Millis, M. A., Sang, X., & Zhong, S. (2012). A pilot programme of organ donation after cardiac death in China. The Lancet, 379(9818), 862-865. [32] Yang, Q., & Miller, G. (2015). East–west differences in perception of brain death: Review of history, current understandings, and directions for future research. Journal of bioethical inquiry, 12, 211-225. [33] Huang, J., Millis, J. M., Mao, Y., Millis, M. A., Sang, X., & Zhong, S. (2015). Voluntary organ donation system adapted to Chinese cultural values and social reality. Liver Transplantation, 21(4), 419-422. [34] Huang, Millis, et al. (2015). [35] Wu, X., & Fang, Q. (2013). Financial compensation for deceased organ donation in China. Journal of Medical Ethics, 39(6), 378-379. [36] An, N., Shi, Y., Jiang, Y., & Zhao, L. (2016). Organ donation in China: the major progress and the continuing problem. Journal of biomedical research, 30(2), 81. [37] Shi, B. Y., Liu, Z. J., & Yu, T. (2020). Development of the organ donation and transplantation system in China. Chinese medical journal, 133(07), 760-765. [38] Robertson, M. P., Hinde, R. L., & Lavee, J. (2019). 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(Authored by members of the International Forum for Transplant Ethics.) [45] Robertson and Lavee, (2022). [46] Robertson and Lavee, (2022). [47] China Tribunal (2020). [48] Consent varies by local law and may be explicit or presumed and use an opt-in or opt-out system and may or may not require the signoff by a close family member. [49] Bain, Christina, Mari, Joseph. June 26, 2018, Organ Trafficking: The Unseen Form of Human Trafficking, ACAMS Today, https://www.acamstoday.org/organ-trafficking-the-unseen-form-of-human-trafficking/; Stammers, T. (2022), "2: Organ trafficking: a neglected aspect of modern slavery", Modern Slavery and Human Trafficking, Bristol, UK: Policy Press. https://bristoluniversitypressdigital.com/view/book/978144736. [50] Do No Harm: Mitigating Human Rights Risks when Interacting with International Medical Institutions & Professionals in Transplantation Medicine, Global Rights Compliance, Legal Advisory Report, April 2022, https://globalrightscompliance.com/project/do-no-harm-policy-guidance-and-legal-advisory-report/. [51] Global Rights Compliance, p. 22. [52] The Stop Forced Organ Harvesting Act of 2023, H.R. 1154, 118th Congress (2023). https://www.congress.gov/bill/118th-congress/house-bill/1154. [53] The Stop Forced Organ Harvesting Act of 2023, H.R. 1154, 118th Congress (2023), https://www.congress.gov/bill/118th-congress/house-bill/1154. [54] Global Rights Compliance notes that Belgium, France (passed law on human rights due diligence in the value supply chain), United Kingdom, United States, Canada, Australia, and New Zealand have legal approaches, resolutions, and pending laws. p. 45. [55] For example, Caplan, A.L. 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[59] World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects, adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964, and amended multiple times, most recently by the 64th WMA General Assembly, Fortaleza, Brazil, October 2013. https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/