Public Health Service Ethics
• New Tools for Planning and Implementation
Mark E White, MD, FACPM
Objective
Introduce you to tools of public health ethics
Give examples of how you may use them
Summarize results of meetings
Take Home Messages
Public health ethics come from you and your society
Public health ethics are tools for planning and
implementation
You must assert your views
Consider the views of others openly in planning
Use public health ethics to make the world a better
place
Why Bother with Ethics?
Explicitly considering ethical perspectives in planning
allows you to make fairer, more effective and
efficient decisions
Openly discussing ethics makes it easier to build
consensus, even with those who disagree
Every decision has an
ethical dimension
20th Century Global
Health Ethics
The Golden Rule: If you take the king’s gold, you
take the king’s rules (funders dictate ethics)
Individualistic ethics
Communitarian ethics
8
Public Health Practice
• Improving a specific population’s health by making
systematic interventions based on
•
Science
Management
Consensus building
Ethics
Examples: surveillance, outbreak investigations,
program implementations, evaluations
Public Health Program Cycle
Planning
Justification
Advocacy & Consensus
Building
Monitoring &
Evaluation
Implementation
9
Where Ethics Can Help
Advocate,
persuade
Planning
Clarify priorities,
assumptions and
targets
Justification
Consensus Building
Persuade,
advocate
Monitoring &
Evaluation
Clarify progress
towards objectives
Implementation
Open, fair
processes
10
Common Ethical Issues
Prioritizing services (science based, fair)
Distributing services fairly geographically and
socially (fair, effective)
Follow up on recommendations of studies (duty)
Restrict freedom (quarantine)
18
What are Ethics Anyway?
Values: “health is good”
Principles are goals: “Help others as you would like
to be helped”
Processes: clarify, prioritize, justify possible courses
of action
Based on ethical principles, values of stakeholders
scientific information
From Drue Barrett, CDC, 2007
7
Values Come From You
People usually list several, including:
Better population health: “Everyone can live healthy,
productive lives”
Social justice: “Everyone treated fairly”
Equity: “Everyone gets an equal chance”
Solidarity: “We are in this together.”
Duty: “Health workers should take care of people with
flu.
Autonomy
Principles of Public
Health Ethics
Based on value of justice
Inclusiveness/solidarity
Duty/Professionalism “Health workers risk their lives
fighting avian influenza”
Science
17
Organizational Ethics:
Principles & Processes
• Contribute to Public Health Public Health Ethical
principles
• Accountability
• Transparency
• Efficiency
• Effectiveness
Public Health
• Based on justice
• Population is patient
• Rights of community > individuals
• Do the most good for the most people
• Protect all, including minorities
• Don’t restrict freedom unless absolutely necessary
Research Ethics
• Based on autonomy/individual rights
• Usually coercive
• Protect interests of subjects
• Assumes no benefit to subjects
• Assumes possible harm to subjects
• Very high standards of proof, documentation
Clinical Ethics
• Based on autonomy/individual rights
• Usually coercive
• Protect autonomy of patients
• Privacy
• Patient must approve
• Provider works for pateint
Why not Combine
Ethics?
Public Health aims to improve the health of
populations
Clinical practice and research aim to improve health
of individuals
Public health ethics most useful in planning and
implementing interventions
Public health ethics are tools, rarely coercive
Putting Perspectives
Together
Cultural relativism:
Cup half empty: nobody agrees completely
Cup half full: everybody agrees on some things
Problem: Western individualists have driven the
discussion so far
Opportunity: Engage Middle Eastern, Asian, Latin
American, African cultures
You must speak out for your values!
15
Relative Importance of
Principles
6
5
4
3
2
1
0
US and Western Europe
Asia
Africa
Latin America
Take Home Messages
Public health ethics come from you
Public health ethics are tools for planning and
implementation
You must assert your views
Consider the views of others openly in planning
Use public health ethics to make the world a better
place
Thank You