Global Health Ethics — MCQs
A GSP4 woman comes for routine sonography for the first time. She has four daughters and expresses a desire for a boy this time, asking for sex determination. To abide by ethical guidelines, what should you do?
According to Sustainable Development Goal 3 (SDG 3) - 'Ensure healthy lives and promote well-being for all at all ages', what is the target for reducing the global maternal mortality ratio by 2030?
In NRHM, the ASHA workers are recruited from the same village. Which part of principles of primary health care is followed here?
The comparison of mortality rates between two countries requires the application of direct standardization. Which of the following parameters makes it necessary to have standardization?
Prohibition of participation in torture by a doctor comes under:
Synovial fluid contains-
Cone of light focuses on which quadrant of tympanic membrane?
Which layer of cornea regulates the hydration of stroma to maintain corneal transparency?
A novel rapid diagnostic test for visceral leishmaniasis shows sensitivity of 85% and specificity of 90% in controlled trials. When deployed in a region with 2% prevalence of VL (as determined by gold standard testing), public health officials note that most positive results are false positives. Evaluate the most appropriate strategy to improve the program's effectiveness.
A low-income country plans to introduce HPV vaccination for cervical cancer prevention but faces budget constraints. Current cervical cancer screening coverage is 15% with VIA (Visual Inspection with Acetic acid). Competing priority is expanding TB-DOTS coverage from 60% to 85%. Using WHO principles of priority setting in resource-limited settings, evaluate the best approach.
Global Health Ethics Indian Medical PG Practice Questions and MCQs
Question 1: A GSP4 woman comes for routine sonography for the first time. She has four daughters and expresses a desire for a boy this time, asking for sex determination. To abide by ethical guidelines, what should you do?
- A. Check routine ANC and sex for developmental abnormalities and do not reveal gender to the patient (Correct Answer)
- B. Check routine ANC and sex for developmental abnormalities and do reveal gender to the patient
- C. Do reveal gender if a girl
- D. Check only routine ANC, do not check sex
Explanation: ***Check routine ANC and sex for developmental abnormalities and do not reveal gender to the patient*** - It is **illegal** and **unethical** to reveal the sex of the fetus in many countries, including India, to prevent **sex-selective abortions**. - The primary purpose of a routine antenatal ultrasound is to assess fetal **health** and **developmental abnormalities**, not to determine sex for parental preference. *Check routine ANC and sex for developmental abnormalities and do reveal gender to the patient* - Revealing the gender to the patient directly facilitates **sex-selective abortion**, which is medically unethical and illegal due to the potential for harm to the fetus and society. - This practice would violate the **Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act** in India, which prohibits gender determination. *Do reveal gender if a girl* - Revealing the gender, regardless of whether it is a boy or a girl, can lead to **gender-biased selective abortions**, particularly in cultures with a strong preference for male offspring. - This action undermines the ethical principles of **non-maleficence** and **justice** by potentially facilitating harm based on gender preference. *Check only routine ANC, do not check sex* - While the primary focus is routine antenatal care, avoiding the assessment of fetal sex entirely could lead to **missing potential developmental abnormalities** that might be identifiable through observation of external genitalia. - A thorough ultrasound examination routinely includes a visual check of fetal anatomy, which can incidentally reveal gender, but this information should not be shared with the parents for selection purposes.
Question 2: According to Sustainable Development Goal 3 (SDG 3) - 'Ensure healthy lives and promote well-being for all at all ages', what is the target for reducing the global maternal mortality ratio by 2030?
