Ethics in Public Health, Health
Care, Health Research and the
Biomedical Sciences
TH Tulchinsky MD MPH
Braun School Public Health
16 November 2010
Ancient Origins of PH
Biblical Principals
Pikuah nefesh - sanctity of human life
Tikun olam – Biblical - repair the world
Ancient India and China - sanitation
Ancient Greece
Hippocratic oath - do no harm
Healthy body-healthy mind
City states
Religion – Charity, after-life
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Medieval
The Church - Religious institutions, relieve
suffering, care of the poor
Aristocracy – noblesse oblige
Universities – royal charters
Cities – royal charters, municipal government
sanitation, hospitals
Guilds – mutual benefit “friendly” societies
Leprosy
Pandemics - undefined
The Plague
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Modern Origins of Public Health Ethics
Miasma and germ theories
Social hygiene
Scientific and PH advances during 19th-20th centuries
Government responsibility –local, state and national
Collective bargaining for health benefits
Tragic distortions of social hygiene – eugenics, genocide
Human rights – Nuremberg, Tuskegee, Helsinki
Universal right to health care (Health for All)
Self responsibility (lifestyle) in health
Advancing technology and rising costs
Public awareness and expectations
Pragmatism and science
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Ten Achievements of Public Health of
the 20th Century
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Control of infectious disease
Vaccination
Motor vehicle safety
Safer workplaces
Decline in deaths coronary heart disease, strokes
Safer and healthier foods
Healthier mothers and babies
Family planning
Fluoridation of drinking water
Recognition of tobacco as a health hazard
MMWR, 1999
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Ethics in Epidemiology
Ethics is a branch of philosophy that deals with
distinctions between right and wrong – with the
moral consequences of human actions.
The ethical principles that arise in epidemiologic
practice and research include:
Informed consent
Confidentiality
Respect for human rights
Scientific integrity
Last JM [ed]. A Dictionary of Epidemiology. Fourth Edition. 2000
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Ethics, Values, and Mission Statements in
Epidemiology
• Core values - fundamental ethical and basic scientific values
support mission and purpose of the profession
• Epidemiologic mission is to acquire new scientific
information needed to maintain, enhance, and promote the
public's health
• Different opinions about core values
• Values in the profession may gradually evolve over time e.g.
euthanasia
• Core values in epidemiology are closely related to core
values in the broader field of public health.
• "Values define us as a group of public health professionals;
values drew many of us into public health”.
Coughlin SS. Epidemiologic Review. 2000;22:169-175
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Moral Reasoning as Guide for Action
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Mandatory and voluntary
Benefits – for society and individuals
Do no harm - balance potential good and harm
Action vs. non action
Autonomy - right of self determination
Justice and equity
Case based approach
Design and conduct of research
Application of knowledge
Conflict of interests – disclosure
Autonomy - informed consent, confidentiality
Screening
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Coughlin S. Emerging Themes in Epidemiology, 2006
Ethical Issues in PH
Routinely in public health, scientific considerations blend
with political and ethical conflicts, and questions of
autonomy, individual rights, coercion, justice,
community, the common good, the norms of research,
and multi-cultural values are central.
In public health today several different types of political
and moral theory overlap, converge, and contend with
one another, including libertarian liberalism, egalitarian
liberalism, utilitarianism, human rights frameworks,
and communitarianism.
http://www.asph.org/UserFiles/E
thicsCurriculum.pdf
Ethics and Public Health:
Model Curriculum, ASPH,
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2003
New Public Health:
Individual and Population Health
Individual Health
Population Health
Bioethics = human rights,
civil liberties and
individual autonomy
approach, medicalized
system, confidentiality,
privacy,
personalized
Public health = utilitarian,
paternalistic, social and legal
responsibility to protect the
public health, community
orientation, accountability,
universal, governmental
responsibility
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Ethics in PH
• Moral imperative of PH to ensure and protect the
health of the population and the individual
• Ethical foundations traditionally implicit in PH
• The right to health
• Responsibility fro population health
• Renewed awareness of and accountability
• Conflict between individual and community rights
• Effects of doing or not doing public health
interventions or “best practices”
• New issues all the time – diasters, genocide
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When and When Not to Act
• Public (community) right to protection and best
available standards
• Dangers/costs of not acting exceed those of acting
• Judgment, experience, evidence, ethics
• Experience of Good Public Health Practice (GPHP)
• Threats of preventable mortality or risk factors
• Public right to know
• Individual rights
• Balance of contradictions
• Accountability, transparency
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Why Study Ethics in PH
• Many issues of conflict between good of the
individual and good of society
• Immunization, chlorination, fluoridation
• Food fortification
• HIV/AIDs, MDRTB, DOTs vs. DOTS Plus
• Aging and chronic diseases
• Genetically modified foods
• Technology and resource allocation
• Stem cell research
• The Case-for-Action
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Basic Questions
• Does society’s responsibilities = paternalism?
• Does freedom of individual = rejection of
responsibility of the state in health?
• Do we need informed consent for all PH
interventions?
• Do individual rights over-ride social responsibility?
E.g. AIDS contact tracing
• “Precautionary Principle” = must prove zero risk of
an new medication or PH intervention?
• Equity in health?
• Adequacy of funding and its allocation?
