Exploring ethical terrain in public health.

Public health is rife with ethical challenges. Ethical principles and values are intrinsic to public health decision making, although they are generally not identified explicitly. One purpose of this article is to discuss public health goals as an ethical/value concern with attention to values that do and should underlie health care in the United States. A second purpose is to introduce frameworks for public health decision making that incorporate ethical considerations into community and health promotion perspectives of public health decision makers. Public health policy makers and providers are urged to explore ethical/value dimensions of the health care system and to use the ethical frameworks in their decision making, expanding the more individualistic perspective of traditional bioethics.     

Ethical issues in public health: a qualitative study of public health practice in Scotland

STUDY OBJECTIVE: To identify ethical issues encountered by staff in the development and implementation of public health activities at two sites in Scotland. DESIGN: Qualitative research study involving face to face semi-structured interviews with participants. SETTING: A public health directorate in a National Health Service Trust, and a public health demonstration project in child health. PARTICIPANTS: Health promotion specialists, managers, nurses, public health consultants and specialists, researchers, trainees, and other public health staff. MAIN RESULTS: Three main categories of ethical issues were identified: paternalism, responsibilities, and ethical decision making. Consulting with the community and sharing information raised issues of paternalism and honesty. Participants identified multiple and sometimes conflicting responsibilities. Barriers to fulfilling responsibilities included meeting targets, working with partners, and political influences. Defining the limits of responsibilities posed challenges. Participants identified values for ideal decision making, but lack of time often led to a more pragmatic approach. CONCLUSION: These empirical findings complement and extend existing discussions of public health ethics, emphasising the complex nature of ethical issues in public health. The implications for public health policy and future research are discussed.     

Public health ethics: informing better public health practice

Public health ethics has emerged and grown as an independent discipline over the last decade. It involves using ethical theory and empirical analyses to determine and justify the right thing to do in public health. In this paper, we distinguish public health ethics from clinical ethics, research ethics, public health law and politics. We then discuss issues in public health ethics including: how to weigh up the benefits, harms and costs of intervening; how to ensure that public health interventions produce fair outcomes; the potential for public health to undermine or promote the rights of citizens; and the significance of being transparent and inclusive in public health interventions. We conclude that the explicit and systematic consideration of ethical issues will, and should, become central to every public health worker's daily practice.     

Ethical issues in epidemiologic research and public health practice

A rich and growing body of literature has emerged on ethics in epidemiologic research and public health practice. Recent articles have included conceptual frameworks of public health ethics and overviews of historical developments in the field. Several important topics in public health ethics have also been highlighted. Attention to ethical issues can facilitate the effective planning, implementation, and growth of a variety of public health programs and research activities. Public health ethics is consistent with the prevention orientation of public health. Ethical concerns can be anticipated or identified early and effectively addressed through careful analysis and consultation.     

Ethics in American health 1: ethical approaches to health policy

I trace the evolution of ethical approaches to health policy in the United States and examine a number of critical unresolved issues pertaining to the current set of frameworks. Several themes emerge. First, fair procedures claim more attention than substantive and procedural principles. Second, in the case of public deliberation, more focus has been placed on factors such as procedural mechanisms than on understanding how individuals and groups value different aspects of health and agree on health-related decisions. Third, the nation needs workable frameworks to guide collective choices about valuable social ends and their trade-offs; purely procedural strategies are limited in illuminating overarching health policy and ethics questions. There is a need to integrate consequential and procedural approaches to health ethics and policy.     

