Ethics
PH 7150
Outline
Definition
Ethical issues in public health
Case studies
Ethics
PH ethics combines public health and practical ethics
Rights of individuals vs community’s interests
Moral principles that govern a person's behavior or the
conducting of an activity. – Oxford dictionary
A systematic process to clarify, prioritize, and justify possible courses of
public health action based on ethical principles, values and beliefs of
stakeholders, and scientific and other information - CDC
3 step approach to decision-making
I. Analyze the ethical dimensions of the issue and context
II. Formulate alternative courses of action and evaluate their ethical
dimensions
III. Provide justification for a particular decision
Public Health Ethics: Cases Spanning the Globe
Resource Allocation
Resources used for one disease/condition cannot be spent on another
Short term vs long term
Who is most at-risk?
Cost/benefit
Efficiency as an ethical consideration
Distribution
Comparative effectiveness research
Cost-effective analysis
Disease Prevention & Control
Individual vs community interests
Cultural beliefs and practices
Mandatory vaccination, treatment, or quarantine
Screening & Surveillance
Criminalization of transmission
Access to care
Universal Declaration of Human Rights: right to health and/or health
care
Lack of care can lead to epidemics or worsening disease states
Is there a limit to the right to care?
Emergencies
Epidemics, natural disasters, or man-made disasters
Require urgent action and quick decisions
Additional limitations on resources
Chronic Disease
“Prevention of disease means forsaking the bad habits which many
people enjoy” (Knowles 1977)
Focusing on just the individual is therefore overly narrow when
identifying policies to prevent chronic diseases . Yet, removing the
individual from the equation is also unhelpful (Schmidt 2009)
Individual, health worker, government, and corporate responsibilities
Environment and Workplace
Work-related cancer, pulmonary disease, injury, safety
Regulation can be difficult due to different regulatory bodies
Acceptable risk
Developed vs developing countries
Scope
Research
Individual and community considerations
Regulations are concerned with research abuses
Practice vs research
Informed consent
Risk/benefit analysis
Vulnerable populations
Results
Conflicts of interest
Jacobson v Massachusetts
Supports states’ rights to create laws and regulations to protect public
health even if they limit individual autonomy
Mandatory vaccination of Smallpox in Boston
No exemptions for adults, only children
Argument that mandatory vaccination (or fine) was “hostile to the
inherent right of every freeman to care for his own body…”
Escalated to the U.S. Supreme Court
US PHS research on STDs
“Tuskegee syphilis study”: U.S. Public Health Service Study of Untreated
Syphilis in the Male Negro, Macon County, Alabama
Public health workers began focusing on syphilis as a poverty-linked
disease, primarily among African Americans.
1930s: Research begins in African-American communities.
Observation of the “natural progression” of the disease
Patients were told they were being treated, but were not, and were
actively prevented from receiving penicillin for any disease.
US PHS research on STDs
Guatemala
Prisoners were intentionally exposed to STDs from infected commercial
sex workers.
Expanded population to soldiers and psychiatric patients with more
invasive means of exposure.
Only half of the infected subjects had documented treatment
Ended in 1948, but exposed in 2003
NYC A1C registry
Proposal to require labs to submit A1C test results to the NYC dept of
health and mental hygiene
Rationale: provide mechanisms to support patient and physicians in
controlling diabetes
Patient and physician were notified at a specific threshold
People were allowed to opt-out