- A. 100
- B. 50
- C. 70 (Correct Answer)
- D. 90
Explanation: ***70*** - SDG 3 aims to reduce the **global maternal mortality ratio** to less than **70 per 100,000 live births** by 2030. - This target emphasizes improving maternal health outcomes worldwide and preventing deaths related to pregnancy and childbirth. *100* - While a reduction is sought, a target of 100 per 100,000 live births is **not ambitious enough** to meet the specific goal set by SDG 3. - The established global target is lower, reflecting a greater commitment to maternal health. *50* - A target of 50 per 100,000 live births would be **more ambitious** than the SDG 3 goal. - While desirable, it is not the specific, agreed-upon target for the global average under SDG 3. *90* - A target of 90 per 100,000 live births is **higher** than the established SDG 3 goal. - This value does not align with the specific global maternal mortality ratio target set for 2030.
Question 3: In NRHM, the ASHA workers are recruited from the same village. Which part of principles of primary health care is followed here?
- A. Appropriate technology
- B. Community participation (Correct Answer)
- C. Intersectorial coordination
- D. Equitable distribution
Explanation: **Community participation** - Recruiting ASHA workers from the same village exemplifies **community participation** by empowering local individuals to lead health initiatives and ensures their understanding of local customs and needs. - This approach fosters trust and acceptability within the community, making health services more **accessible and relevant** to the population. *Appropriate technology* - This principle refers to the use of **scientifically sound and acceptable methods** and tools that are affordable and relevant to local conditions. - While ASHAs use appropriate technologies, their recruitment method itself doesn't directly illustrate this principle. *Intersectorial coordination* - This involves collaborative efforts between the health sector and other sectors like education, agriculture, and sanitation, to address the **social determinants of health**. - Recruiting ASHAs addresses human resources within the health sector, not coordination between different sectors. *Equitable distribution* - This principle aims to ensure that health resources and services are **available to all people regardless of their geographic location** or socioeconomic status. - While having ASHAs in rural areas contributes to equity, the specific act of recruiting them *from the same village* primarily highlights community involvement and local ownership, rather than just the distribution of services.
Question 4: The comparison of mortality rates between two countries requires the application of direct standardization. Which of the following parameters makes it necessary to have standardization?
- A. Numerators
- B. Denominators
- C. Causes of death
- D. Age distributions (Correct Answer)
Explanation: ***Age distributions*** - **Direct standardization** is crucial when comparing mortality rates between populations with different **age structures**. A population with a larger proportion of older individuals will naturally have a higher crude mortality rate regardless of underlying health. - By standardizing for age, we can remove the confounding effect of age and get a more accurate comparison of **disease burden** or **healthcare effectiveness**. *Numerators* - The numerator in mortality rates typically represents the **number of deaths**, which is a direct count and does not inherently require standardization to be understood. - While the numerator is essential for calculating the rate, its raw value doesn't introduce bias in comparison as much as population characteristics. *Denominators* - The denominator represents the **total population at risk**, which is used in calculating crude mortality rates. - While vital for rate calculation, the denominator itself doesn't directly cause a need for standardization; rather, the **composition** of the denominator (e.g., age groups) is the critical factor. *Causes of death* - While comparing **specific causes of death** can be informative, the "cause of death" itself does not necessitate overall mortality rate standardization. - Standardization focuses on population characteristics (like age) that influence the overall likelihood of death, not the specific etiology.
Question 5: Prohibition of participation in torture by a doctor comes under:
- A. Declaration of Helsinki
- B. Declaration of Oslo
- C. Declaration of Tokyo (Correct Answer)
- D. Declaration of Geneva
Explanation: ***Declaration of Tokyo*** - The **Declaration of Tokyo (1975)** specifically addresses the **prohibition of participation by doctors in torture** and other cruel, inhuman, or degrading treatment. - It mandates that physicians must not condone, facilitate, or participate in any form of torture, even under threat or duress. *Declaration of Helsinki* - This declaration focuses primarily on **ethical principles for medical research involving human subjects**. - It sets guidelines for **informed consent**, risk-benefit assessment, and the protection of vulnerable populations in research. *Declaration of Oslo* - The Declaration of Oslo (1970) deals with **therapeutic abortion** and the ethical considerations surrounding it. - It provides guidance on the physician's role and responsibilities when considering termination of pregnancy. *Declaration of Geneva* - Often referred to as a modern Hippocratic Oath, the Declaration of Geneva (1948) outlines the **general ethical duties of physicians**. - It emphasizes core principles such as respect for human life, professional secrecy, and beneficence, but does not specifically detail prohibitions regarding torture.
