Human rights, ethics, and
pandemic influenza
Alan Hinman and Aun Lor
July 2011
Outline of presentation
•
•
•
•
•
•
Definitions
Concepts of human rights
Public health impact on human rights
Principles of ethics
Principles of ethical practice of public health
Human rights/ethical issues in pandemic
influenza
What is health?
“Health is a complete state of mental and
physical well-being, not merely the absence
of disease”
WHO charter
What is public health?
The mission of public health is “fulfilling
society’s interest in assuring conditions in
which people can be healthy.”
Institute of Medicine
Fundamental characteristics of
human rights
• Set of beliefs about societal basis of
human well-being
• Series of non-provable statements about
what people need to maintain their human
dignity
• Rights of individuals
• Inhere to individuals because they are
human
• Apply to all people around the world
• Principally involve the relationship
between the state and the individual
Pubic Health and Human Rights-1
• Both PH and HR are vitally concerned with
social justice
• However, many PH workers do not view what
they do as human rights activities
• Many HR workers do not consider PH indices
as important indicators of HR
• Working together, PH and HR workers can
have much greater impact
Pubic Health and Human Rights-2
• HR workers tend to focus on denial of HR
• PH workers tend to focus on achieving
health (a human right)
• How can we bring them to common
understanding?
Preamble to WHO Constitution
"The enjoyment of the highest attainable
standard of health is one of the fundamental
rights of every human being without
distinction of race, religion, political belief,
economic or social condition.”
Human Rights Documents
citing Health Rights - 1
 Universal Declaration of Human Rights
 International Covenant on Economic,
Social and Cultural Rights
 International Covenant on Civil and
Political Rights
 International Convention on the
Elimination of All Forms of Racial
Discrimination
Human Rights Documents
citing Health Rights - 2
 Convention on the Elimination of All Forms
of Discrimination Against Women
 Convention on the Rights of the Child
 Declaration on the Elimination of all Forms
of Intolerance and of Discrimination Based
on Religion or Belief
 ILO Convention Concerning Indigenous
and Tribal Peoples in Independent
Countries
Human Rights Documents
citing Health Rights - 3
 Standard Minimum Rules for the Treatment
of Prisoners
 African (Banjul) Charter on Human and
Peoples' Rights
 European Social Charter
 Cairo Declaration on Human Rights in
Islam
 American Declaration of the Rights and
Duties of Man
Universal Declaration of Human Rights - 1
• Article 23 (1) - Everyone has the right
to…favorable conditions of work
• Article 25 (1) - Everyone has the right to a
standard of living adequate for the health
and well-being of himself and of his family,
including food,…medical care…and the right
to security in the event
of…sickness…widowhood, old age or other
lack of livelihood in circumstances beyond
his control
UDHR - 2
• Article 25(2) - Motherhood and childhood are
entitled to special care and assistance
• Article 26 (1) - Everyone has the right to
education
International Covenant on Civil and
Political Rights (ICCPR)
• Article 7.…no one shall be subjected without
his free consent to medical or scientific
experimentation
• Article 22 (2)...no restrictions on the exercise
of this right [freedom of association] other
than those which are prescribed by law and
which are necessary…[for]the protection of
public health…
• Article 24 (2) - Every child shall be registered
immediately after birth…
International Covenant on Economic,
Social, and Cultural Rights - 1
• Article 7 (b)…right of everyone to the
enjoyment of just and favourable conditions
of work which ensure…safe and healthy
working conditions
• Article 10 (2) - Special protection should be
accorded to mothers during a reasonable
period before and after childbirth
• Article 10 (3) Special measures of protection
and assistance should be taken on behalf of
all children and young persons
ICESCR - 2
• Article 12 (1)…right of everyone to the
enjoyment of the highest attainable standard
of physical and mental health
• Article 12 (2a)...reduction of the stillbirth-rate
and of infant mortality and for the healthy
development of the child
ICESCR - 3
• Article 12 (2b) …improvement of all
aspects of environmental and industrial
hygiene
• Article 12 (2c) …prevention, treatment and
control of epidemic, endemic,
occupational and other diseases
• Article 12 (2d) …creation of conditions
which would assure to all medical service
and medical attention in the event of
sickness
ICESCR & Immunization
The core obligation of governments
“to ensure access to immunization against the
community’s major infectious diseases.”
General comment 14
American Declaration of the rights
and duties of man
• Article 7 - All women, during pregnancy and
the nursing period, and all children have the
right to special protection, care and aid
• Article 11 - Every person has the right to the
preservation of his health through sanitary
and social measures relating to…medical
care, to the extent permitted by public and
community resources
Developing a public health and
human rights impact assessment
• Define the public health problem
• Describe the proposed public health program
• Identify the anticipated public health impact
(beneficial and adverse effects)
• Identify the anticipated human rights impact
(beneficial and adverse effects)
• Identify alternative approaches
• Describe the reasons for decision to select
the proposed program or not to implement
the program
Conditions in which human rights may
be restricted - Syracusa principles
• Restriction is provided for and carried out in
accordance with the law
• Restriction is in the interest of a legitimate
objective of general interest, e.g., public
safety, public order, public health
• Restriction is strictly necessary in a
democratic society to achieve the objective
• There are no less intrusive and restrictive
means available to reach the same goal
• Restriction is not imposed arbitrarily, i.e., in
an unreasonable or otherwise discriminatory
manner
Civil and political rights that may be
limited
• Right to liberty
• Right to security of persons
• Freedom from arbitrary arrest, detention, or
exile
• Freedom of movement
• Freedom from interference of privacy, family,
home
• Right to peaceful assembly and association
• Freedom of opinion and expression
Ethics, Morals, and Values
• Morality refers to “social conventions about
right and wrong human conduct that are so
widely shared that they form a stable
communal consensus.”
