PORTLAND STATE UNIVERSITY
PAH 573: Values and Ethics in Health
Spring 20??
Class Meetings:
Monday, 6:40 – 9:20 p.m.
Location TBA
Professor:
Sherril B. Gelmon, Dr.P.H.
Professor of Public Health
Mark O. Hatfield School of Government
Office:
Room 670N, College of Urban and Public Affairs
Contact Via:
Phone: 503-725-3044; Fax: 503-725-8250
E-mail: gelmons@pdx.edu
Office Hours:
Mondays, 4:00 - 5:30 p.m. and Tuesdays, 2:00 – 3:30 p.m.
Other times by appointment.
Course Description
This course addresses issues and questions regarding values and ethics in health, with particular
attention to public health practice and health policy and management. It provides students with
opportunities to consider issues in health and social services that challenge values and pose
ethical issues, and assists students in addressing these issues in the context of both personal and
organizational values and beliefs. Specific course content includes, but is not limited to, ethical
issues such as reproductive issues, emerging diseases, product liability, pharmaceutical controls,
advertising, occupational and environmental issues, and research dilemmas.
Prerequisites
There are no formal prerequisites for this course, although it is generally taken late in the
Master’s program after many other health courses. Students should have good familiarity with
the organization and delivery of health or social services, either through work experience or class
learning. If you feel you do not have this knowledge, please speak to me during the first week of
classes to discuss the suitability of the class for you.
Learning Competencies
The learning competencies for each student to develop by the completion of this class are to:
• develop knowledge of ethical issues in public health and health management;
• analyze personal values and understand how they shape individual responses to ethical
challenges;
 understand the nature of ethical conflict;
• conduct ethical analyses by applying knowledge of ethics to a variety of issues; and
• gain skills in articulating and critiquing ethical controversies.
At the conclusion of the course, students will be asked to determine the extent to which they
have developed these competencies through their own learning.
1
Methods of Evaluation
There will be multiple methods of evaluation that will determine both your course grade and the
evaluation of the course itself.
1. Evaluation of Students
The course grade will be determined as follows:
Personal values statement
Case analysis
Group ethical analysis and presentation
Response to ethical challenge
Class participation
10%
20%
30%
25%
15%
2. Evaluation of Course and Professor
I am eager to receive your feedback on the class, and will conduct brief process evaluations
periodically to invite your input. On the basis of your comments, we will make "mid-course
corrections" as necessary to ensure that the class meets your needs and is responsive to your
suggestions, while still fulfilling the learning objectives set out above. A final evaluation of the
course and the professor will be conducted during the last class session.
Required Readings
There is one required textbook for this course; it is available in the PSU bookstore:
Barry S. Levy and Victor W. Sidel, eds. Social Injustice and Public Health. New York,
NY: Oxford University Press, Inc., 2006.
There are some excerpts from the Encyclopedia of Bioethics that you are required to read in
advance of the class on April 14th. The encyclopedia is in the reference section on the 2nd floor
of the PSU library, and in the reference department of the OHSU library (Section 21). You will
use these materials throughout the class. The citation is:
Stephen G. Post, ed. Encyclopedia of Bioethics. Third edition. New York: Macmillan
Publishing Company, 2004. [PSU: QH 332.E52 2004; OHSU: WB 13 E566 2004]
Please read the following sections and bring copies of these with you for the class discussion on
April 14th:
 Bioethics, Vol. 1 (p. 278-286)
 Harm, Vol. 2 (p. 1033-1038)
 Justice, Vol. 3 (p. 1354-1361)
 Responsibility, Vol. 4 (p. 2379-2385)
 Rights: Patients Rights, Vol. 4 (p. 1995-2004); Rights of Conscience, Vol. 1 (p. 517-520).
Description of Major Assignments
1. Personal Values Statement (10% of course grade)
I would like you to begin thinking about your own values and perspectives on ethical issues in
health by writing a personal values statement. This will build on an exercise we will complete in
class during the first session. This assignment is due at the beginning of class on April 14th.