Integrating ethics, health policy and health systems in low- and middle-income countries: case studies from Malaysia and Pakistan

Scientific progress is a significant basis for change in public-health policy and practice, but the field also invests in value-laden concepts and responds daily to sociopolitical, cultural and evaluative concerns. The concepts that drive much of public-health practice are shaped by the collective and individual mores that define social systems. This paper seeks to describe the ethics processes in play when public-health mechanisms are established in low- and middle-income countries, by focusing on two cases where ethics played a crucial role in producing positive institutional change in public-health policy. First, we introduce an overview of the relationship between ethics and public health; second, we provide a conceptual framework for the ethical analysis of health system events, noting how this approach might enhance the power of existing frameworks; and third, we demonstrate the interplay of these frameworks through the analysis of a programme to enhance road safety in Malaysia and an initiative to establish a national ethics committee in Pakistan. We conclude that, while ethics are gradually being integrated into public-health policy decisions in many developing health systems, ethical analysis is often implicit and undervalued. This paper highlights the need to analyse public-health decision-making from an ethical perspective.     

Richtig gute epidemiologische Praxis

Objective/methods

The need for public health ethics and ethics in epidemiology has recently become more obvious. In this article a methodological and normative framework for public health ethics is discussed.

Results

Some of the prevalent approaches of public health ethics and ethics in epidemiology are missing a systematic philosophical account and/or norms that are relevant and enlightening for the ethical discussion in public health. For an approach of public health ethics one can learn from bioethics and adopt methodologies that have been applied and elaborated in this field. However, there is a need for a set of principles in public health ethics that differs from the bioethical principles. Ethical codes and guidelines are already applied in the practice of epidemiology and public health without relating these to ethical principles. This is a deficit for goal-oriented ethical reasoning in public health and epidemiology.

Conclusion

An applied ethical discourse in public health can be helpful for public health and epidemiology. Ethical principles facilitate coherent reasoning that enriches the discussion of ethical problems as opposed to only relying on very specific moral rules as in codes and guidelines.     

Professionalism and ethics in the public health curriculum

As the public's health-care needs increase in complexity, renewed attention is being given to the ethical dimensions of public health decision-making and the development of public health ethics as a bounded area of teaching and research. This article provides an overview of approaches to public health ethics and decision-making, and suggests ways to incorporate the professionalism competencies into the teaching of public health practice. The teaching of ethics language, concepts, and tools for decision analysis helps to prepare students for the inevitable ethical choices they will have to make in their professional practice. The teaching of ethics and professionalism and the experiences of professionals enrich each other and foster the critical link between education and practice.     

The promise of public health: ethical reflections

Public health is in the spotlight of public and political concern, providing a unique window of opportunity for its revitalization and restoration as a pillar of the Canadian health care system. The establishment of a Federal Public Health Agency is a critical first step. The public health community has identified key challenges toward this renewal. However, public health ethics have received little attention and, when addressed, have focussed almost exclusively on communicable diseases. The ethical issues inherent in public health transcend infectious diseases and are distinct from clinical and research ethics. Identifying and addressing ethical issues at the heart of public health, including the public interest and the common good, as well as fundamental issues related to the core functions of public health will be essential if this revitalization of public health is to be achieved. While legal and regulatory reforms are necessary, they will not be sufficient to adequately address fundamental questions of the valuing of public health or the ethical issues in public health. Elements of a research agenda on the ethical foundations of public health reform are identified here.     

Law as a tool for preventing chronic diseases: expanding the range of effective public health strategies

Law, which is a fundamental element of effective public health policy and practice, played a crucial role in many of public health's greatest achievements of the 20th century. Still, conceptual legal frameworks for the systematic application of law to chronic disease prevention and control have not been fully recognized and used to address public health needs. Development and implementation of legal frameworks could broaden the range of effective public health strategies and provide valuable tools for the public health workforce, especially for state and local health department program managers and state and national policy makers. In an effort to expand the range of effective public health interventions, the Centers for Disease Control and Prevention will work with its partners to explore the development of systematic legal frameworks as a tool for preventing chronic diseases and addressing the growing epidemic of obesity, heart disease, stroke, and other chronic diseases and their risk factors.     

