Current ethical issues in PH Final.pptx

1. CURRENT ETHICAL
ISSUES IN PUBLIC
HEALTH
PH610702
DR MOHD HANAFIAH AHMAD HIJAZI
DR JONATHAN BIN LAMIT
DR MAZLIANAH MAZLAN
DR PRAVEEN ABRAHAM DEVASAGAYAM
1

2. SLO
• Evolution of public health ethics
• Common ethical issues and situations related to public health –
please include the followings in your discussion :
• ethical issues related to :
• public health surveillance, emergency response and outbreak investigation
• Health promotion and disease prevention
• Public health screening programs
• How these common issues could cost severe consequences
• Methods of prevention or controlling these ethical problems
2

3. Definition
• Ethics
• the branch of philosophy that deals with distinctions
between right and wrong – with the moral
consequences of human action”
(Coughlin & Beauchamp. 1996)
• Public Health
• “the art and science of preventing disease, prolonging
life and promoting health through the organized
efforts of society” (Acheson, 1988; WHO).
• Public Health Ethics
• “A systematic process to clarify, prioritize, and justify
possible courses of public health action based on
ethical principles, values and beliefs of stakeholders,
and scientific and other information” (CDC 2011).
3

4. History of Bioethics
Ancient era
• Medical code of
ethics
• Hippocrates -
ancient Greek
Hippocratic Oath,
which required
physicians above
all to “do no
harm;”
1800-1900
• Professional code
of ethics
• Foundation of the
first code of
ethics established
in 1846(American
Medical
Association)
based on Thomas
Percival
documentation.
1947
• Research ethics
• The Nuremberg
Code 1947
• In response to
the gross abuses
in human
experimentation
performed in
Nazi Germany -
Experiment to
be scientifically
necessary,
conducted by
qualified
personnel and
documented by
informed
consent.
2000
• Public Health ethics
• Relatively new
field of bioethics,
and is related to
moral
implications of a
wide range of
activities aimed at
maintaining and
improving the
population
health.
4

5. Public Health Ethics challenges
Relatively new field that
combines public health and
practical ethics
Unfamiliar area, difficult to
delineate its scope
Articulate an approach specific
enough to provide clear
guidance yet sufficiently flexible
and encompassing to adapt to
global contexts
Helps guide practical decisions
affecting population or
community health based on
scientific evidence and in
accordance with accepted
values and standards of right
and wrong
5

6. Clinical Ethics vs Public Health Ethics (PHE)
• Adapted from Distinguishing Public Health Ethics from Medical Ethics. J. Thomas, UNC IPH
Clinical Ethics PHE
Traditional medical ethics emphasizes
individuals:
• Autonomy
• Right to decline
• Nonmaleficence
• Do no harm
• Beneficence
• Seek benefits for patients
• Justice
• Providing equal care to all
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
6

7. Clinical ethics focus/tendency Public health ethics focus/tendency
Treatment of disease and injury Prevention of disease and injury
Medical interventions by clinical professionals Range of interventions by various professionals
Individual benefit seeking and harm avoidance based on
health care provider’s fiduciary relation to a patient
Social, community, or population benefit seeking and harm
avoidance based on collective action
Respect for individual patients Relational autonomy of interdependent citizens
Professional duty to place the interests of the patient over that
of provider
Duty to the community to address health concerns that
individuals cannot solve and that require collective action
Authority based on the prestige and trustworthiness of the
physician and the medical profession as a whole
Authority based on law, which is a principal tool of public
health policy for creating health regulations
Informed consent sought from an individual patient for specific
medical interventions
Community consent and building a social consensus through
ongoing dialogue and collaboration with the public
Justice concerns largely limited to treating patients equally and
ensuring universal access to health care
Central concern with social justice regarding health and
achieving health equity
Barrett, H. D., Ortmann, W. L., Dawson, A., Saenz, C., Reis, A., & Bolan, G. (2016). Public Health Ethics:
Cases Spanning the Globe (Public Health Ethics Analysis Book 3) (1st ed. 2016 ed.). Springer.
7