2
The purpose of the assignment is to reflect on how you approach issues of values and ethics in
health. Please provide your thoughts/comments on each of the following:
 your background in health services -- professional training and experience, as well as other
significant interactions with the health system (your own, family or friends) which have
ethical overtones or have challenged your values;
 your background in ethics -- religious upbringing, family, culture; courses in philosophy,
theology or other perspectives on moral decision-making; preferred style of reasoning;
 other experiences that will help you focus your own perspective on values and ethics, and
will help me understand your learning style for this course;
 your learning goals for a course on values and ethics in health;
 your thoughts on your responses on the personal values exercise completed in class on March
31st; and
 interpretation of this analysis in the context of either the Public Health Code of Ethics or the
ACHE Code of Ethics (see citation under description of Session 2 -- April 7).
The values statement must be typed, double-spaced using a normal 12 point font and standard 1"
margins, and proofread for spelling and grammar. It should be 4-5 pages in length. A late
assignment will result in a reduction in course credit. Graded assignments will be returned in
class on April 21st.
2. Case Analysis (20%)
The case analysis will allow you to refine your skills at presenting or writing up an ethical
analysis, and will not require detailed literature review. The analysis will follow a framework
we will use in class for resolving ethical dilemmas. You will either present the case in class, or
prepare a written analysis. A list of cases from which to choose is appended; each student will
indicate their preferences for the case they would like to review in class on March 31st, as well
as their preference for oral or written presentation. Cases will be assigned within two days of the
first class and notification emailed to students. Only one student will present each case in class;
more than one student may write up each case. The schedule of case presentations complements
content being discussed in each class session.
Public domain copies of the cases (PDF files) will be emailed to all class members two weeks
prior to each class. You may also access the cases in either the PSU or OHSU libraries, or
through online access. You are expected to have read the case before class, and should bring a
copy of the case and supporting commentaries to class with you. Most cases and commentaries
are a total of 2-3 pages in length. The case analysis is worth 20% of your final grade. Written
and oral case presentations are worth equal amounts.
For oral presentations, the presenter will prepare and distribute an outline of the presentation,
copies of the slides used in the presentation (use of PowerPoint is encouraged), and questions for
discussion. The presentation should briefly summarize the key points of the case, and emphasize
analysis of the material using the framework for analysis. The presentation should be 10 minutes
in length, followed by 10 minutes of discussion facilitated by the presenter. No written
submission is necessary for the oral presentations. Presenters should email their PowerPoint
presentation to the professor no later than 8:00 p.m. the evening before their presentation day.
3
The written cases are due at the beginning of class on the same day as the oral presentation.
These should be 4-5 pages in length. The written submission should briefly summarize the key
points of the case, and emphasize analysis of the material using the framework for analysis. It
must be typed, double-spaced using a normal font (12 point) and standard 1" margins, and
proofread for spelling and grammar. A late assignment will result in a reduction in course credit.
3. Group Ethical Analysis and Presentation (30%)
The aim of this assignment is to work as a group to conduct an ethical analysis, debate multiple
perspectives, achieve some consensus on ways to approach the issue, and present your findings.
Particular attention should be paid to means of reconciling potentially conflicting perspectives,
and the socio-political ramifications of choosing various resolutions to ethical issues. The topics
are based upon the section of the text entitled “What Needs to Be Done” and present the
opportunity to highlight elements of the four core concepts that will be discussed throughout this
course -- rights, harm, responsibility, and justice. At least one other chapter from the text is
designated as an area of focus for illustrating the core ethical analysis. The topics to choose from
are:
 Addressing social injustice in a human rights context (Ch. 22, plus Ch. 17 on
assaultive violence and war)
 Promoting social justice through public health policies, programs and services (Ch.
23, plus Ch. 20 on oral health)
 Strengthening communities and the roles of individuals in community life (Ch. 24,
plus Ch. 18 on environmental health and Ch. 19 on occupational safety and health)
 Promoting social justice through education in public health (Ch. 25, plus Ch. 14 on
nutrition)
 Protecting human rights through international and national law (Ch. 27, plus Ch. 21
on international health)
 Promoting equitable and sustainable human development (Ch. 28, plus Ch. 12 on
medical care and Ch. 15 on chronic diseases)
Before the class on April 7th, students should email their ranked preferences for the group
project to the professor (please rank all six choices); groups will be assigned in the class on
April 7th. The groups will use a common framework for ethical analysis that we will discuss in
class. All presentations will take place in the final class session on June 2nd.