Public-Health-Ethik in Abgrenzung zur Medizinethik

Until now there are only a few approaches in the German-speaking realm to establish an explicit ethical framework for moral issues of public health--although a need for public health ethics in times of SARS and avian flu is obvious. One deficit of the discussion so far is that there is no systematic separation of medical ethics and public health ethics. Thus, the core and interdisciplinary focus of public health is often not met. However, to frame discussions of moral issues within a specific public health ethics framework seems to be fruitful. This paper deals with the conceptual differences of medical ethics and public health ethics. The discussion helps both applied ethical discourses to sharpen their focus and strengthen their appeal. The author develops and presents a conceptual and normative frame for public health ethics and offers a concise set of ethical principles for the discussion of moral challenges in public health.     

公共卫生事件传播应遵守的公共健康伦理道德

公共卫生事件往往会引起社会广泛关注,进而在一定程度上影响政府的公信力和社会和谐稳定,作为公共卫生从业人员,应遵守公共健康伦理道德,发布任何消息前都要考虑到公众的理解能力和可能引发的社会影响。现以近年来发生的媒体传播的两个公共卫生事件为例,分析讨论公共卫生从业人员应遵循的伦理道德:公共卫生从业人员不应当通过新闻媒体向公众告知没有得到证实的假设;公共卫生从业人员必须确保以客观的、审慎的方式向公众公开研究成果;只有在研究成果经过严格的科学审查后,才应当把他们公布于众;公共卫生从业人员要明确自身的沟通责任,在发布任何报告前,必须考虑到对公众的影响。     

Beyond evidence--to ethics: a decision-making framework for health promotion, public health and health improvement

Echoing the rise of 'evidence-based medicine', the concept of evidence-based policy and practice in the inter-related fields of health promotion, public health and health improvement has attracted increasing attention over the past two decades. More recently, again with roots traceable to biomedical thinking, there has been growing interest in ethics in relation to these fields. This paper links these two topical themes in a practical way. It explores the extent to which policies and activities 'on the ground' can and should be based on evidence, and considers the relative places of evidence and ethics in decision-making. It goes on to present the 'decision-making triangle', a framework that gives primacy to a set of ethical principles--with available evidence and plausible theory being used to inform the application of these. After introducing the concept of 'ethical logic modelling', the paper concludes by suggesting an 'ethical imperative' for health promotion, public health and health improvement: to make decisions based on the explicit application of ethical principles, using available evidence and theory appropriately.     

Critical public health ethics and Canada's role in global health

This commentary introduces critical public health ethics as an innovative lens for considering Canada's role in global health. Arising from the relatively young field of public health ethics, this analytic perspective sheds light on questions regarding public health policy, research and practice that often remain shaded from view because of traditional ways of thinking about public health. The advantage of a critical public health ethics lens is illustrated through the example of Canada's role in scaling up access to HIV treatments in developing countries.     

Patient safety: This is public health

Avoidable patient harm is a major public health concern, and may already have surpassed heart disease as the leading cause of death in the United States. While the public health community has contributed much to one aspect of patient harm prevention, infection control, the tools and techniques of public health have far more to offer to the emerging field of patient safety science. Patient safety practice has become increasingly professionalized in recent years, but specialist degree programs in the field remain scarce. Healthcare organizations should consider graduate training in public health as an avenue for investing in the professional development of patient safety practitioners, and schools and programs of public health should support further research and teaching to support patient safety improvement.     

A review of improved ethical practices in environmental and public health research: case examples from native communities.

This article presents a review of 14 case studies and articles of research ethics issues in the conduct of environmental and public health research with Native American and other indigenous populations. The purpose of this review is to highlight new practices in the ethical conduct of research with native community populations. The findings from this review can promote more dialogue and policy development on the issue of community protections in research. Formal guidelines exist in ethical codes for individual rights as human subjects, but there is a lack of development on community rights in the ethics of research. This review illustrates how community-based participatory research practices can provide working guidelines that can overcome past research harms. More important, the compilations of guidelines offer tested field methods for improving the ethical conduct of research with native community populations.     

