Public Health Service Ethics

• New Tools for Planning and Implementation

Mark E White, MD, FACPM

Objective

Introduce you to tools of public health ethics

Give examples of how you may use them

Summarize results of meetings

Take Home Messages

Public health ethics come from you and your society

Public health ethics are tools for planning and implementation

You must assert your views

Consider the views of others openly in planning

Use public health ethics to make the world a better place

Why Bother with Ethics?

Explicitly considering ethical perspectives in planning allows you to make fairer, more effective and efficient decisions

Openly discussing ethics makes it easier to build consensus, even with those who disagree

Every decision has an ethical dimension

8

20th Century Global Health Ethics

The Golden Rule: If you take the king’s gold, you take the king’s rules (funders dictate ethics)

Individualistic ethics

Communitarian ethics

Public Health Practice• Improving a specific population’s health by making

systematic interventions based on

Science

Management

Consensus building

Ethics

• Examples: surveillance, outbreak investigations, program implementations, evaluations

9

Public Health Program Cycle

Planning

Advocacy & Consensus Building

ImplementationMonitoring & Evaluation

Justification

10

Where Ethics Can Help

Planning

Consensus Building

ImplementationMonitoring & Evaluation

Justification

Clarify priorities, assumptions and

targets

Persuade, advocate

Clarify progress towards objectives

Advocate, persuade

Open, fair processes

18

Common Ethical Issues

Prioritizing services (science based, fair)

Distributing services fairly geographically and socially (fair, effective)

Follow up on recommendations of studies (duty)

Restrict freedom (quarantine)

7

What are Ethics Anyway?

Values: “health is good”

Principles are goals: “Help others as you would like to be helped”

Processes: clarify, prioritize, justify possible courses of action

Based on ethical principles, values of stakeholders scientific information

From Drue Barrett, CDC, 2007

Values Come From You

Better population health: “Everyone can live healthy, productive lives”

Social justice: “Everyone treated fairly”

Equity: “Everyone gets an equal chance”

Solidarity: “We are in this together.”

Duty: “Health workers should take care of people with flu.

Autonomy

People usually list several, including:

17

Principles of Public Health Ethics

Based on value of justice

Inclusiveness/solidarity

Duty/Professionalism “Health workers risk their lives fighting avian influenza”

Science

Organizational Ethics: Principles & Processes

• Contribute to Public Health Public Health Ethical principles

• Accountability

• Transparency

• Efficiency

• Effectiveness

Public Health

• Based on justice

• Population is patient

• Rights of community > individuals

• Do the most good for the most people

• Protect all, including minorities

• Don’t restrict freedom unless absolutely necessary

Research Ethics

• Based on autonomy/individual rights

• Usually coercive

• Protect interests of subjects

• Assumes no benefit to subjects

• Assumes possible harm to subjects

• Very high standards of proof, documentation

Clinical Ethics

• Based on autonomy/individual rights

• Usually coercive

• Protect autonomy of patients

• Privacy

• Patient must approve

• Provider works for pateint

Why not Combine Ethics?

Public Health aims to improve the health of populations

Clinical practice and research aim to improve health of individuals

Public health ethics most useful in planning and implementing interventions

Public health ethics are tools, rarely coercive

15

Putting Perspectives Together

Cultural relativism:

Cup half empty: nobody agrees completely

Cup half full: everybody agrees on some things

Problem: Western individualists have driven the discussion so far

Opportunity: Engage Middle Eastern, Asian, Latin American, African cultures

You must speak out for your values!

Relative Importance of Principles

Take Home Messages

Public health ethics come from you

Public health ethics are tools for planning and implementation

You must assert your views

Consider the views of others openly in planning

Use public health ethics to make the world a better place

Thank You