ETHICAL ISSUES IN PUBLIC HEALTH
By- Dr. Dharmendra Gahwai
Guided by – Dr.Y.D. Badgaiyan
Prof. and Head
Deptt. Of Community Medicine
From the time immemorial doctors have
been held in high esteem by the society in
different parts of the world.
Medical ethics have existed ever since the
practice of medicine.
The society consider the doctor as friend-
philosopher and guide, which bestows
enormous responsibility upon the doctor.
This responsibility is quite apart from
technical skills and is more to do with
qualities of human understanding.
Medical Ethics is all about this
Dictionary meaning – “System of moral
principle, rules and conduct.”
Origin of this word is from ETHOS which
Ethics is defined as “the ability to distinguish
between right and wrong and to act
“Ethics is the activity of man directed
to secure the inner perfection of his
- Albert Schweitzer.
Medical Ethics is described as code of
behavior accepted voluntarily within
the profession as to statutes and
regulations imposed by official
The oldest code of medical ethics is
Hippocratic oath .
Though now, some 25 centuries old ,
its basic tenets remain as valid as
In view of changing world scenario, the Oath
was restated into the Declaration of Geneva
by the World Medical Association after the
The Medical Council of India gives a copy of
declaration to concerned applicant for
registration who shall read and agree to abide
1. I solemnly pledge myself to consecrate my life in
service of humanity.
2.Even under threat, I will not use my medical
knowledge contrary to the laws of humanity.
3.I will maintain utmost respect for human life from
the time of conception.
4.I will not permit considerations of religion,
nationality, race , party politics or social standing
to intervene between my duty and my patient.
5. I will practice my profession with conscience and
6.The health of my patient will be my first
7. I will respect the secrets, which are confined in me.
8. I will give to my teacher the respect and gratitude
which is their due.
9. I will maintain by all means of my power , the honour
and noble traditions of medical profession.
10. My colleagues will be my brother.
I make this promises solemnly, freely and
upon my honour.
PRINCIPLES OF ETHICS
4.Justice or equity.
PRINCIPLE OF BENEFICENCE
Beneficence refers to the tradition of
acting always in the patient’s best
interest to maximise benefits and
PRINCIPLE OF NON-MALEFICENCE
This principle ensures that treatment or
research not ought to produce any harm to
By any mean of -
PRINCIPLE OF AUTONOMY
Respect for an individual’s autonomy or ability to
make decisions for him/herself includes-
respect for their privacy and confidentiality
need to provide sufficient information for them to
make informed choices
truth telling and
protection of persons with diminished or impaired
PRINCIPLE OF JUSTICE or EQUITY
Justice refers to the need to treat all people equally
Society uses a variety of factors as a criteria for
distributive justice, including :
to each person an equal share
to each person according to need
to each person according to effort
to each person according to contribution
to each person according to merit
to each person according to free-market exchanges
Justice (equity) is a concept of fairness and
It not only means equal share in the
distribution of health care (equality)
But, more importantly priority should be
given to those who are in need , in proportion
to their need (equity).
We should strive to provide some
decent minimum level of health care
for all citizens, regardless of ability
to pay .
For a Public Health Specialist
the emphasis is on the greater
good of larger number of
people and the principle of
justice plays an important role.
1. USE OF DRUGS – -Banned drugs.
-Herbs and remedies.
-Iatrogenic disorders due to drugs.
- Community need vs autonomy.
- Target vs Human dignity
- Abortion vs MTP.
3.ABORTION AND INFERTILITY •Aid vs Adoption.
•Prenatal sex determination .
• Rights of embryo.
4. DEFINING DEATH •Criteria for irreversible damage.
•Euthanasia and Right to die with
Today , no nation of the earth can escape the
consequences of AIDS.
The incurable nature of disease and the
venereal and blood transmissible nature of
HIV acquisition give rise to peculiar dilemma
The ethical issues involved with
AIDS are –
1.The treatment of AIDS cases :
-The doctor is not entitled to refuse to treat a patient
with AIDS or HIV positive.
2. Disclosure to other health professionals:
- confidentiality vs prevention of spread of infection.
3. Serological screening:
- it is unethical to take up serological testing without
- however, there is no other way to identify HIV carriers.
