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An introduction to ethical issues in public health practice and research I gave to master students in the Public Health Institute in Sudan -- My Home Country. This was on Jan. 5, 2012.
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Introduction to ethical issues in public healthwith emphasis on Pandemic Preparedness
Ghaiath M. A. HusseinAssistant Professor of BioethicsFaulty of medicine, King Fahad Medical CityRiyadh, Saudi ArabiaEmail: [email protected] Phone: 00966566511653
Public Health Institute (Khartoum, Jan. 5, 2012)
Public Health Institute (Sudan)
Outline
Public health (vs. clinical care) What’s Ethics? What is Public Health
Ethics (PHE)? Sources of ethical concern in public
health practice and research Why are pandemics ethically unique? Levels of pandemic effects and their
ethical implications Guiding ethical principles How to deal with ethical tensions in PH?
Which one would you drink?
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WHY? Place matters?
What do you think?
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He Killed Her!!
Levels of moral response
The expressive level (unanalyzed expressions or feeling that, by themselves, don’t provide reasons or justification)
The pre-reflective level (justification via law, religious tenets, social values, codes of ethics, etc.; accepted uncritically)
The reflective level (reasoned ethical argument/defense based on ethical principles, rules, virtues, values to which we consciously subscribe; justification provided)
Thomas J and Waluchow W, 1998
Public Health Institute (Sudan)
Ethical/Moral reasoning
It is the process we need to go through to reach a decision about an ethical issue.
It helps us to differentiate: Values and ethical principles Facts: description of the way the world is; an
actual state of affairs (“is”) Values: judgment about the way things should
be (“ought”). Ethical principles: they are meant to guide
actions. Key values in bioethics have corresponding (e.g., principle of respect for autonomy)
Public Health Institute (Sudan)
Public Health Institute (Sudan)
Key definitions and concepts
What is Public Health about?What is ethics/bioethics?What is Public Health Ethics?What is an ethical issue?
Public Health Institute (Sudan)
What is Public health about?
Definitions: “Public health is what we, as a society, do collectively to
assure the conditions for people to be healthy.” (IOM, 1988);
“the process of mobilizing and engaging local, regional, national and international resources to assure the conditions in which people can be healthy” (Oxford Textbook of public health, 2004)
"Public health is primarily concerned with the health of the entire population“ (Childress et al.)
Scope: health promotion and disease prevention throughout society)
Fields: Policy; Practice; and Research
Disease preventionHealth promotionEpidemiological studies Biostatistics
Occupational healthEnvironmental healthDeterminants of healthWSH
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Morality and Ethics…
Morality & Ethics: Morality: the beliefs and standards of good and
bad, right and wrong, that people actually do and should follow in a society, while ethics is defined as the systematic study of morality.
Metaethics: tries to clarify the rational standards and methods for the study of ethics
Normative ethics: develops ethical principles, rules, and ideals that spell out standards of good and bad, right and wrong.
What is ethics?
A system of moral principles or standards governing conduct.
a system of principles by which human actions and proposals may be judged good or bad, right or wrong;
A set of rules or a standard governing the conduct of a particular class of human action or profession;
Any set of moral principles or values recognized by a particular religion, belief or philosophy;
The principles of right conduct of an individual. (UNESCO/IUBS/Eubios Living Bioethics Dictionary version 1.4)
Public Health Institute (Sudan)
What is bioethics?
It is derived from Greek bio- life and ethicos moral.
The science/art that aims at identification, analysis, and resolution of the ethical issues in almost any field that is related to human life and health.
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Questions answered by Bioethics
▪ deciding what we should do (what decisions are morally right or acceptable);
▪ explaining why we should do it (how do we justify our decision in moral terms); and▪ describing how we should do it
(the method or manner of our response when we act on our decision).
Public Health Institute (Sudan)
Ethics
Bioethics
Clinical Ethics
Research ethics
Resource Allocation
ethics
Public Health ethics
Nursing ethics
other
Business ethics
Environmental ethics
Social ethics
Organizational ethics
IT ethics
Other
Public Health Institute (Sudan)
Public Health Institute (Sudan)
Bioethics & Public Health Ethics (PHE) Bioethics: is normative ethics applied to
decision-making and public policy in the domains of biology, health care and research.
Domains: Clinical/medical ethics Research ethics Public health ethics Environmental ethics Resource allocation ethics Organizational ethics, etc.
• Public Health Ethics (PHE): the identification, analysis, and resolution of ethical problems arising in public health practice and research
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Public Health Ethics – Focus on Pandemics
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Let’s give it a thought!
Within its efforts to control the spread of Pandemic Influenza A H1N1 during the Hajj season (2010), the Saudi government was able to provide a total of 2,500,000 doses of the newly produced vaccine.
The pilgrims are estimated to be 3,500,000; the working staff who are in contact with pilgrims (entries, security & health) are about 120,000 persons
Who should have the vaccine? Who’s first?
Public Health Institute (Sudan)
Public Health Institute (Sudan)
Sources of ethical concern in public health practice and research Public vs. individual rights Scarcity of resources Socio-political factors:
Poverty, illiteracy , minorities, vulnerability Abuse of power (public engagement)
Socio-cultural factors: Local beliefs vs. “international guidelines” Role of families and community leaders
Urgency to contain public health threats Inequalities (national and international)
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Ethical Challenges During a Pandemic
Practicality/Feasibility• Overload on health system• Urgency • Scarcity of resources
(Pharmaceutical & Non-pharmaceutical)
• Ambiguity Ethical Guidance•What is the philosophical/religious justification?•What are the guiding principles & values?•How to implement?