– The practice
• Ethics is the systematic study of morality, a
philosophical account of justified behavior
– The theory
Values
• “…core beliefs or desires which guide or
motivate attitudes or actions…values are
core beliefs which determine how we will
behave in certain situations”
– “Making Ethical Decisions” – Josephson Ethical Institute
Autonomy
• Classic medical ethics definitions
– Self-determination - persons must be selfgoverning, rational, and not coerced
– Respecting the wishes and choices of
persons who have the capacity to decide
– Protecting those who lack this capacity
• Public health forms:
– Privacy
– Freedom of action
Beneficence
• Providing benefits
• Balancing benefits with harms
• Protecting persons’ interests and promoting
the welfare of others
• In public health ethics, must be interpreted
broadly – in light of social needs
• Example: Overall goal of public health policy
Nonmaleficence
• First, do no harm
• Balancing benefits and harms
• Example: Considering the side effect profile
of a prescription drug
Justice
•
•
•
•
•
Fairness
Treating similar cases similarly
Equality of opportunity
Equity in access
At the core of public health
• Example: Ensuring equal access to
vulnerable populations
Veracity
• Duty to tell the truth or not to lie
• Lies add power to the liar and diminish the
power of the deceived
Public Health Principles
• Public health assumes background principles
– Social justice
– Pragmatism
– Equality
– The Common Good
– Community
– Prevention
– Access
– Liberty
– Privacy
Principles of the ethical practice of
public health - 1
1. Public health should address principally the
fundamental causes of disease and
requirements for health, aiming to prevent
adverse health outcomes.
2. Public health should achieve community
health in a way that respects the rights of
individuals in the community.
3. Public health policies, programs, and
priorities should be developed and
evaluated through processes that ensure an
opportunity for input from community
members.
Public Health Leadership Society
Principles of the ethical practice of
public health - 2
4. Public health should advocate and work for
the empowerment of disenfranchised
community members, aiming to ensure that
the basic resources and conditions
necessary for health are accessible to all.
5. Public health should seek the information
needed to implement effective policies and
programs that protect and promote health.
Principles of the ethical practice of
public health - 3
6. Public health institutions should provide
communities with the information they have
that is needed for decisions on policies or
programs and should obtain the community’s
consent for their implementation.
7. Public health institutions should act in a
timely manner on the information they have
within the resources and the mandate given to
them by the public.
Principles of the ethical practice of
public health - 4
8. Public health programs and policies should
incorporate a variety of approaches that
anticipate and respect diverse values,
beliefs, and cultures in the community.
9. Public health programs and policies should
be implemented in a manner that most
enhances the physical and social
environment.
Principles of the ethical practice of
public health - 5
10. Public health institutions should protect the
confidentiality of information that can bring
harm to an individual or community if made
public. Exceptions must be justified on the
basis of the high likelihood of significant
harm to the individual or others.
11. Public health institutions should ensure the
professional competence of their employees.
12. Public health institutions and their
employees should engage in collaborations
and affiliations in ways that build the public’s
trust and the institution’s effectiveness.
Human rights/ethical issues in
pandemic influenza
• Delays and shortages in availability of
vaccines and antiviral drugs - need to
prioritize
• Isolation/quarantine
• School closings/social distancing
• Disruption of national/community
infrastructures including transportation,
commerce, utilities and public safety due to
widespread illness and death among workers
and their families
US priority groups for vaccine - 1
1A
• Vaccine/antiviral manufacturers and others
essential to manufacturing and critical support
• Medical workers and public health workers
involved in direct patient contact
1B
• Persons >65 yr old with > 1 high-risk
conditions
• Persons >6 mo with history of hospitalization
for pneumonia or influenza in past year
US priority groups for vaccine - 2
1C
• Pregnant women
• Household contacts of severely
immunocompromised persons
• Household contacts of children <6 mo old
1D
• Public health emergency response workers
critical to pandemic response
• Key government leaders
US priority groups for vaccine - 3
2A
• Healthy persons >65 yr old
• Persons 6 mo – 64 yr old with 1 high-risk
condition
• Persons 6 – 23 mo old, healthy
2B
• Other public health emergency responders
• Public safety workers
• Utility workers
• Transportation workers
• Telecommunications/IT essential workers
US priority groups for vaccine - 4
3
• other key government health decisionmakers
• Funeral directors/embalmers
4
• Healthy persons 2 – 64 yr old not included in
above categories
US priority groups for antiviral drugs - 1
1. Patients admitted to hospital
2. Health care workers with direct patient contact
and EMS providers
3. Highest risk outpatients – immunocompromised
persons and pregnant women
4. Pandemic helath responders, public safety,
government decision-makers
5. Increased risk outpatients – children 12 -23 mo
old , persons >65 yr old, persons with
underlying medical conditions
US priority groups for antiviral drugs - 2
6. Outbreak response in nursing homes/other
residential settings
7. HCWs in emergency departments, intensive
care units, dialysis centers, EMS providers
8. Pandemic societal responders (critical
infrastructure groups), HCW without direct
patient contact
9. Other outpatients
Conclusions
• Human rights and ethics play an important
role in public health programs
• Enjoyment of human rights may be restricted
in order to achieve legitimate public health
goals
• We should strive to limit negative human
rights impact of public health programs
• All decisions should be made according to
ethical principles