4. Blood donations:
Whether destroying the infected blood is enough ?
• Should not the donor be informed about his/her status regarding
HIV positivity ?
Prevention of spread of infection to spouse and
• So , should not the spouse and family members be informed about
HIV-positive status of patient?
5. Individual vs Social responsibilities:
• It seems reasonable in the interest of an individual in
particular and the society in general to let them to be
• But, Questions are ,
- how the issue should be communicated to the person’s
family (spouse) and friends,
- whether patient consent is required for it or not;
- all these need a wider consideration with danger to
others in society.
Recently in a landmark case of Dr.Yepthomi
vs. Apollo Hospital , Chennai, the Hon’ble
Supreme Court has ruled that
- “prospective spouses have a right to know
about HIV status of their prospective
counterparts and disclosure by concerned
hospital cannot be a breech of confidentiality.”
MedicalTermination of Pregnancy(MTP)
Act 1972 , specifies
- the conditions, under which pregnancy can be
- Persons, who can perform the termination and
- Places, where such a procedure can be
Ethical issues in abortion are-
• The view that fetus has the same right to life as
that of other individual.
• The modern Geneva convention code says -
“ I will maintain the utmost respect for human life
from the time of conception.”
• So, the debate is in between -
“Murder of an innocent” vs “the Right of a women”.
UTILITARIANISM (rule-utilitarianism )
(Middle course between the two views)
The arguments in favor are-
1. The health of mother is more important then
2. If, the expected quality of fetus life is so poor
that, it is better not experience it.
3. When well being of society is improved by
permitting abortion in certain conditions.
1. Abortion should be performed only as a
therapeutic measure .
2. A decision to terminate the pregnancy should
normally be approved in writing by at-least
two doctors .
Under the present law,
voluntary euthanasia would be
regarded as suicide in the patient
who consents and murder in the
doctor who administers .
Two ethical components are –
AIM and AUTONOMY
The fundamental aim of medical care is
however , relief of pain and suffering by
putting an end to a patient – is a misery ,
could be considered beneficence.
But, killing can hardly be constructed as no
Autonomy , affects doctors , patient and
As we know, a patient has right to refuse
Does this autonomy extend to
asking for euthanasia ?
In view of the fact that sterilization drives are
of public importance in countries where there
is population explosion,
So, the social and ethical issues may be
(as in case of Emergency period in INDIA)
In some states where the statutory law
provides for therapeutic sterilization but does
not provide for non therapeutic one
physicians and hospitals perform
sterilizations for purely social or economic
reasons are illegal and therefore , it is
While ethical issues in medical research
and practices are discussed and
debated but ethics in public health and
public health policies is rarely discussed
and given very little importance.
1. Immunization for Pertussis.
2. Fluoridation of water.
3. Rights of patient with contagious
4. Universal iodization of salt.
Immunization for Pertussis
• Since 1933, there have been reports of
neurological complications after immunization
• The inconclusive nature of complication resulted
debate in media particularly in Britain.
• The rate of immunization halved from >78.5% in
1971 to 37% in 1974.
• An epidemic of pertusis was reported and under
Vaccine Damage Payment Act £ 10000 each has
been paid over 500 children.
In this case beneficence was observed that
the immunization protect the children
against disease .
But , due to neurological side effects the
principles of non-maleficence was not
At individual level parents can exercise
freedom not to immunize.(autonomy)
however , such decision could fail the
In 1981 , a case control study named National
Childhood Encephalopathy Study (NCES) was
initiated in England to assess the association
between serious neurological illness and
They did not report any significant
association between encephalopathy and
In 1988 ,the famousVaccine
CourtTrial vindicated the use
of the vaccine and observed
that is far from causing
Fluoridation of water
From the 1930’s it was noted that there was
an inverse relationship between the levels of
fluoride in drinking water and occurrence of
This suggested a preventive measures of
policy of adding fluoride to water with low
There were objections on the grounds of
undesirable side effects such as development of
Down Syndrome and Cancer in area of
fluoridation of water.
The second objection was related to it being a
Non-maleficence : objection due to suspicion
of excess fluoride leads to cancer is justifiable
with ethical principle of non-maleficence.
