Ethical Issues in Public
Health Practice in Michigan
Sarah E. Gollust, Nancy M. Baum, MHS, Susan D.
Goold, MD, MHSA, MA, and Peter D. Jacobson, JD, MPH
Public Health Systems Research Interest Group
Annual Meeting
June 7, 2008
Background

Academic distinction made between bioethics
and public health ethics

Limited empirical evidence on the extent to
which public health practitioners experience
ethical challenges in daily work
Project Goals

Build empirical base for public health ethics

Identify ethical issues practitioners experience
in their daily work

Gain understanding of methods of resolution
Methods

Site selection: 13 local health departments
(LHDs) selected for variation in:




Geographic location
Population characteristics
Governance structure
Recruitment: snowball sampling, starting with
health officers at each LHD
Source: Michigan’s Guide
to Public Health for Local
Governing Entities,
November 2006, MALPH
Characteristics of Participating Agencies
Site
N per
site
County or
District
Setting
LHD 1
3
County
Urban
LHD 2
3
District
Rural
LHD 3
3
County
Rural
LHD 4
4
County
Urban
LHD 5
5
County
Urban
LHD 6
4
County
Urban
LHD 7
4
County
Rural
LHD 8
3
District
Rural
LHD 9
4
County
Rural
LHD 10
4
County
Rural/Urban
MDCH
6
State
N/A
+ 1 City Department Employee and 1 County Commissioner (neither affiliated
with sites above)
Occupations of Study Participants
Occupation
n
Health Officers
10
Medical/Dental Directors (non-HO)
4
Environmental Health
6
Nursing or Clinic Staff
8
Health Educator
2
Emergency Preparedness
1
Communications/Public Relations
2
Other (LHD employees)
4
County Commissioner/ BOH Member
2
State Employee
6
Total
45
Methods, cont.

Semi-structured, mostly face-to-face
interviews with 45 practitioners to identify:





Ethical issues faced in practice
Underlying values
Processes for resolution
Demographics and personal exposure to ethics
Qualitative coding and analysis of transcripts
Results
Ease Discussing Ethics

Few practitioners rely on ethical constructs or
use the “language” of ethics

No difficulty identifying or discussing ethical
issues
Ethical Challenges - 5 Major Themes
1) Appropriate use of public health authority
Balancing public health benefits with individuals’
autonomy or businesses’ economic viability
2) Decisions related to resource allocation
Choosing among populations/programs
Allocating scarce resources
Allocating practitioners’ time
5 Major Themes, cont.
3) Political interference in practice
Politics dictates programming, not evidence
Focus on political “issues of the day” rather than
community needs
4) Assuring standards of quality care
Across different populations
During emergencies
5 Major Themes, cont.
5) Questioning the role or scope of public
health
Traditional protection from infectious disease
vs. Safety net
vs. Inclusion of social determinants of health
Public Context

Professional ethics




Personnel issues, managing employees
Public sector duties
Relationships with private sector
Conflicts of interest
Public Health Values

Diversity of values, no clear hierarchy or
focus across participants







Helping the most vulnerable
Using public funds efficiently
Being consistent
Being data-driven
Being fair
Greatest good for the greatest numbers of people
Personal responsibility
Resources Used to Resolve
Ethical Challenges




Consultation with colleagues
Reliance on personal experience
Reliance on personal moral grounding
Almost no use of formal frameworks
Discussion
Discussion

Practitioners recognize that their work
demands nuanced, ethically-laden decisions

Sense of “doing the right thing” animates
practitioners’ daily practice
Discussion

Few differences in major types of ethical
issues across practitioners and departments

Practitioners use little formal assistance to
process and resolve ethical issues

Creating effective frameworks to assist
practitioners will be a challenge
Contribution to Public Health
Systems Research

Qualitative research informs the interactive
effects of policy and the organizational
environment on practice

Identifies how systems-level factors (e.g.,
funding restrictions) affect practitioners’ daily
work
Contribution to Public Health
Systems Research

Recognizes that ethical decision-making is an
integral part of delivering public health
services


E.g., decisions allocating resources
May suggest ways to design a system that
facilitates ethical decision-making and
reduces ethical conflict
Acknowledgements

Greenwall Foundation

Robert M. Pestronk (study consultant)

45 public health professionals for offering us
their considerable insights
More information
My email: sgollust@umich.edu
Study publications:



Baum et al. Looking Ahead: Addressing Ethical
Challenges in Public Health Practice. Journal of Law,
Medicine, and Ethics. 2007; 35(4): 657-667.

Gollust et al. Politics and Public Health Practice: Left and
Right Meets Wrong and Right. Journal of Public Health
Management and Practice. 2008; Forthcoming.