The group work will build on the class readings and discussion; additional literature review may
be necessary beyond course materials. Each presentation will last 15 minutes, followed by 10
minutes of discussion (facilitated by the group). All members of a group are expected to present.
The presenters are expected to provide an outline of the presentation, copies of the slides used in
the presentation (use of PowerPoint is recommended), and questions for discussion. The 30% of
course credit will be allocated as follows: 15% group presentation, including use of printed
materials and audiovisual aids (all students receive the same credit; you will be evaluated by the
professor); 10% assessment of individual performance in the group presentation by the professor;
and 5% peer evaluation of the group. No written paper is required.
4. Response to Ethical Challenge (25%)
Certain topics challenge our own values, and require consideration of ethical implications to
resolve them. This assignment will enable you to draw upon group discussion to consider the
4
ramifications of a topic, and you will then independently write up the assignment. The groups
will be pre-assigned by the professor and will be announced at the beginning of class on May
5th; you will work in that group during that class session. No other group meeting should take
place regarding this assignment. The topics will be assigned to ensure that each student has the
opportunity to discuss and consider as many topics as possible, taking into consideration each
student's topic selection for the case analysis and for the group presentation.
A brief scenario will be provided for each topic. Your discussion and written submission should
include the following: identification of key players and their roles; ethical implications;
consideration of core topics of justice, rights, harm, and responsibility; and how this issue can be
resolved in an ethical manner. You should draw upon course materials and discussions;
additional citations are necessary only if you need them to support your discussion. It should be
3-4 pages in length. Your write-up of the ethical challenge is due at the beginning of class on
May 12th. It will be returned in class on May 19th.
5. Class Participation (15%)
Fifteen percent of the grade will be allocated to class participation; this includes preparation for
each class session, active participation in discussions, and general involvement in class activities.
Participation in the class sessions is an important part of your learning -- to reflect on the reading
and thinking you are doing related to the course content, to engage in discussions with your
classmates and professor, and to ask questions and seek answers from all participants in the
class. You are expected to attend all class sessions. If you must miss a class, please let me know
in advance so that you may arrange to make up missed content.
Expectations
A course syllabus can be viewed as a contract between the professor and the students. This
syllabus includes all expectations for performance in the class, and you should now understand
what is required of you, and the deadlines for assignments. If you have questions about any of
these expectations, please discuss them with me as soon as possible. Any changes in the course
requirements or schedule will be communicated in class. I will try to be accommodating of
personal crises that affect attendance or submission of assignments in terms of working out
suitable and fair arrangements for grading, but also need to be fair to all students in the class.
Course Schedule (note to curriculum committee – readings subject to change each year)
The following is the anticipated schedule of class topics, readings, and assignments. Assigned
readings should be completed in advance of the class when they will be discussed; please bring
your readings to class to facilitate reference during class discussions.
Session 1 – March 31
Introductions and overview of syllabus
Identification of core ethical issues
Understanding ethics and its relationship to law, politics, other frameworks
Values exercise
Due: Indicate preferences for case analysis
Within two days of class: Assign cases for presentation/write-up
Due before class on April 7 by email: Indicate preferences for group presentations
5
Session 2 – April 7: Introduction to ethical theory and applications
Population and community perspectives
Public health ethics
(continued next page)
6
Session 2 – April 7 (continued)
Justice and health services
Codes of ethical practice and conduct
Framework for ethical analysis
Assign groups for group presentations
Readings: Levy and Sidel, Chapters 1, 2
Steven Pinker. “The Moral Instinct.” New York Times Magazine, January 13, 2008.
