Ethics and public health: forging a strong relationship

The field of bioethics arose in the late 1960s in response to the emerging ethical dilemmas of that era. The field for many years focused in general on the dilemmas generated by high-technology medicine rather than on issues of population health and the ethical problems of public health programs and regulations. The time has come to more fully integrate the ethical problems of public health into the field of public health and, at the same time, into the field of bioethics. Public health raises a number of moral problems that extend beyond the earlier boundaries of bioethics and require their own form of ethical analysis.     

Photovoice ethics: perspectives from Flint Photovoice.

Photovoice is a participatory health promotion strategy in which people use cameras to document their health and work realities. As participants engage in a group process of critical reflection, they may advocate for change in their communities by using the power of their images and stories to communicate with policy makers. In public health initiatives from China to California, community people have used photovoice to carry out participatory needs assessment, conduct participatory evaluation, and reach policy makers to improve community health. This article begins to address ethical issues raised by the use of photovoice: the potential for invasion of privacy and how that may be prevented; issues in recruitment, representation, participation, and advocacy; and specific methodological techniques that should be used to minimize participants' risks and to maximize benefits. The authors describe lessons learned from the large-scale Flint Photovoice involving youth, adults, and policy makers.     

Translating ethics: researching public health and medical practices in Nepal

Conducting anthropological research into situations where public health interventions are ongoing raises a number of complex ethical issues. This paper addresses this by focusing on recent debate around questions of informed consent in research situations into health care in the 'developing' world. Two issues are developed: firstly, that of anthropological engagement with medical research trials; and secondly, how medical ethics debates have impinged upon and influenced anthropological ideas of ethics. Drawing on personal anthropological research into the implementation of the WHO prescribed tuberculosis control programme (DOTS) in the context of Nepal, I outline a number of ethical dilemmas and issues that arose. This research context included other ongoing research into DOTS implementation, as well as the local culture of health care provision. It involved moving between a number of sites and subject positions while interacting with heath professionals and patients. In conclusion, rather than prescribing ethical norms for researchers in such situations, I argue that we need more ethnographic examples and case studies as a means of thinking through the issues. I suggest that we need to reflect on both the ethical issues that arise when undertaking research into multifaceted public health interventions and into the situations where ethical guidelines and stipulations are formulated. The best place for this may be the Internet, where we increasingly see the conditions emerging for open dialogue.     

Occupational health practice and exposure to nanoparticles: reconciling scientific evidence, ethical aspects, and legal requirements

The paper aims at focusing the relationship between scientific evidence and ethical values' issues of occupational health practice according to the new Italian law 81/2008 stating that the occupational health physician (OHP) is required to act according to the Code of Ethics of the International Commission on Occupational Health. The code itself emphasizes that (i) the practice should be relevant, knowledge-based, sound, and appropriate to the occupational risks and (ii) the objectives and methods of health surveillance must be clearly defined. Because exposure to nanoparticles involves several uncertainties about health effects and may limit the effectiveness of workers' health surveillance, OHPs face a several ethical dilemmas, involving different stakeholders. The dilemmas arising from the practice should be dealt with according to the ethical principles of beneficence, autonomy, and justice in order to take a decision.     

Ethical issues in nutrition and human immunodeficiency virus.

Ethical dilemmas often arise in the provision of healthcare. In view of the advances in human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) medical management since the late 1990s, many of the challenges and ethical dilemmas encountered by healthcare professionals have changed from terminal or end-of-life issues to long-term management issues. This article presents 5 case scenarios on common ethical issues faced by those providing nutrition care to people living with HIV/AIDS and addresses key questions to ask in the ethical deliberative process. Ethical dilemmas surrounding the use of complementary and alternative medicine, providing aggressive nutrition support, dealing with third-party payers for supplement reimbursement, and managing patients with mental health disorders and substance abuse issues are discussed, with possible solutions presented from an ethics point of view.     