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Mapping of ethical issues in pandemic
International
Disproportional burden
COI (®Tamiflu, vaccine)
Community & NationalResource
allocation
Consent Public
engagementSub-optimal
productsSurveillance (research?)Inequalities
Trials (review)
Individual Loss of proper
ty &work hours
Access to care
Restricted
movement
Confidentialit
y
Professional duty
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Ethical Guidance in a Pandemic
Philosophical
• Deontological • Utilitarian (act
& rule)• Rights-based• Virtue • Casuistry• Social-contract• Principlism
Religious
• Islamic ethics & jurisprudence (Purposes of Law ‘Sharia’)
• Christian ethics
Guiding Principles
• Utility• Efficiency • Liberty • Transparency • Participation • Review and
revisability• Effectiveness • Fairness• Reciprocity• Solidarity
Public Health Institute (Sudan)
Overview on Guiding Philosophies
Deontology and principilism: Deontology is duty-based, people should act so as
to fulfill their duties to others; acts should always follow a set of maxims (e.g. do not lie); and less concerned with the act’s consequences.
Principilism is one way of approaching professional deontology
Examples: Hippocrates’ oath (“First, do no harm” or “Primum non
nocere”) Belmont Report, produced in 1978 (three principles) Beauchamp and Childress in 2001 (four principles—
beneficence, non-maleficence, respect for persons, and justice)
Rights-based ethics: involves a larger number of principles and is addressed more to the actions of institutions and governments, e.g. Universal Declaration on Bioethics and Human Rights, (UNESCO) in October 2005. It provides more binding legal rights
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Overview on Guiding Philosophies…cont.
Consequentialism (utilitarianism) the right action is that which produces
the greatest sum of pleasure in the relevant population,
• Act utilitarianism: a person should act in the way that produces the best outcome;
Rule utilitarianism: looks at the consequences of general rules instead of the consequences of individual acts
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GUIDING ETHICAL PRINCIPLES Utility: acting so as to produce the greatest good. Efficiency: calls for minimizing the resources needed
to produce a particular result or maximizing the result that can be produced from a particular set of resources.
Liberty: one should impose the least burden on personal self-determination that is necessary to achieve a legitimate goal
Fairness: “treating like cases alike” Reciprocity: individuals (professionals) accept of the
risk in executing their duties would engender reciprocal duties on the part of the community to them
Proportionality: actions taken proportional to need
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Ethics of the Decision-making Process
If we can not agree on what’s fair distribution, let’s at least agree on a procedural justice (fair process).
“Fair process” (Norman Daniels’ A4R) suggests a set of principles that need to be followed in decision making: Transparency/publicity: information about the processes and
bases of decisions should be made available to the affected population
Participation: the stakeholders should be involved in the processes of formulating the objectives and adopting the policies.
Effectiveness/Relevance: states that there must be ways to translate the other principles into practice relevant to meeting population health needs fairly
Appeal: Stakeholders should have a way to appeal policies after they have been adopted, and processes should be in place that allow policies and plans to be reviewed and revised.
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Research & “Research-like” Activities
Research or ‘practice’?
Research
Urgent
Fast track review
Prior approval
Not urgent RECs
PracticeEthics
considered?
Implement policy
Add ethical considerati
ons
Yes
No
Public Health Institute (Sudan)
How to deal with ethical issues in PH?
Source of tension
Suggested ethical/practical approach
Differences in guiding references/principles
-Local (national) deliberation-Regional meetings-Unifying/Uniforming int’l ethical guidance to include local sources
Scarcity of resources
-Develop a fair decision-making process-Prior priority setting standards & guidance
Urgency -Prior planning-‘Ethical drills’-‘Fast track’ review mechanism -On-call ethicist
Public Health Institute (Sudan)
Key messages and conclusions
Proactive ethical preparedness, learning from past experiences (SARS, H5N1, and H1N1)
Involvement of ethics in the PH policy development process
Active public engagement Develop an ethics comprehensive and flexible
consultation and review mechanism International (UN) agencies should advocate for the
least powerful nations (Fair international governance) Though agreeing on the guiding principles to make a
fair decision is difficult; it is possible to agree on a fair decision making process
Make sure the voice of the voiceless is heard!
Public Health Institute (Sudan)
Questions & Discussion
Feel free to contact:
Ghaiath HusseinAssistant Professor of BioethicsFaulty of medicine, King Fahad Medical CityRiyadh, Saudi ArabiaEmail: [email protected] Phone: 00966566511653
Public Health Institute (Sudan)
References
Principles of the Ethical Practice of Public Health; Public Health Leadership Society (2002)
Ethics and Public Health: Model Curriculum. Ed. Bruce Jennings et al. (2003)
Childress JF, Faden RR, Gaare RD, Gostin LO, Kahn J, Bonnie RJ, Kass NE, Mastroianni AC, Moreno JD, Nieburg P: Public health ethics: mapping the terrain. J Law Med Ethics 2002, 30:170-8.
Public health: disconnections between policy, practice and research. Jansen et al. Health Research Policy and Systems 2010, 8:37
Ethical issues in epidemiologic research and public health practice. Steven S Coughlin. Emerging Themes in Epidemiology 2006, 3:16
Accountability for reasonableness. Norman Daniels, BMJ 2000;321:1300-1301