Principles for the justification of public health intervention

OBJECTIVES: The objective of this paper is to discuss principles relevant to ethical deliberation in public health. METHODS: Conceptual analysis and literature review. RESULTS: Four principles are identified: The Harm Principle, The Principle of Least Restrictive Means, The Reciprocity Principle, and The Transparency Principle. Two examples of how the principles are applied in practice are provided. INTERPRETATION: The paper illustrates how clinical ethics is not an appropriate model for public health ethics and argues that the type of reasoning involved in public health ethics may be at potential variance from that of empirical science. Further research and debate on the appropriate ethics for public health are required.     

Pol-ethical considerations in public health: The views of Swedish health care politicians

Background: Public health policy is often concerned with theconflicting values emanating from the individually formulatedethics for curative care and more collectively oriented ethics.In this study we have focused on the pol-ethical considerationsinvolved in Swedish health care politicians' assessment of publichealth measures. Methods: We described a hypothetical situationin a questionnaire, where a community has a 50% excess mortalityfor disease X, compared to the national average. Scientificdisagreements were identified and discussed. The respondentsgave their preference for a specific intervention strategy andconsidered, on a graded scale, 17 different value statementsrelated to ethical principles and intervention strategies. Results:Only one out of 451 politicians preferred the alternative ‘nointervention’. The majority preferred an interventionincluding active involvement of primary health care. There wasoverall strong support for equity and beneficence. A factoranalysis gave a model for the association between ethical values,political affiliation and choice of intervention strategies.The relative weights of autonomy and equity were strongly relatedto political affiliation. Conclusions: Among Swedish healthcare politicians there is consensus about the value of performinginterventions in public health when the problem is large, evenif there is some uncertainty about the consequences. Their overallstrong support for equity and beneficence implies that theseprinciples are crucial when formulating policies for interventions.Politicians need to state their ethical standpoint explicitlyso that we as citizens can judge their decisions and actionsbased on our own political ideology and support for basic ethicalprinciples.     

Policy incongruence and public health professionals' dissonance: the case of immigrants and welfare policy

The steady increase in immigrants to the United States has fueled a critical analysis of the process of allocation of health and social benefits to these newcomers. The myriad of interests and values surrounding this issue precipitated the formulation and adoption of the Personal Responsibility and Work Opportunity (Welfare Reform) Act of 1996. This dramatic welfare reform impacts federal, state, and local agencies that are required to determine the eligibility of benefits and manage the attendant consequences to the public as well as members of this vulnerable group. Especially challenging are the decisions confronting public health professionals who struggle to reconcile the resulting policy, programmatic mandates, and compliance imperatives with prevailing public health principles and practice norms. This paper proposes a framework for understanding the incongruence between the provisions of the law as it pertains to legal and illegal immigrants and public health values. The impact of policy incongruence and professionals' dissonance on public health practice norms is explored with an explicit focus on public health outcomes and legal implications. The examination of tuberculosis as a health example reveals the policy conflicts and public health dilemmas. Finally, the paper elicits a range of options available to public professionals for responding to these legal mandates.     

Evidence and ethics in public health: the experience of SARS in Canada

Making decisions on the basis of evidence is a central tenet of all health-care disciplines, including public health. However, it is not entirely clear what it means to base decisions on evidence; debates on evidence-based approaches often lack a clear understanding of the nature of evidence and obscure the normative underpinnings of evidence. Public health decision making requires an acceptance of limitations such as the availability of funding for research to provide complete evidence for any given decision, the ethical constraints on the creation of certain types of evidence and the ongoing dilemma between the need to take action and the need to gather more information. Using the example of the SARS outbreak in Canada, the inter-relationships between evidence and ethics are explored. I outline a set of critical questions for the global public health community to discuss regarding the nature of the relationship between evidence-based public health practice and ethics.