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: ghaiathme@gmail.com Phone: 00966566511653

EMPHNET Meeting (Sharm Elsheikh, Dec. 5, 2011)

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?

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

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.

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

Public Health Ethics – Focus on Pandemics

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?

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)

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?

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

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

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

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

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

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.

Research & “Research-like” Activities

Research or ‘practice’?

Research

Urgent

Fast track review

Prior approval

Not urgent

RECs

Practice

Ethics considered?

Implement policy

Add ethical considerations

Yes

No

How to deal with ethical tensions in PH & during

pandemic?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

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!

Questions & Discussion

Feel free to contact:

Ghaiath HusseinAssistant Professor of BioethicsFaulty of medicine, King Fahad Medical CityRiyadh, Saudi ArabiaEmail: ghaiathme@gmail.com Phone: 00966566511653

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