Download and review American College of Healthcare Executives "Code of Ethics" at
www.ache.org/abt_ache/code.cfm
Handout: AMA “Principles of Medical Ethics Preamble” and “ANA Code of Ethics for
Nurses Provisions”
Download and review the “Public Health Code of Ethical Practices” at
http://www.apha.org/programs/education/progeduethicalguidelines.htm
Download and review AcademyHealth’s “Ethical Guidelines for Managing Conflicts of
Interest in Health Services Research” at
http://www.academyhealth.org/ethics/summary.htm
Session 3 – April 14: Bioethics, justice, rights, harm, responsibility
Readings: Selections from the Encyclopedia of Bioethics
Due: Personal values statement
Case #1: “Shouldering the Burden of Care”
Case #2: “Old Enough”
Case #3: “The Child That Might Be Born …”
Due: Written case analyses of Cases #1-3
Session 4 – April 21: Perspectives of Individual Identity
Gender, race, sexual orientation, different abilities
Readings: Levy and Sidel, Chapters 3, 4, 7, 8
Case #4: “Competent Refusal of Nursing Care”
Case #5: “Making Room for Alternatives”
Case #6: “Culture Clash Involving Intersex”
Due: Written case analyses of Cases #4-6
Return: Written case analyses of Cases #1-3
Return: Personal values statement
Session 5 – April 28: Lifecycle and Life Events Perspectives
Younger, older, incarcerated, and homeless people
Readings: Levy and Sidel, Chapters 5, 6, 9, 10
Case #7: “A Request for ICSI”
Case #8: “Resuscitating a Bad Patient”
Case #9: “Dialysis for a Prisoner of War”
Due: Written case analyses of Cases #7-9
Return: Written case analyses of Cases #4-6
Session 6 – May 5: Responding to an Ethical Challenge
In-class group work, followed by individual written assignment
Return: Written case analyses of Cases #7-9
7
Session 7 – May 12: Situational Perspectives
Migrants, people with infectious diseases, people with mental health issues
Advance directives and individual choice
Readings: Levy and Sidel, Chapters 11, 13, 16
"Making Health Care Decisions When You Can't Speak for Yourself" (Oregon advance
directive)
Case #10: “Before He Wakes”
Case #11: “Doctor, Will You Turn Off My LVAD?”
Case #12: “Covert Video Surveillance in Pediatric Care”
Due: Written case analyses of Cases #10-12
Due: Response to ethical challenge
Session 8 – May 19: Ethical issues in research
Readings: Levy and Sidel, Chapter 26
Vanessa Gamble. "Under the Shadow of Tuskegee" American Journal of Public Health
87 (November 1997): 1773-1778.
Carl Elliott. “Guinea-Pigging.” The New Yorker January 7, 2008.
PSU Human Subjects Research Review Committee “Application Guidelines for Research
Involving Human Subjects” available at http://www.rsp.pdx.edu/forms/hsrrc_app.pdf
Also review the narrative for 1) Application and Review and 2) Review Types at
http://www.rsp.pdx.edu/compliance_human.php (this narrative is also included in the
Application Guidelines)
Case #13: “The Abuse of Alternative Medicine?"
Case #14: “All for One, or One For All?”
Case #15: “Informed Consent from the Doctor?”
Due: Written case analyses of Cases #13-15
Return: Written case analyses of Cases #10-12
Return: Response to ethical challenge
Session 9 – May 26
No class, Memorial Day Holiday
Session 10 – June 2: What Needs To Be Done
Group presentations
Reflections on learning about values and ethical issues
Final course evaluation
Return: Written case analyses of Cases #13-15
8
Schedule of Assignments for Personal Planning
Class Session
1 – March 31
Personal
Values
In-class
exercise
Case
Ethical
Challenge
Indicate preferences
Cases assigned
2 – April 7
Indicate preferences
Groups assigned
3 – April 14
Write-up due
#1-3 due
4 – April 21
Returned
#4-6 due
5 – April 28
#7-9 due
6 – May 5
In-class work
7 – May 12
#10-12 due
Write-up due
8 – May 19
#13-15 due
Returned
9 – May 26
10 – June 2
Group Ethical
Analysis and
Presentation
Memorial Day Holiday, no class
Presentations
9
Hastings Center Report Case Studies (subject to change each year)
April 14
Case #1: “Shouldering the Burden of Care” Vol. 35, #5, September-October, 2002, p. 14-15
Focus: 52 year old woman caring for her elderly demented mother at home, facing decision to
place the mother in a nursing home despite mother’s wishes and opposition of family members
Issues: Autonomy, rights, harm, benefit for self vs. benefit for others
Present:
Write:
Case #2: “Old Enough” Vol. 37, #6, November-December 2007, p. 15-16
Focus: 13 year old girl, Jehovah’s Witness, refuses treatment with blood products on religious
basis, pediatrician may seek court order to require treatment
Issues: Autonomy, religious beliefs vs. professional judgment, harm
Present:
Write:
Case #3: “The Child That Might Be Born …” Vol. 32, #3, May-June, 2002, p. 11-12
Focus: Parents seeking in vitro fertilization treatment to conceive a child who can provide cord
blood to treat thalassemia of their 3 year old child
Issues: Rights, harm, personal welfare, physical and psychological risks/consequences
Present:
Write:
April 21
Case #4: “Competent Refusal of Nursing Care” Vol. 36, #2, March-April 2006, p. 14-15
Focus: 50 year old morbidly obese Hawaiian woman with a history of diabetes, hypotension, and
chronic atrial fibrillation; refuses to accept nursing care
Issues: Rights, choice, professional responsibility vs. patient preference
Present:
Write:
Case #5: “Making Room for Alternatives” Vol. 30, #3, May-June, 2000, p. 26-28
Focus: 10 year old Hmong boy, end-stage renal disease, parents want Hmong shaman
intervention, hospital wants to intervene and impose traditional medical treatment
Issues: Cultural preferences, rights, tolerance, ambiguity, justice
Present:
Write:
Case #6: "Culture Clash Involving Intersex” Vol. 33, #4, July-August 2003, p. 12-14
Focus: 13 year old Middle Eastern boy, unclear gender assignment, surgical intervention
Issues: Gender identity, parental vs. child consent, cultural values
Present:
Write:
April 28
Case #7: “A Request for ICSI” Vol. 30, #2, March-April, 2000, p. 23-25
Focus: Couple in mid-thirties, married 10 years, he is HIV positive, seek special reproductive
technology to enable them to have their own biological child
Issues: Rights, risks, harm, professional liability, medical uncertainty
Present:
Write:
Case #8: “Resuscitating a Bad Patient” Vol. 37, #1, January-February 2007, p. 14-16
Focus: Elderly male, multiple chronic illnesses, no DNR order, professional staff think DNR
would be appropriate
10
Issues: Individual autonomy, professional judgment, rights, decision-making authority
Present:
Write:
Case #9: "Dialysis for a Prisoner of War" Vol. 34, #6, November-December 2004, p. 11-13.
Focus: Suspected terrorist captured by US forces in Afghanistan, suffering from renal failure,
question of giving dialysis to facilitate interrogation despite prisoner refusal
Issues: Personal choice, rights, interplay of law
Present:
Write:
May 12
Case #10: “Before He Wakes” Vol. 35, #4, July-August 2005, p. 15-16
Focus: 85 year old retired male professor, has advance directive but physician wishes to
continue treatment
Issues: Futility, choice, rights, professional authority vs. patient preference
Present:
Write:
Case #11: “Doctor, Will You Turn Off My LVAD?” Vol. 38, #1, January-February 2008, p. 1415
Focus: 62 year old man with chronic heart disease, has LVAD, considerable discomfort and
indignity, wishes to have LVAD disconnected, knowing he will die within hours
Issues: Self-determination, harm, rights, professional judgment
Present:
Write:
Case #12: “Covert Video Surveillance in Pediatric Care” Vol. 32, #6, November-December
2002, p. 10-12
Focus: 2 year old child, suspicion of Munchausens Syndrome by Proxy, where parents
intentionally inflict injury
Issues: Violence towards child, use of covert video surveillance to confirm MSBP
Present:
Write:
May 19
Case #13: "The Abuse of Alternative Medicine?" Vol. 33, #5, Sept.-October 2003, p. 13-14
Focus: 5 year old with acute lymphoblastic leukemia, use of alternative medicines
Issues: Choice, alternative vs. conventional therapies, legal intervention in therapy
Present:
Write:
Case #14: “All for One, or One For All?” Vol. 37, #4, July-August, 2007, p. 13-15
Focus: 4 year old with rare cancer, parents seek use of experimental drug in FDA testing stage,
manufacturer refuses based on risks
Issues: Risk-taking, access to experimental drugs, potential liability, harm
Present:
Write:
Case #15: “Informed Consent from the Doctor?” Vol. 34, #4, July-August 2004, p. 12-13
Focus: Father of 13 year old boy with cancer, doctor seeks father’s consent for son to participate
in a clinical trial, lack of clarity regarding informed consent
Issues: Informed consent, rights, autonomy, harm
Present:
Write:
11
12