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Old-New Battles
• UK Variolists oppose vaccination vs. smallpox C19th
• US Opposition to public health departments in 1920s
• UK GPs oppose immunization with pertussis (1980s)
and MMR (2002+)
• AMA opposes to national health insurance 1920s +
• Civil rights vs. HIV control, 1980s US
• Anti-fluoridation 1950s to present
• Resistance to innovations e.g. MMR, Hib, Pap smear
• Anti-food fortification in Europe
• Anti-genetic engineering of food in Europe
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PH Ethical Issues
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Responsibility to protect society
Responsibility to the individual
Individual vs. community rights
Government responsibility
Corporate responsibility
Right to health care
Personal responsibility - self care
Quality of care
Freedom of choice
Acting on evidence vs. not acting
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PH Law and Ethics
• Gov’t obligation to protect health of the population
• Power of government to legislate, tax, spend,
regulate, punish
• Restriction of personal and business liberties e.g.
seat belt laws; smoking restrictions vs. human rights
• Economic, social impact of intervention vs. nonintervention e.g. inequities of the poor and rural
• Laws enacted by legislative bodies
• Court decisions
• Public scrutiny
• Accountability
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Individual Rights and PH Ethical Issues
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Right to quality health services
Provider responsibility to act for benefit of client
Euthanasia - right to die
Confidentiality – right to privacy
Informed consent – right to know
Birth control – religion vs. individual rights
Supply and distribution of resources for health
Incentives - disincentives
Equity – social, ethnic, regional
Social solidarity
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Groups at Special Risk
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Women
Children
Civilians in war and terror situations
Disaster victims
Native peoples
Minority groups
Prisoners
Military
Refugees and internal migrants
Mentally ill
Rural vs. urban
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Individual and Community PH Ethics
Individual
Community
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Sanitation
Herd immunity
Universal access
Education
Gatekeeper function
Mandatory reporting
Case follow-up
Resources for health
Cost containment
Equity
Minority and special
groups
• High risk groups
Personal hygiene
Immunization
Right to health care
Self care
Choice of provider
Right to know
Right to die
Confidentiality
Privacy
Informed consent
Patients Bill of Rights
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Public Health: “the Slippery Slope”
• 1920’s-1930’s: Eugenics movement
• 1930’s-1940’s: Mass sterilization of "defectives" in
United States and Sweden.
• 1930-1940’s: Mass murder of “defectives” in
Germany (750,000)
• 1940’s: Quarantining as pretext for ghettos by Nazis
• 1940s: Concentration camps, human experimentation
• 1940s: The Holocaust (6 million Jews and others)
• 1946 – Nuremberg Trials
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Landmarks on Individual Rights: the
Biomedical Model
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Focus on individual informed consent
Concern of exploitation and abuse of the individual
Eugenics and forced sterilization
Concentration camp medical “experiments” Nuremberg trials
Helsinki declaration
Tuskegee experiment
Declaration of human rights
Health for All
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Nuremberg Code 1946
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Nazi experiments and industrialized murder
Doctors found guilty and executed
Set new conditions for research
Subjects must have:
– Right to knowledge of purpose and effects of experiment
– Right of voluntary consent
– Right to end participation
• Scientist in charge responsible for:
– Scientific basis or validity of the hypothesis
– To terminate experiments likely to cause injury, disability,
death
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Universal Declaration of Human Rights,
1948
Article 25.
Everyone has the right to a standard of living adequate
for the health and well-being of himself and of his
family, including food, clothing, housing and medical
care and necessary social services etc.
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Helsinki Declaration 1964
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World Medical Assembly 1964 to present
Privacy and integrity of individual protected
Adequate informed consent
Research for valid scientific benefits
Accepted scientific principles
Benefits outweigh risks
Publication
Protect control group
Individual well-being vs. needs of science and
society
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Tuskegee Experiment
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Tuskegee, Mississippi
Duration 1932-1972
Conducted by US Public Health Service
To observe the natural history of syphilis
Group of black men
Treatment with penicillin available (1942)
Failed to provide information to subjects
Unethical (possibly criminal) behavior
New standards resulted
Apology by President Clinton 1996
Continues to influence sectors of US public in
response to public health initiatives
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Health for All
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WHO definition of health, 1948
Alma Ata, 1978 Health for All
Health care as a universal human right
Government responsibility
Wide acceptance
Important to help shift priorities
Still unfulfilled
Health targets
Priorities and cost-benefit decisions
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Changing Concepts of Disease
• 1960s – Ivan Illitch and McKeowan – medical care of
little value; health gains result of sanitary and
nutritional adavances
• 1970s – Marc Lalonde Health Field Concept: genetic,
environment (physical and social), lifestyle and
medical factors in health
• Evidence of risk factors for disease e.g. smoking, diet
exercise e.g. smoking and Framingham studies
• Blaming the victim vs. self responsibility?
• Health targets US Surgeon General and WHO
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Ethics
Law
Government
New Public Health
Public
Opinion
Inter
national
standards
Individual
Health
Population
Health
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The New Public Health
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Sanitation, environment, infectious disease control
Managing health systems and resources
National target e.g. reduce stroke mortality
Health promotion e.g. food fortification, smoking
restriction
Health education e.g. nutrition, exercise, self care
Personal preventive services e.g. hypertension, MI,
CHF, diabetes
Clinical standards, guidelines e.g. AMI, diabetes
Ambulatory and home care
Long term care
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Tasks of the ASPHER Ethics
Working Group
• Develop overall ethical standards of ASPHER
EUPHA and member organizations
• Develop ethical standards for public health
practice
• Develop curricula for undergraduate, masters
and PhD level studies of PH
• Promote research and publication in ethical
issues in PH
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Summary
• Government responsibility to legislate, tax, regulate
and enforce for the public health
• Protection and pro-active services for the weak, the
needy, for equity and social solidarity
• Ethical considerations
• Rights of society
• Rights of individuals
• Responsibility of individuals
• Informed consent for research
• Precaution vs. inertia
• Importance of New Public Health
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What would your mother tell
you to do?
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