Ethics in international health research: a perspective from the developing world

Health research plays a pivotal role in addressing inequities in health and human development, but to achieve these objectives the research must be based on sound scientific and ethical principles. Although it is accepted that ethics play a central role in health research in developing countries, much of the recent debate has focused on controversies surrounding internationally sponsored research and has taken place largely without adequate participation of the developing countries. The relationship between ethical guidelines and regulations, and indigenously sponsored and public health research has not been adequately explored. For example, while the fundamental principles of ethical health research, such as community participation, informed consent, and shared benefits and burdens, remain sacrosanct other issues, such as standards of care and prior agreements, merit greater public debate within developing countries. In particular, the relationship of existing ethical guidelines to epidemiological and public health research merits further exploration. In order to support health research in developing countries that is both relevant and meaningful, the focus must be on developing health research that promotes equity and on developing local capacity in bioethics. Only through such proactive measures can we address the emerging ethical dilemmas and challenges that globalization and the genomics revolution will bring in their wake.     

Social workers' participation in the resolution of ethical dilemmas in hospice care

Ethical dilemmas are inherent in every health care setting. A sample of hospice social workers with no direct access to a hospice ethics committee (N = 110) was surveyed regarding ethical issues in hospice care, how the issues were managed, and the extent to which social workers participated in resolution of ethical dilemmas. Common issues discussed were the patients' medical condition, involvement of family, and family denial of terminal illness. Difficult cases were discussed most often in interdisciplinary team meetings. Social workers were most involved in traditional social work activities, such as providing knowledge of community resources and patients' psychosocial histories and promoting self-determination in policies.     

A Social Work Perspective on Ethical Practice in End-Stage Renal Disease

Social workers increasingly are defining problems that they encounter in practice in health settings as ethical dilemmas. A distinction is made between those practice questions that can best be answered by an appeal to theoretical or empirical knowledge and expertise (clinical questions) and those with invoke values and ethical imperatives (ethical questions). End-stage renal disease poses in high relief the practice dilemmas that are encountered by social workers and offers an opportunity to explore and clarify issues resolving them. Using an exchange framework as a basis for analysis, common ethical problems of end-stage renal services are discussed.     

On the nature and ethics of health promotion. An attempt at a systematic analysis

This paper attempts to analyse the notion of health promotion and related conceptual issues within an action-theoretical framework. The purpose is both theoretical and ethical. The paper provides a taxonomy as well as a system for classifying various types of health promotion. This system is inspired by Professor G H von Wright's theory of action explanation. The theoretical framework is used in the ethical part of the paper where some major ethical dilemmas in health promotion are analysed. Particular attention is paid to the use of manipulation and force in health promotion. An attempt is made to define when such measures are justified in various health enhancing contexts.     

Ethical and Regulatory Issues with Conducting Sexuality Research with LGBT Adolescents: A Call to Action for a Scientifically Informed Approach

Lesbian, gay, bisexual, and transgender (LGBT) adolescents experience disparities in mental and sexual health. There is also a lack of research on this population relative to other adolescents, which limits our ability to effectively address these health disparities. Researchers may unfortunately avoid conducting research with this population because of anticipated or actual experiences with difficulties in obtaining IRB approval. A case example is provided to illustrate the ethical and regulatory issues related to research with LGBT adolescents. Relevant U.S. federal and local regulations related to research on sexual and mental health with adolescents is then reviewed. Data are presented demonstrating that requiring parental consent for LGBT youth under age 18 would likely alter study result. Data are also presented on participants' appraisals of the risks and discomforts associated with research participation. The provision of such empirical data on the risks of research participation is consistent with the goal of moving the IRB process of risk/benefit assessment from being entirely subjective to being evidence-based. Finally, recommendations are provided on how to approach these issues in IRB applications and investigators are called to help to build a corpus of scholarship that can advance empirical knowledge in this area.     

