Ethics in Public Health
TH Tulchinsky MD MPH
Braun School Public Health
April 2004
Ancient and Medieval Origins of
Ethical Standards in PH
• Ancient
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“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
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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
• Community
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
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
NY Times, May 27, 2004
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.
The assisted-suicide law in Oregon is the product of a 1994 voter initiative. It
allows adults with incurable diseases who are likely to die in six months to
obtain lethal drugs from their doctors. The doctors may prescribe but not
administer the drugs, and are granted immunity from liability. About 30 people
a year have used the law to end their lives since it became effective in 1997,
about one per thousand deaths in Oregon.
The court was not deciding the morality or appropriateness of assisted suicide and
gave no opinion on whether the practice is inconsistent with the public interest
or constitutes illegitimate medical care. This case is simply about who gets to
decide. State governments bear primary responsibility for evaluating
physician-assisted suicide. In our concept of federalism, and state lawmakers,
not the federal government, are primary regulators of professional medical
conduct.
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