Introduction to PUBLIC HEALTH ETHICS

1. Introduction toPUBLIC HEALTH ETHICS July 29, 2005 Michael Smith, JD, MPH candidate University of Virginia/ORISE Fellow Public Health Law Program Centers for Disease Control and Prevention Atlanta, Georgia

2. PresentationObjectives • Distinguish Public Health Ethics from other professional ethics involved in public health (medical, public/private, etc.) • Introduce key ethical principles and issues in Public Health Ethics • The Public Health Code of Ethics • Update on Public Health Ethics at CDC • Resources for further information

3. What is Public Health Ethics? • A systematic approach to balancing competing interests and providing justification for public health policies and decisions. • Often individual rights of autonomy and privacy v. community interests and responsibilities • “Public health law provides authority to place significant restrictions on individuals; the law describes what public health can do, Public Health Ethics helps in determining what public health should do.” • Alan Melnick, PHLS & Clackamas County (Oregon) Public Health Officer

4. Public Health ethics emphasizes populations: Interdependence individual actions effect others Participation public health decisions should include input from the public Scientific Evidence reasoned interventions based on facts, not beliefs or conjecture Medical Ethics v. Public Health Ethics* Traditional medical ethics emphasizes individuals: • Autonomy • right to decline care • Nonmaleficence • do no harm • Beneficence • seek benefit of patients • Justice • providing equal care to all * Adapted from Distinguishing Public Health Ethics from Medical Ethics, J. Thomas, UNC IPH

5. Ethical Theories and Values Public Health Ethics entails multiple ethical theories and values: • Consequentialism • focus on the outcomes of actions • Deontology • focus on rights, duties, or other intrinsic moral features of actions • Casuistical Reasoning • examining the relevant similarities and differences between cases (stare decisis) • Utilitarianism • do the greatest good for the greatest number of people • Egalitarianism • fair procedure and distribution of benefits and burdens

6. Examples of Public Health Ethical Problems • Flu vaccine allocation during shortage • How will values of utility and equality be balanced in prioritizing groups, and how are those decisions communicated to the public? • Narrow social utility – ensure first responders receive vaccine so they can assist others • Medical utility – ensure that populations at highest risk of mortality from flu receive vaccine • Egalitarian – first come, first served or a lottery system to allow equal access • Detention and observed therapy of TB patients in NY • NY law provides public health with the power to detain TB patients who are suspected of non-compliance to their treatment regimens in a locked hospital ward • How should public health determine that a patient is a compliance risk? • Should the patient be detained until they finish the treatment regimen, or only until they are no longer contagious?

7. Principles of the Ethical Practice of Public Health: Code of Ethics • Promulgated by the Public Health Leadership Society (PHLS) in 2002 • 12 Principles to guide public health • Adopted by American Public Health Association (APHA) in 2002 • Intended to be a living document • Available at: http://www.phls.org

8. Principles of the Ethical Practice of Public Health: Code of Ethics • Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes. • Public health should achieve community health in a way that respects the rights of individuals in the community. • Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members. • Public health should advocate for, or work for the empowerment of, disenfranchised community members, ensuring that the basic resources and conditions necessary for health are accessible to all people in the community • Public health should seek the information needed to implement effective policies and programs that protect and promote health • 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.

9. Principles of the Ethical Practice of Public Health: Code of Ethics • 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 • Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community. • Public health programs and policies should be implemented in a manner that most enhances the physical and social environment. • 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. • Public health institutions should ensure the professional competence of their employees. • Public health institutions and their employees should engage in collaboration and affiliations in ways that build the public’s trust and the institution’s effectiveness.

10. Proposed Public Health Ethics Framework • Included in forthcoming edition of Law in Public Health Practice • Developed by R. Gaare Bernheim, P. Nieburg, and R. Bonnie • Guide to analysis of ethical question in public health

11. Proposed Public Health Ethics Framework • Analyze the public health issue and context • What are the risks and harms of concern? • What are the public health goals? • What are the ethical conflicts and competing moral claims of stakeholders in the situation? • Is the source or scope of authority in question? Are laws and regulations otherwise relevant? • Are precedent cases or the historical context relevant? • Do professional codes of ethics provide guidance?

12. Proposed Public Health Ethics Framework • Evaluate and balance the ethical conflicts • To chose from among numerous public health options: Is a particular public health action more justifiable by ethical considerations than others? • Does the public health action produce a balance of benefits over harms? • Are the benefits and burdens distributed fairly (distributive justice), and do legitimate representatives of affected groups have the opportunity to participate in decisions (procedural justice)? • Does the public health action respect individual choices and interest (autonomy, liberty)? • Does the public health action respect professional and civic roles and values, such as honesty, trustworthiness, promise-keeping, and protecting confidentiality?

13. Proposed Public Health Ethics Framework • Evaluate and balance the ethical conflicts • To justify a particular public health action: Does the public health goal and the values it serves justify overriding the conflicting value(s)? • Effectiveness: Is the public health goal likely to be accomplished? • Proportionality: Will the probable benefits of the action outweigh the infringed moral considerations? • Necessity: Is the action necessary to achieve the goal? • Impartiality: Are the burdens and benefits of the action distributed fairly? • Least infringement: Is the action the least restrictive and least intrusive? • Public justification: Can public health agents offer public justification that citizens, and in particular those most affected, could find acceptable in principle?

14. Public Health Ethics at CDC • Ethics Subcommittee to the Advisory Committee to the Director (external) • Provide counsel to CDC director regarding a broad range of public health ethics questions and issues arising from programs, scientists, and practitioners • Develop CDC’s capacity to identify, analyze, and resolve ethical issues • FACA committee subject to rules for announced and public meetings

15. Public Health Ethics at CDC • Internal Public Health Ethics Committee • Develop a framework and recommendations for strengthening CDC through the integration of public health ethics into our science, practices, policies, and programs over the next one to five years • Participate with CDC, Center, and CIO leaders in providing public health ethics leadership

16. Internal Public Health Ethics Committee • Committee still in formative stage • Each CIO providing an ethics lead representative on the committee • Currently working to build capacity and expertise on the committee • Two workgroups to address: • Scope of Public Health Ethics Committee • Consultants, gatekeepers, experts, facilitators, trainers? • Training and capacity building • Working on roll-out plan for Public Health Ethics

17. Additional Public Health Ethics Resources • http://www.phls.org – Public Health Leadership Society website (Principles of the Ethical Practice of Public Health - Code of Ethics) • http://www.sph.unc.edu/oce/phethics - UNC School of Public Health modules on Public Health Ethics (4 modules, 30-40 minutes each) • http://www.asph.org/document.cfm?page=782 – Association of Schools of Public Health website with Ethics and Public Health: Model Curriculum • Bayer, Ronald & Amy Fairchild, The Genesis of Public Health Ethics, Bioethics, Volume 18, No. 6 (2004) • Childress, James et al, Public Health Ethics: Mapping the Terrain, Journal of Law, Medicine, & Ethics, Volume 30:2, (Summer, 2002) • Kass, Nancy, An Ethics Framework for Public Health, American Journal of Public Health, Volume 91, No. 11 (November, 2001) • Callahan, Daniel & Bruce Jennings, Ethics and Public Health: Forging a Strong Relationship, American Journal of Public Health, Volume 92, No. 2 (February, 2002) "The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.”