Introduction to ethical issues in public health ghaiath
EMPHNET Meeting (Sharm Elsheikh, Dec. 5, 2011) Ghaiath M. A. Hussein Assistant Professor of Bioethics Faulty of medicine, King Fahad Medical City Riyadh, Saudi Arabia Email: email@example.com Phone: 00966566511653
Public health (vs. clinical care) What’s Ethics? What is Public Health Ethics (PHE)? Sources of ethical concern in public health practice and research Why are pandemics ethically unique? Levels of pandemic effects and their ethical implications Guiding ethical principles How to deal with ethical tensions in PH?
Definitions: “Public health is what we, as a society, do collectively to assure the conditions for people to be healthy.” (IOM, 1988); “the process of mobilizing and engaging local, regional, national and international resources to assure the conditions in which people can be healthy” (Oxford Textbook of public health, 2004) "Public health is primarily concerned with the health of the entire population“ (Childress et al.) Scope: health promotion and disease prevention throughout society) Fields: Policy; Practice; and Research Disease prevention Occupational health Health promotion Environmental health Epidemiological studies Determinants of health WSH Biostatistics
Morality & Ethics: Morality: the beliefs and standards of good and bad, right and wrong, that people actually do and should follow in a society, while ethics is defined as the systematic study of morality. Metaethics: tries to clarify the rational standards and methods for the study of ethics Normative ethics: develops ethical principles, rules, and ideals that spell out standards of good and bad, right and wrong.
Bioethics: is normative ethics applied to decision- making and public policy in the domains of biology, health care and research. Domains: Clinical/medical ethics Research ethics Public health ethics Environmental ethics Resource allocation ethics Organizational ethics, etc.• Public Health Ethics (PHE): the identification, analysis, and resolution of ethical problems arising in public health practice and research
Within its efforts to control the spread of Pandemic Influenza A H1N1 during the Hajj season (2010), the Saudi government was able to provide a total of 2,500,000 doses of the newly produced vaccine. The pilgrims are estimated to be 3,500,000; the working staff who are in contact with pilgrims (entries, security & health) are about 120,000 persons Who should have the vaccine? Who’s first?
Public vs. individual rights Scarcity of resources Socio-political factors: Poverty, illiteracy , minorities, vulnerability Abuse of power (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)
Disproportional burden Resource allocation Consent Public engagement Sub-optimal products Loss ofCOI (®Tamiflu, Surveillance property Access Restricted Confiden Professiona vaccine) (research?) &work to care movement tiality l duty Inequalities hours Trials (review)
Deontology and principilism: Deontology is duty-based, people should act so as to fulfill their duties to others; acts should always follow a set of maxims (e.g. do not lie); and less concerned with the act’s consequences. Principilism is one way of approaching professional deontology Examples: Hippocrates’ oath (“First, do no harm” or “Primum non nocere”) Belmont Report, produced in 1978 (three principles) Beauchamp and Childress in 2001 (four principles—beneficence, non- maleficence, respect for persons, and justice) Rights-based ethics: involves a larger number of principles and is addressed more to the actions of institutions and governments, e.g. Universal Declaration on Bioethics and Human Rights, (UNESCO) in October 2005. It provides more binding legal rights
Consequentialism (utilitarianism) the right action is that which produces the greatest sum of pleasure in the relevant population,• Act utilitarianism: a person should act in the way that produces the best outcome; Rule utilitarianism: looks at the consequences of general rules instead of the consequences of individual acts
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 Fairness: “treating like cases alike” Reciprocity: individuals (professionals) accept of the risk in executing their duties would engender reciprocal duties on the part of the community to them Proportionality: actions taken proportional to need
If we can not agree on what’s fair distribution, let’s at least agree on a procedural justice (fair process). “Fair process” (Norman Daniels’ A4R) suggests a set of principles that need to be followed in decision making: Transparency/publicity: information about the processes and bases of decisions should be made available to the affected population Participation: the stakeholders should be involved in the processes of formulating the objectives and adopting the policies. Effectiveness/Relevance: states that there must be ways to translate the other principles into practice relevant to meeting population health needs fairly Appeal: Stakeholders should have a way to appeal policies after they have been adopted, and processes should be in place that allow policies and plans to be reviewed and revised.
Fast track review Urgent Prior approval Research Not urgent RECsResearch or ‘practice’? Implement policy Ethics Practice considered? Add ethical considerations
Source of tension Suggested ethical/practical approachDifferences in -Local (national) deliberationguiding -Regional meetingsreferences/principles -Unifying/Uniforming int’l ethical guidance to include local sourcesScarcity of resources -Develop a fair decision-making process -Prior priority setting standards & guidanceUrgency -Prior planning -‘Ethical drills’ -‘Fast track’ review mechanism -On-call ethicist
Proactive ethical preparedness, learning from past experiences (SARS, H5N1, and H1N1) Involvement of ethics in the PH policy development process Active public engagement Develop an ethics comprehensive and flexible consultation and review mechanism International (UN) agencies should advocate for the least powerful nations (Fair international governance) Though agreeing on the guiding principles to make a fair decision is difficult; it is possible to agree on a fair decision making process Make sure the voice of the voiceless is heard!
Questions & DiscussionFeel free to contact:Ghaiath HusseinAssistant Professor of BioethicsFaulty of medicine, King FahadMedical CityRiyadh, Saudi ArabiaEmail:firstname.lastname@example.orgPhone: 00966566511653
Principles of the Ethical Practice of Public Health; Public Health Leadership Society (2002) Ethics and Public Health: Model Curriculum. Ed. Bruce Jennings et al. (2003) Childress JF, Faden RR, Gaare RD, Gostin LO, Kahn J, Bonnie RJ, Kass NE, Mastroianni AC, Moreno JD, Nieburg P: Public health ethics: mapping the terrain. J Law Med Ethics 2002, 30:170-8. Public health: disconnections between policy, practice and research. Jansen et al. Health Research Policy and Systems 2010, 8:37 Ethical issues in epidemiologic research and public health practice. Steven S Coughlin. Emerging Themes in Epidemiology 2006, 3:16 Accountability for reasonableness. Norman Daniels, BMJ 2000;321:1300-1301