This lecture was given as a part of the Introduction to Epidemiology & Community Medicine Course given for third-year medical students.

1. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD
Third year
Level 6
Lecture 16
Ethical and Legal Issues in Public
Health

2. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD
• Differentiate the ethical issues related to public health compared to
those in clinical practice
• Outline the ethical issues encountered during public health practice
• Gain an overview of the basics of public health ethics
• Learn to apply public health ethics tools to address ethical
challenges that commonly arise in the practice of public health

3. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD
Aspect Clinical care Public health
Main aim Treat sick individuals (cure) Protect healthy individuals from getting ill
(prevention)
Beneficiaries Individuals (healthy or sick) and families Population (community)
Scope Clinical care, diagnosis, and treatment Health education, health promotion, and
community-based interventions
Fields
(specialties)
Internal medicine, surgery, paediatrics,
obstetrics and gynecology, etc.
Epidemiology, health promotion,
biostatistics
Occupational health, etc.
Guidance Clinical guidelines, hospital policies, etc. PH guidelines, regulations, laws
Examples of
ethical issues
and
questions
Issues related to the individuals’ right to
decide (autonomy), privacy and
confidentiality, etc.
- When is it ethical to disclose a
patient’s medical information?
- How to decide which patient should
have which service (e.g. an ICU bed)?
Issues related to the tension between the
individual rights (interests) and the public
good (interests)
- When is it ethical to limit the freedom
of movement of a patient with an
infectious disease (e.g. in case of
pandemic)?
- Do parents have the right to refuse
vaccinating their children?

4. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD

5. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD
• In Countristan, treatment of all TB patients is free. Patients are expected to
show to the nearest health center (HC) to receive the treatment under direct
observation (DOTS).
• The HC keeps a record of ‘which patient had which dose’.
• The TB officer in that region of Coutristan noted that one of the TB patient, Mr.
Contagious, did not receive his doses for the last couple of weeks.
• The Officer approached Mr. Contagious to persuade him to take the doses on
time.
• The patient refused. The Officer presented an official request to the Attorney
General (AG) in the region saying that “Mr. Contagious presents danger to the
public.”
• The AG issued an Order of Arrest against Mr. Contagious for the whole duration
of the TB treatment.
 What are the ethical issues at stake here?

6. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD
• Public Health Ethics (PHE):
–the identification, analysis, and
resolution of ethical problems arising
in public health practice and research

7. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD
• Public vs. individuals’ rights
• Scarcity of resources
• Socio-political factors:
–Poverty, illiteracy , minorities, vulnerability
–Abuse of power (‘Nanny State’ & public engagement)
• Socio-cultural factors:
–Local beliefs vs. “international guidelines”
–Role of families and community leaders
• Urgency to contain public health threats
• Inequalities (national and international)

8. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD
Disproportional
burden
COI (®Tamiflu,
vaccine)
Resource
allocation
Consent
Public
engagement
Sub-optimal
products
Surveillance
(research?)
Inequalities
Trials (review)

9. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD
Philosophical
• Deontological
• Utilitarian (act & rule)
• Rights-based
• Virtue
• Casuistry
• Social-contract
• Principlism
Religious
• Islamic ethics &
jurisprudence
(Purposes of Law
‘Sharia’)
• Christian ethics
• Jewish Ethics
• ?Oriental
Philosophies
(Buddhist, Confucian,
etc.)
PH Guiding Principles
• Utility
• Efficiency
• Liberty
• Transparency
• Participation
• Review and
revisability
• Effectiveness
• Fairness
• Reciprocity
• Solidarity
• Proportionality

10. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD
• Utility: acting so as to produce the greatest good.
• Efficiency: calls for minimizing the resources needed to produce a
particular result or maximizing the result that can be produced
from a particular set of resources.
• Liberty: one should impose the least burden on personal self-
determination that is necessary to achieve a legitimate goal

11. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD
• Fairness: “treating like cases alike”
– For example, a given population in a given geographical area who share
similar demographic public health characteristics are expected to have
the same public health interventions. Any skew from that norm need to
be justified on epidemiological evidence not for economic or racial
reasons
• Reciprocity: individuals (professionals) accept of the risk in
executing their duties would engender reciprocal duties on the
part of the community to them
– For example, recognition, appraisal, compensation for their families,
and provision of healthcare conditions that meet the universal
conditions for infection control.
• Proportionality: actions taken proportional to need

12. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD
1. Public health should address the fundamental causes of disease
aiming to prevent adverse health outcomes.
2. Public health should achieve community health in a way that
respects the rights of individuals in the community.
3. Public health policies, programs, and priorities should be
developed and evaluated through processes that ensure an
opportunity for input from community members.
4. Public health should advocate for ensuring that the basic
resources and conditions necessary for health are accessible to all
people in the community.
5. Public health should seek the information needed to implement
effective policies and programs that protect and promote health.

13. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD
6. 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.
7. 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.
8. Public health programs and policies should incorporate a variety of
approaches that anticipate and respect diverse values, beliefs, and
cultures in the community.
9. Public health programs and policies should be implemented in a
manner that most enhances the physical and social environment.

14. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD
10. Public health institutions should protect the confidentiality of
information that can bring harm to an individual or community if
made public.
11. Public health institutions should ensure the professional
competence of their employees.
12. Public health institutions and their employees should engage in
collaborations and affiliations in ways that build the public’s trust and
the institution’s effectiveness.

15. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD
EPIDEMIOLOGY
Leon Gordis
fifth edition 2013
by Saunders, an imprint
of Elsevier inc.
ISBN: 978-1-4557-3733
www.elsevier com/permissions.

16. EPIDEMIOLOGY & COMMUNITY MEDICINE
WRITTEN AND COMPILED BY DR. GHAIATH HUSSEIN MD, PHD
Basic epidemiology
R Bonita, R Beaglehole
and T Kjellström
2nd edition 2006
World Health Organization
ISBN 92 4 154707 3
ISBN 978 92 4 154707 9
e-mail: permissions@who.int