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
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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
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Public Health Program Cycle
Planning
Advocacy & Consensus Building
ImplementationMonitoring & Evaluation
Justification
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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
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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)
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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:
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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
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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