Ethics in Public Health
TH Tulchinsky MD MPH
Braun School Public Health
April 2004
Ancient and Medieval Origins of
Ethical Standards in PH
• Ancient
– “Pikuah nefesh” - sanctity of human life
– “Tikun olam” - repair the world
– Hippocratic oath - do no harm
– Greece –
• Healthy body-healthy mind
• City states
– Religion – Charity, after-life
• Medieval
– Municipalities – sanitation
– Guilds – mutual benefits societies
Modern Origins of Public Health
Ethics
Scientific advance in medicine and
public health during 19th-20th
centuries
Government responsibility –local, state
and national
Collective bargaining for health benefits
Universal right to health care (health
for all)
Self responsibility (lifestyle) in health
Advancing technology and costs
Public awareness and expectations
Ten Achievements of Public Health
of the 20th Century
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Control of infectious disease
Vaccination
Motor vehicle safety
Safer workplaces
Decline in deaths from coronary heart
disease, strokes
Safer and healthier foods
Healthier mothers and babies
Family planning
Fluoridation of drinking water
Recognition of tobacco as a health hazard
Source: MMWR, 1999
Ethics in Epidemiology
Ethics is a branch of philosophy that deals with
distinctions between right and wrong – with
the moral consequences of human actions.
The ethical principles that arise in
epidemiologic practice and research include:
Informed consent
Confidentiality
Respect for human rights
Scientific integrity
Last JM [ed]. A Dictionary of Epidemiology. Fourth
Edition. 2000
New Public Health:
Individual and Population Health
Individual Health
Population Health
Bioethics =
human rights,
civil liberties and
individual
autonomy
approach,
medicalized
system
Public health =
utilitarian,
paternalistic,
social responsibility,
communitarian
orientation
Ethics in PH
• Moral imperative of PH to ensure and
protect the health of the population and
the individual
• Ethical foundations traditionally implicit
in PH
• The right to health?
• Renewed awareness of conflict between
individual rights and community rights
• Effects of doing or not doing public health
interventions or “best practices”
When and When Not to Act
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Judgment, experience, evidence, ethics
Experience of Good Public Health Practice
Threat of preventable mortality or risk factor
When dangers/costs of not acting exceed those
of acting
Public right to know
Public right to protection
Individual rights
Balance
Accountability, transparency
Why Study Ethics in PH
• Many issues of conflict between good of
the individual and good of society
• Immunization, chlorination, fluoridation
• HIV/AIDs, MDRTB, DOTs vs DOTS Plus
• Aging and chronic diseases
• Human Genome Project
• Genetically modified foods
• Technology and resource allocation
• The Case-for-Action
Basic Questions
• Dies society’s responsibilities =
paternalism?
• Does freedom of individual = hostility to the
state in all it’s manifestations?
• Do we need informed consent for all PH
interventions?
• Do individual rights over-ride social
responsibility? E.g. AIDS contact tracing?
• The “Precautionary principle” = must prove
zero risk of intervention?
• Equity in health?
• Adequate funding and its allocation
Old-New Battles
• UK Variolists oppose vaccination vs.
smallpox C19th
• US Opposition to public health departments
in 1920s
• UK GPs oppose immunization with pertussis
(1980s) and MMR (2002)
• AMA opposes to national health insurance
1920s to present
• Civil rights vs HIV control, 1980s US
• Anti-fluoridationism 1950s to present
• Anti-food fortification in Europe
• Anti-genetic engineering of food in Europe
PH Ethical Issues
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Responsibility to protect society
Responsibility to the individual
Individual vs community rights
Government responsibility
Corporate responsibility
Right to health care
Personal responsibility - self care
Quality of care
Freedom of choice
PH Law and Ethics
• Gov’t obligation to protect health of the
population
• Power of government to legislate, tax,
spend, regulate, punish
• Restriction of personal liberties e.g. seat
belt laws or smoking restrictions vs.
human rights
• Economic and social impact of
intervention vs. non-intervention
• Laws enacted by legislative bodies and
court decisions
Individual Rights and PH Ethical Issues
• Right to quality health services
• Provider responsibility to act for benefit of
client
• Euthenasia - right to die
• Confidentiality – right to privacy
• Informed consent – right to know
• Birth control – religion vs. individual rights
• Supply and distribution of resources for
health
• Incentives - disincentives
• Equity – social, ethnic, regional
• Social solidarity
Groups at Special Risk
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Women
Children
Civilians in war and terror situations
Disaster victims
Native peoples
Minority groups
Prisoners
Military
Refugees and internal migrants
Mentally ill
Rural vs. urban
In
• Individual
Personal hygiene
Immunization
Right to health care
Self care
Choice of provider
Right to know
Right to die
Confidentiality
Privacy
Informed consent
Patients Bill of Rights
• Community
Sanitation
Herd immunity
Universal access
Education
Gatekeeper function
Mandatory reporting
Case follow-up
Resources for health
Cost containment
Equity
Minority and special
groups
High risk groups
Public Health, Experimentation and
“the Slippery Slope”
• 1920’s-1930’s: Eugenics
• 1930’s-1940’s: Mass sterilization of
"defectives" in the USA and Sweden.