Ethical Issues in Public Health Practice in Michigan

Objectives. We sought to ascertain the types of ethical challenges public health practitioners face in practice and to identify approaches used to resolve such challenges.Methods. We conducted 45 semistructured interviews with public health practitioners across a range of occupations (e.g., health officers, medical directors, sanitarians, nurses) at 13 health departments in Michigan.Results. Through qualitative analysis, we identified 5 broad categories of ethical issues common across occupations and locations: (1) determining appropriate use of public health authority, (2) making decisions related to resource allocation, (3) negotiating political interference in public health practice, (4) ensuring standards of quality of care, and (5) questioning the role or scope of public health. Participants cited a variety of values guiding their decision-making that did not coalesce around core values often associated with public health, such as social justice or utilitarianism. Public health practitioners relied on consultations with colleagues to resolve challenges, infrequently using frameworks for decision-making.Conclusions. Public health practitioners showed a nuanced understanding of ethical issues and navigated ethical challenges with minimal formal assistance. Decision-making guides that are empirically informed and tailored for practitioners might have some value.In 2002, the Public Health Leadership Institute stepped beyond the implicit assumption that an ethical foundation exists for public health practice and formally articulated a code of ethics.¹ The creation of the code was an effort both to clarify and to publicize the ethical underpinnings of the field. Numerous scholars have likewise identified areas within public health practice and policy that they suggest engender ethical issues, tensions, and debate. Often, the literature on public health ethics emphasizes distinctions between ethical challenges that arise in clinical medicine and those that arise in public health practice. Many have argued that the orientation, problems, and values of public health are different enough from those of medicine that the tools and constructs of bioethics or medical ethics are insufficient to address ethical issues in public health. In particular, scholars suggest that the emphasis on individual autonomy in bioethics does not cohere with the population orientation of public health.^2–6Despite the development of the code of ethics and an abundance of theoretical analysis, a dearth of empirical evidence remains about the types and nature of ethical issues faced by public health practitioners and how they approach or resolve such issues. Two previous studies in the United States have examined areas of ethical tension for practitioners. Bernheim⁷ conducted 3 focus group interviews with practitioners from different levels of government. These practitioners identified ethical issues in the areas of public–private partnerships, allocation of scarce resources, collection and use of data, and politics.⁷ A study of public health nurses in Louisiana reported ethical conflicts in the areas of confidentiality, informed consent, conflict of interest, and whistle-blowing.⁸Although these 2 studies highlighted some ethical issues for practitioners, further development of the empirical knowledge base is essential for progress in the fledgling field of public health ethics. Solid philosophical and empirical grounding may enable theory and practice to validate and enhance each other. A deeper understanding also may help clarify the types of evaluation tools most useful for decision-making and resolution of ethical conflict. To begin to fill these gaps in the literature, we interviewed public health practitioners in Michigan to broaden our understanding of what constitutes an ethical challenge in public health practice and to explore the processes that practitioners use to deal with ethical issues that arise.     

For the good of many: an infection control perspective on ethics

The decisions made by infection control personnel affect both individuals and those in the broader patient population in a health care facility. In making the decisions required to provide an environment free of infectious risks, while maintaining the rights of individuals to attain optimal health outcomes, infection control practitioners are often confronted with ethical dilemmas.This article describes an ethical dilemma commonly faced in infection control practice, where the needs of one patient must be weighed against the needs of the patient population. A case study describing the decision to isolate an infectious patient is presented, highlighting the role that ethics plays in decisions made to control infection. A decision making framework is applied to ensure that the needs of both individuals and groups are considered. Resource considerations and the need to conform to basic microbiological and epidemiological principles are also considered. The various issues in conflict are described, analysed, resolved and rationalised. The use of a decision making framework can help to ensure that competing interests are carefully considered to produce an ethical, and optimal, decision.     

Ethical dilemmas in research on Internet communities

There has been a rapid growth in the number of articles using Internet data sources to illuminate health behavior. However, little has been written about the ethical considerations of online research, especially studies involving data from Internet discussion boards. Guidelines are needed to ensure ethical conduct. In this article, the authors examine how a youth-focused research program negotiated ethical practices in the creation of its comprehensive health site and online message board. They address three situations in which ethical predicaments arose: (a) enrolling research participants, (b) protecting participants from risk or harm, and (c) linking public and private data. Drawing on the ethical principles of autonomy, nonmaleficence, justice, and beneficence, the authors present practical guidelines for resolving ethical dilemmas in research on Internet communities.     

Ethical dilemmas in choosing a healthful diet: vote with your fork!

Dietary guidelines for health promotion and disease prevention in the USA recommend a consumption pattern based largely on grains, fruit and vegetables, with smaller amounts of meat and dairy foods, and even smaller amounts of foods high in fat and sugar. Such diets are demonstrably health promoting, but following them raises ethical issues related to the role of nutritionists in advising the public about healthful dietary choices, as well as to the role of the food industry in food production and marketing. In the USA a shift towards a more plant-based diet would affect the economic interests of producers of food commodities, food products and meals prepared outside the home; it would also affect the environment, food prices, trade with other countries (developing as well as industrialized) and relationships among the food industry, government agencies (domestic and international) and food and nutrition professionals. In a free-market economy any dietary choice has consequences for food producers. Thus, considerations of ethical dilemmas in choosing healthful diets suggest that food choices are political acts that offer opportunities for all parties concerned to examine the consequences of such choices and 'vote with forks'.     

