Introduction to Public Health Ethics

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Introduction to Public Health Ethics
Delia Wolf, MD, JD, MSCI Associate Dean,
Regulatory Affairs and Regulatory
Compliance Lecturer, Health Policy and
Management Harvard School of Public
Health KAU-Public Health Ethics Course May 5,
2015
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Outline

• Review of medical ethics principles
• Implications for research
• Why public health ethics
• Medical vs public health ethics
• Core questions of public health ethics
• Ethical frameworks for analysis of ethical issues
  in public health research and practice
• Points to consider case studies

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Principles of Medical Ethics - Review

• Autonomy
• Respecting the autonomous choices of persons
• Nonmaleficence
• Do no harm - avoiding the causation of harm
• Beneficence
• Do good - providing benefits
• Justice
• Fair distribution of benefits, risks and cost

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Autonomy

• Right to choose
• requires decision making capacity, but lack of
  capacity should be proven, not assumed
• Free of coercion and undue influence
• Right to accept or decline information
• Disclosure
• Understanding
• Voluntariness

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Nonmaleficence Beneficence

• Nonmaleficence
• Not to cause harm
• Beneficence
• To prevent harm
• To remove harm
• To do or promote good

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Justice

• Fairness in distribution
• To each person an equal share
• To each person according to individual need
• To each person according to individual effort
• To each person according to contribution
• To each person according to merit

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Implications for Research
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Why Public Health Ethics?

• Recent public health events/threats, such as the
  SARS, swine flu outbreaks, and resistant strains
  of TB (XDR-TB)
• Developing technology, such as new vaccines
• Growing obesity problem
• Ongoing disparities in health globally
• To answer questions such as
• How to balance individual rights versus
  protection of community health?
• How do we decide which conditions/diseases to
  screen for (priority setting)?
• How to decide when harm has occurred or may
  occur?

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Case 1 TB Victim

• Daniels contracted tuberculosis in Russian and
  returned to Arizona in the US to seek better
  healthcare. He refused to comply with public
  health authorities' orders to wear a mask to
  prevent the spread of respiratory secretions in
  public. When public health authorities were made
  aware of Daniels case, he was subsequently
  detained under a court order and place in a
  prison cell where he was denied access to
  communication technologies and kept under video
  surveillance and bright lights for 24 hours/day.
  His case drew the attention of civil liberties
  activists, who regarded this detention as a
  violation of basic civil rights

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Case 2 MDR/XDR-TB cases

• It was evident that multiple and extensive
  drug-resistant tuberculosis is extensively
  endemic in South Africa. In order to contain the
  epidemic, health authorities have used
  hospital-based treatment, including mandatory
  detention. Non-compliance has occurred
  patients escaping from hospital treatment and
  living in the community while still infectious.
  South African police have been used to search for
  those patients and return them to hospital
  against their will.

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Case 3 Obesity Surveillance

• A Body Mass Index (BMI) surveillance program will
  be implemented by public health nurses in a
  representative sample of elementary school
  (children aged 5 11 years). Passive (opt out)
  consent (with forms mailed to childrens homes)
  will provide robust and representative
  population-level statistics and contribute to the
  development of evidence-based public health
  programs and policy.

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Medical vs. Public Health Ethics
Medical Ethics Public Health Ethics
Focuses on respect individual patient/subject and his/her right to choose Focuses on promoting population benefit
Prevent harm, do good for each patient/subject Pursuit collective or common/public goods
Fair distribution of benefits, risks and cost what is due or owed to individuals/group Promoting equity at the population level how does the intervention affect the overall burden of health and illness in society
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Distinctiveness of Public Health Ethics

• Focus on population
• As opposed to an individual patient/subject
• Focus on systems of practice
• As opposed to individual decision making
• Inherently multi-dimensional
• As opposed to a particular medical
  specialty/healthcare professional
• Future and preventive orientation
• As opposed to current needs for treatment

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Core Questions of Public Health Ethics

• What are the goals of public health?
• How to adjudicate between individual rights and
  freedoms on the one hand, and protecting and
  promoting the publics health (common goods) on
  the other. In other words, the extent to which it
  is right to interfere with someone elses liberty
  in order to protect them and/or others from harm?

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Characteristics of Common Goods

• Indivisible
• Community/public as a whole (i.e., clean air)
• Non-excludable
• Open to being enjoyed by all
• Cooperation dependent
• Requires cooperation from multiple parties

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Ethical Frameworks

• Many operational frameworks have been proposed
  for the analysis of ethical issues in public
  health practice and research
• Childress et al. enumerate five considerations
• Effectiveness
• Proportionality
• Necessity
• Least infringement
• Public justification

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Ethical Frameworks (cont.)

• Upshurs four principles to guide the
  justification of public health intervention
• Harm principle it is applicable when
  predictable harm is likely to occur for
  individuals with infectious diseases, who are
  untreated may pose harm to communities
• Least Restrictive Means education and
  facilitation are preferred to interdiction and
  incarceration
• Reciprocity if restrictive measures are
  invoked, assistance and protections must be
  provided to those who are restricted/detained
• Discourse ethics representation of those to be
  restricted

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Points to Consider

• Identify the key public health ethics issues
  presented in the case and why they are public
  health ethics issues
• Identify the key relevant information (i.e.,
  biological, economic, social, cultural,
  political, or ethical)
• Assess knowledge gaps (i.e., what information is
  useful to know), as well as the basis for these
  facts
• Identify the key stakeholders in the case and the
  most appropriate decision makers and or
  government authorities to approach the ethical
  issue, if applicable

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Points to Consider (cont.)

• Identify the key values and concerns of the
  identified stakeholders and any potential risks
  and benefits
• Identify the options available to the decision
  maker, including reasonable alternatives courses
  of action, and consideration of implications and
  the potential intended and unintended outcomes,
  and
• Suggest a resolution of decision to the case by
  choosing the supported option, and justify this
  decision

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Case 4 Outdoor Smoke-free Policies
Municipalities are increasingly prohibiting
smoking in parks and other outdoor public spaces.
Smoke-free spaces are primarily justified on the
basis of three goals (1) reducing exposure to
secondhand smoke (2) encouraging people to quit
smoking, and (3) preventing youth smoking
initiation. Does evidence demonstrate that such
bans effectively, equitably and ethically
accomplish these goals?