• 1930-1940’s: Mass euthanasia of
“defectives” in Germany
• 1940’s: Quarantining epidemic disease as
pretext for ghettos by Nazis
• 1940s Concentration camp human
experimentation
• 1940s: The Holocaust
Eugenics: “America’s Dirty Little Secret”
• Slavery and racism and slavery in America’s past.
• 19th C eugenics movement founded
• Oliver Wendell Holmes Jr.'s US Supreme Court
decision of 1927, which affirmed Virginia's right to
sterilize Carrie Buck, a supposedly "feebleminded"
woman:
• "It is better for all the world, if instead of waiting to
execute degenerate offspring for crime, or to let
them starve for their imbecility, society can
prevent those who are manifestly unfit from
continuing their kind." And referring to Buck's
mother, who was also considered feebleminded,
and her daughter, who it was assumed must be
feebleminded, he concluded in words that have
become infamous: "Three generations of
imbeciles are enough."
Eugenics spreads to fertile
territory
By 1933, when the Nazi sterilization
law are passed, there were about 20
states in America that already had
sterilization laws. Hitler praises
American eugenicist policies in 'Mein
Kampf.'
Paul Lombardo,
Professor of bioethics and law, University of Virginia
Landmarks re Individual
Rights: the Biomedical Model
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Focus on individual informed consent
Concern of exploitation of the individual
Nuremberg trials
Helsinki declaration
Tuskegee experiment
Declaration of human rights
Health for All
Nuremberg Code 1946
• Nazi experiments on prisoners
• Set new conditions for research
• Subjects must have:
– Knowledge
– Right of voluntary consent
– Ability to end participation
• Scientist in charge responsible for:
– Scientific basis or validity of the hypothesis
– To terminate experiments likely to cause
injury, disability, death
Universal Declaration of
Human Rights, 1948
Article 25.
Everyone has the right to a standard of living
adequate for the health and well-being of
himself and of his family, including food,
clothing, housing and medical care and
necessary social services etc.
Article 30.
Nothing in this Declaration may be interpreted as
implying .. person any right to engage in any
activity or to perform any act aimed at the
destruction of any of the rights and freedoms
set forth herein
Helsinki Declaration 1964
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World Medical Assembly 1964 to 1996
Privacy and integrity of individual protected
Adequate informed consent
Research for valid scientific benefits
Accepted scientific principles
Benefits outweigh risks
Publication
Protect control group
Individual well-being vs. those of science
and society
Tuskegee Experiment
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Tuskegee, Mississippi
Duration 1932-1972
Conducted by US Public Health Service
Observe natural history of syphilis
Treatment with penicillin available (1942)
Failed to provide information to subjects
Unethical (possibly criminal) behavior
New standards resulted
Apology by President Clinton 1996
Continues to influence sectors of US public
in response to public health initiatives
Health for All
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WHO definition of health, 1948
Alma Ata, 1978 Health for All
Health care as a universal human right
Government responsibility
Wide acceptance
Important to help shift priorities
Still unfulfilled
Health targets
Priorities and cost-benefit decisions
Changing Concepts of Disease
• 1960s – Illitch and McKeowan – medical care
of little value, health gains result of
nutritional gains
• 1970s – Lalonde Health Field Concept =
genetic, environment (physical and social),
lifestyle and medical factors
• Evidence of risk factors for disease e.g.
smoking, diet exercise e.g. smoking and
Framingham studies
• ? Blaming the victim vs. self responsibility?
• Health targets US Surgeon General and WHO
APHA 2002, Principles of the
Ethical Practice of Public Health
• Address fundamental causes of disease
and requirements for health
• Respect the rights of community residents
• Advocate empowerment of the
disenfranchised
• Enhance the physical and social
environment
• Act within a timely manner
• Promote collaboration and affiliations to
build the public’s trust
Oregon’s Death with Dignity Act
A US federal appeals court upheld the only law in
the nation authorizing doctors to help their
terminally ill patients commit suicide. The
decision, by a divided three-judge panel of the
Court of Appeals in San Francisco, said the
Justice Department did not have the power to
punish the doctors involved. The majority
rebuked US Attorney General John Ashcroft,
saying he had overstepped his authority in trying
to block enforcement of the state law.
"The AG’s unilateral attempt to regulate general
medical practices historically entrusted to state
lawmakers …interferes with democratic debate
about physician-assisted suicide and far exceeds
… his authority under federal law. The US Justice
Department could ask an 11-member panel of the
Ninth Circuit to rehear the case or appeal to the
US Supreme Court.
Basics of Prevention
• Primary prevention = prevent a disease
from occurring
• Secondary prevention = prevent
complications from a disease
• Tertiary prevention = restore and
maintain maximum function
New Public Health
Individual
Health
Population
Health
The New Public Health
• Managing health systems and resources
• National target e.g. reduce stroke mortality
• Health education e.g. nutrition, exercise,
self care
• Health promotion e.g. food fortification
• Personal preventive services e.g.
hypertension
• Clinical standards eg. AMI, diabetes
• Long Term Care e.g. prevention of 2nd MI,
CHF
Summary
• Government responsibility to legislate, tax,
regulate and enforce for the public health
• Protection of the weak, equity
• Legal and ethical considerations
• Rights of society
• Rights of individuals
• Responsibility of individuals
• Informed consent for research
• Precaution vs. inertia
• Importance of New Public Health