Building evidence for legal decision making in real time: legal triage in public health emergencies

Similar to the triaging of patients by health care workers, legal and public health professionals must prioritize and respond to issues of law and ethics in declared public health emergencies. As revealed by the 2009-2010 H1N1 influenza outbreak and other events, there are considerable inconsistencies among professionals regarding how to best approach these issues during a public health emergency. Our project explores these inconsistencies by attempting to assess how practitioners make legal and ethical decisions in real-time emergencies to further critical public health objectives. Using a fictitious scenario and interactive visualization environment, we observed real-time decision-making processes among knowledgeable participants. Although participants' decisions and perspectives varied, the exercise demonstrated an increase in the perception of the relevance of legal preparedness in multiple aspects of the decision-making process and some key lessons learned for consideration in future repetitions of the exercise and actual, real-time emergency events.     

Research on tobacco use among teenagers: ethical challenges

Recent increases in adolescent smoking portend upcoming public health challenges as the majority of smokers initiate long-term addiction during youth, but experience major health consequences later in life. To effectively address this important teenage and adult health issue, critical research information and early interventions are needed, yet conducting tobacco research with teen smokers poses substantial challenges, including several ethical dilemmas. This paper reviews some of the ethical issues presented in etiologic and clinical treatment research addressing adolescent smoking. Common problems and possible solutions are presented. Issues of parent/guardian involvement, decision-making ability of teens, the need to maintain confidentiality are discussed, along with the specific problems of recruitment, compensation, and ethical challenges that arise in group treatment settings. Context-specific ethical adjustments and alternative perspectives are likely to be needed if we are to overcome procedural difficulties in conducting teen smoking studies.     

Ethical issues in nanomedicine: Tempest in a teapot?

Nanomedicine offers remarkable options for new therapeutic avenues. As methods in nanomedicine advance, ethical questions conjunctly arise. Nanomedicine is an exceptional niche in several aspects as it reflects risks and uncertainties not encountered in other areas of medical research or practice. Nanomedicine partially overlaps, partially interlocks and partially exceeds other medical disciplines. Some interpreters agree that advances in nanotechnology may pose varied ethical challenges, whilst others argue that these challenges are not new and that nanotechnology basically echoes recurrent bioethical dilemmas. The purpose of this article is to discuss some of the ethical issues related to nanomedicine and to reflect on the question whether nanomedicine generates ethical challenges of new and unique nature. Such a determination should have implications on regulatory processes and professional conducts and protocols in the future.     

The ethics of executive compensation in the Canadian public health system

The method of executive compensation in the Canadian public health system presently contains complex ethical issues related to transparency and fairness, not only within single organizations, but across provinces, and in comparison with other wage earners. The increasing interest of the public, elected officials, and health decision makers in public sector compensation will bring heightened scrutiny and intervention in the future. This article explores some of the current ethical issues of executive compensation and their implications and points to reform initiatives for the future.     

The pharmaceutical sales rep/physician relationship in Turkey: ethical issues in an international context

In many developed countries, the physician/pharmaceutical sales representative relationship has increasingly become the focus of ethical questions. Given this context, the purpose of the present study was to determine the ethical dilemmas faced by pharmaceutical sales representatives in Turkey in their relations with physicians, and to identify possible solutions. Through an investigator-designed questionnaire, the ethical problems perceived by 215 pharmaceutical sales representatives were quantitatively analyzed. Nearly all of the participants (96.7%) reported that they had faced ethical dilemmas in marketing drugs to physicians. The most commonly reported problems included paramedical requests (for free lab test kits, etc.) and the necessity of bargaining with physicians over the use of their firm's drugs by offering gifts and sponsorships. The participants in the study felt that physicians were the primary source of ethical problems in the marketing of drugs, and the participants' most highly ranked potential solution to these ethical problems was a better understanding, on the part of physicians, of the role of pharmaceutical sales representatives. At the end of this study, suggestions are given with a view to helping health policy makers understand and address the current controversies involving drug company representatives and physicians.