Question 6: Synovial fluid contains-
- A. Keratan sulphate
- B. Hyaluronic acid (Correct Answer)
- C. Dermatan sulphate
- D. Chondroitin sulphate
Explanation: ***Hyaluronic acid*** - **Hyaluronic acid** is a major component of **synovial fluid**, providing **viscosity** and **lubrication** to joints, which is crucial for reducing friction between articular cartilages. - It's a **glycosaminoglycan** (GAG) responsible for the fluid's unique rheological properties, maintaining joint health and function. *Keratan sulphate* - **Keratan sulphate** is primarily found in **cartilage**, **cornea**, and **bone**, contributing to their structural integrity. - It is not a significant component of **synovial fluid** itself; rather, it is part of the extracellular matrix of surrounding tissues. *Dermatan sulphate* - **Dermatan sulphate** is typically found in **skin**, **blood vessels**, and **heart valves**, where it plays a role in tissue organization and repair. - It is not a characteristic or primary component of **synovial fluid**. *Chondroitin sulphate* - **Chondroitin sulphate** is a GAG abundant in **cartilage**, contributing to its **compressive strength** and elasticity. - While essential for **joint health**, it is found within the cartilage matrix, not freely in high concentrations within the **synovial fluid**.
Question 7: Cone of light focuses on which quadrant of tympanic membrane?
- A. Anteroinferior (Correct Answer)
- B. Posteroinferior
- C. Anterosuperior
- D. Posterosuperior
Explanation: ***Anteroinferior*** - The **cone of light** (or light reflex) is a characteristic triangular reflection of the otoscope's light, normally visible in the **anteroinferior quadrant** of a healthy tympanic membrane. - Its presence indicates a **healthy, intact eardrum** with normal tension and transparency; its absence or distortion can suggest pathology. *Posteroinferior* - While part of the tympanic membrane, the **posteroinferior quadrant** does not normally exhibit the focused cone of light. - This area is more often associated with the **round window niche** on its medial aspect in relation to the middle ear. *Anterosuperior* - The **anterosuperior quadrant** is located above the handle of the malleus and does not show the cone of light reflection. - This area contains the **anterior malleolar fold** and part of the **pars flaccida** (attic region). *Posterosuperior* - The **posterosuperior quadrant** is also not the usual site for the cone of light. - This area is relevant for the proximity to the **facial nerve** and structures like the **long process of the incus**.
Question 8: Which layer of cornea regulates the hydration of stroma to maintain corneal transparency?
- A. Endothelium (Correct Answer)
- B. Epithelium
- C. Descemet membrane
- D. Stroma
Explanation: ***Endothelium*** - The **corneal endothelium** is a single layer of cells that actively pumps fluid out of the corneal stroma, maintaining its deturgescence and transparency. - This **pump function** involves **Na+/K+-ATPase** pumps, preventing stromal edema by regulating water content. *Epithelium* - The **corneal epithelium** serves as a barrier against trauma and infection, but its primary role is not in regulating stromal hydration. - It maintains the corneal surface integrity and provides a smooth optical surface for light refraction. *Descemet membrane* - **Descemet's membrane** is the basement membrane of the corneal endothelium, contributing to the structural integrity and elasticity of the cornea. - It does not actively participate in the regulation of corneal stromal hydration. *Stroma* - The **corneal stroma** is the thickest layer of the cornea, composed primarily of collagen fibrils and keratocytes. - While it is the layer that needs to be hydrated to maintain transparency, it does not actively regulate its own hydration; rather, it is a target of hydration control.