However, it was not based on scientific facts.
Autonomy : the second objection was with
compulsory medication (fluoridation) .
This illustrates conflicts between the
principle of Autonomy with the positive
community effects of fluoridation
However, in Britain (1985) , the Report of
theWorking Committee on Fluoridation
ofWater and Cancer found no evidence of
association of fluoridation of water and
development of Cancer.
Contagious Venereal Disease
Dr.Yepthomi a doctor from Nagaland filed a
petition seeking compensation from the
Apollo Hospital Chennai , which had found
that he was HIV-positive and disclosed it to
would be Bride’s family.
The marriage was immediately called off.
This case illustrates the conflict between
respect for autonomy and principle of
In such a case, where there is a clash of two
fundamental rights, namely the patient’s
right to confidentiality and the bride’s right to
lead to healthy life ,the right of public interest
would be enforced through the court.
The Supreme Court of India has given a
judgment on right to marry of a patient with
contagious venereal disease , that “ so long as a
person is not cured of the disease , his right to
marry is suspended.”
The Hon’ble Supreme Court has ruled that
“prospective spouses have a right to know about
HIV status of their prospective counterparts and
disclosure by concerned hospital cannot be a
breech of confidentiality.”
Universal Iodization of Salt
• On Sept. 2000 , the Govt of India lifted the
ban on the sale of non-iodized salt which was
enforced in Nov 1997.
• The reason given was that food consumption
is a matter of individual choice (Autonomy)
and cannot be forced upon people.
Universal Iodization of Salt
1. Beneficence : Fortification of salt with iodine
can be considered as a vaccine for proper
growth and development of child.
2. Non-maleficence : No untoward effect of
excess iodine consumption.
3. Justice(equity) : Priorities should be given to
those in need.(in iodine deficient area).
4. Autonomy : Universal salt iodization is a
compulsory medication and therefore , a
violation of individual autonomy.
The conflict seems to be between equity and
The best option is obviously to have a salt
iodization programme only in iodine deficient
Respect for autonomy and equity (justice) is
The decision is often taken by the court or by
scientist in given cases.
Both of them are not right forum
for decision regarding the public
Three principles must be followed in arriving
at any decision on ethical issues in public
The process should ensure that the decision
would be :
1.Taken by representative body.
2. An informed consent.
INDIAN ACTS/ORDERS RELATED TO HEALTH
Epidemic DiseasesAct – 1897
Red Cross Society (Allocation of Property Act) – 1936
Drugs and Cosmetics Act – 1940
Indian Nursing CouncilAct – 1947
DentistsAct – 1948
PharmacyAct – 1948
Employees State InsuranceAct – 1948
MedicalCouncil of India Act – 1956, amended 2002
Drugs and Magic Remedies Act (Objectionable advertisements),
Prevention of Cruelty toAnimals Act – 1960
ChildrenAct – 1960
Maternity Benefit Act – 1961
Central Council for Indian Medicine Act – 1970
INDIAN ACTS/ORDERS RELATED TO HEALTH
MedicalTermination of PregnancyAct – 1971
Consumer ProtectionAct – 1986
Environment ProtectionAct – 1986
Mental HealthAct – 1987 being amended
RehabilitationCouncil of India Act - 1992
Pre-natal DiagnosticTechniques (Regulation and Prevention of
Misuse)Act -1994, amended 2002
OrganTransplantationAct – 1994
Persons with Disabilities (Equal Opportunity, Protection of Rights
and Full ParticipationAct, 1995
Pre-conception and Prenatal DiagnosticTechniques (Prohibition of
sex selection)Act - 2003
Guidelines for Exchange of Biological Material (MOH order, 1997)
Right to InformationAct - 2005
• Ethical decisions are rarely simple.
• No more rules and laws, but what we
needed now is clear thinking about the key
issues and conflicts of interests.
• While the decision is important , the process
of arriving at that decision is of paramount
• The public and government will have to make
informed choices .
The World Health Organization says public
health as “an art and a science”.
The art of the public health is to persuade the
public and government to adopt the policies
that are derived from scientific data.
It is time that we moved from ad-hoc
approach to a more rational scientific
approach in solving ethical issue in
public health policy.