Question 9: A novel rapid diagnostic test for visceral leishmaniasis shows sensitivity of 85% and specificity of 90% in controlled trials. When deployed in a region with 2% prevalence of VL (as determined by gold standard testing), public health officials note that most positive results are false positives. Evaluate the most appropriate strategy to improve the program's effectiveness.
- A. Abandon the rapid test and use only microscopy
- B. Use the test only in symptomatic patients with high pre-test probability (Correct Answer)
- C. Implement two-tier testing with confirmatory parasitological diagnosis for all RDT positives
- D. Lower the diagnostic threshold to increase sensitivity
Explanation: ### Use the test only in symptomatic patients with high pre-test probability - In a **low-prevalence** setting (2%), the **positive predictive value (PPV)** is inherently low despite high specificity, leading to a high number of **false positives** [1]. - Restricting the test to those with clinical suspicion (e.g., splenomegaly, prolonged fever) increases the **pre-test probability**, which significantly improves the PPV and program efficiency [2], [3]. ### Abandon the rapid test and use only microscopy - Microscopy (e.g., splenic or bone marrow aspirates) is **invasive**, technically demanding, and often impractical for large-scale field use in poor regions. - Rapid tests are essential for **point-of-care** diagnostics; the issue is not the test's utility but its application in a low-prevalence population. ### Implement two-tier testing with confirmatory parasitological diagnosis for all RDT positives - While this improves accuracy, parasitological confirmation is highly **labor-intensive** and requires **invasive procedures** that are difficult to scale in a public health program. - It does not address the underlying inefficiency of testing low-risk individuals, which wastes resources before the confirmatory step is even reached. ### Lower the diagnostic threshold to increase sensitivity - Lowering the threshold would increase the number of **false positives** because sensitivity and specificity are inversely related [1]. - In this scenario, the primary goal is to improve **specificity/PPV** to reduce false positives, not to find more potentially negative cases by increasing sensitivity.
Question 10: A low-income country plans to introduce HPV vaccination for cervical cancer prevention but faces budget constraints. Current cervical cancer screening coverage is 15% with VIA (Visual Inspection with Acetic acid). Competing priority is expanding TB-DOTS coverage from 60% to 85%. Using WHO principles of priority setting in resource-limited settings, evaluate the best approach.
- A. Expand TB-DOTS coverage first due to immediate mortality impact and higher baseline coverage (Correct Answer)
- B. Prioritize HPV vaccination as it provides long-term prevention
- C. Focus on improving VIA screening coverage instead of vaccination
- D. Implement both programs equally with 50% budget allocation each
Explanation: ***Expand TB-DOTS coverage first due to immediate mortality impact and higher baseline coverage*** - According to **WHO priority-setting principles**, interventions for high-mortality infectious diseases like **Tuberculosis** typically take precedence due to immediate impact on life expectancy. [1] - Expanding an existing, successful program from **60% to 85%** is more cost-effective and feasible than initiating new high-cost long-term interventions like **HPV vaccination** in resource-limited settings. [1] *Prioritize HPV vaccination as it provides long-term prevention* - **HPV vaccination** yields benefits only after decades; in constrained budgets, programs addressing **immediate disease burden** are prioritized. - The high **initial cost** and logistical requirements for refrigeration and multi-dose delivery often make it secondary to fundamental public health needs. *Focus on improving VIA screening coverage instead of vaccination* - While **VIA (Visual Inspection with Acetic acid)** is low-cost, improving it from a low **15% baseline** does not address the high mortality risk associated with **TB outbreaks**. - Screening programs require robust **linking to treatment centers**, which may not be as well-established as the existing **TB-DOTS infrastructure**. *Implement both programs equally with 50% budget allocation each* - An equal **50% budget allocation** ignores the principle of **marginal cost-effectiveness**, where underfunding two programs may lead to both being ineffective. - **WHO principles** advocate for focusing resources on the **burden of disease** and existing capacity rather than arbitrary split funding.
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