8. Evolution of PHE
• Two main concerns have led to the formation of PHE frameworks
• Overcoming of the public interests over individual liberty and autonomy
• Priority setting and allocation of scarce resources, especially in developing
countries.
8

9. Evolution of PHE
1997
Yan-Guang Wang reported
inadequacy of principlism
framework.
Suggested an improved
bioethical framework would
include principles of
tolerance, autonomy,
beneficence, and care for
and care about.
Tolerance and care should
play a key role because of
interdependence of humans,
whereby autonomy and care
will be in conflict.
2001
Nancy Kass was the first
American pioneer on PH
thinking who designed a
practical framework for PHE.
One of the first persons who
called PH professionals for
moral reasoning based on
both facts and values.
She proposed a framework
based on two key values of
rights and social justice.
By emphasizing positive
rights, in addition to negative
rights, she pointed out the
duty of the state to protect
the public from harm and
promote PH.
2002
Childress et al. tried to
conceptualize PHE.
Investigated the
development and
effect of different
perceptions of the
concept of “public”
over time.
2008
Baylis et al presented a
theoretical framework
of relative morality as
a feature of PHE
treating public as
related social beings.
Revised in 2010 by the
authors, is based on
three fundamental
values: relative
autonomy, relative
social justice and
relative solidarity.
9

10. 10

11. SLO
• Evolution of public health ethics
• Common ethical issues and situations related to public health –
please include the followings in your discussion :
ethical issues related to :
• public health surveillance, emergency response and outbreak investigation
• Health promotion and disease prevention
• Public health screening programs
• How these common issues could cost severe consequences
• Methods of prevention or controlling these ethical problems
11

12. Ethical issues related to :
Public health surveillance, emergency response and
outbreak investigation
Public Health Surveillance
Definition Surveillance can be defined as the ongoing, systematic collection, analysis, and
interpretation of outcome-specific data, with the timely dissemination of these data to
those responsible for preventing and controlling disease or injury
Functions – to measure and monitor changes in health status, risk factors, and health service access
and utilization. The effective dissemination of information is as important as data
collection and analysis; the collected information must have a demonstrated utility
– early warning system;
– document the impact of an intervention, or track progress towards specified
goals; and
– monitor and clarify the epidemiology of health problems
Ethical issue -Privacy and confidentiality of health information – technological advances can
disseminate the information/ hacked
-Balanced against possible risks and harms – surveillance data should not be
collected if not going to used
12

13. Sources of Ethical Issues
• Privacy
• Confidentiality
• Autonomy
(consent)
Data/sampl
e
collection
• Benefits
• Harms
• Autonomy
(consent)
Method
s
used
• Justic
e
• Trust
Outcome
s
13

14. Ethical issues related to :
Public health surveillance, emergency response and
outbreak investigation
emergency response and outbreak investigation
Definition • public health activities undertaken in an urgent or emergency situation, usually because
of an imminent health threat to the population
• public or government authorities perceive an imminent threat that demands immediate
action
Function to determine the nature and magnitude of a public health problem in the community and to
implement appropriate measures to address the problem
Ethical issues Privacy: Consider MOH cars in front of a house
Confidentiality:
• Patient’s address and contacts are shared with teams
• Timely information to public via mass media - SARS,H1N1 Social media
- facebook
Autonomy: Do patients have right to say no to outbreak investigation?
Stigma: quarantine at airport
14

15. Ethical issues related to: Health promotion and
disease prevention
Health Promotion and disease prevention
Definition the process of enabling people to increase control over, and to improve, their
health; for healthier society, reduce fiscal expenditure, increase productivity &
efficiency
Ethical Issue Need of voluntary participation – community empowerment
Avoidance of excessive incentives
Justice- related issues
Need for sensitivity to ethnic and cultural habits, avoid ‘top-down’ planning
Avoid conflicts of interest
To present facts about health hazards or health opportunities in a truthful way
Avoid distorting the facts
15

16. Ethical issues related to: Public health
screening programs
Public health screening programs
Definition Presumptive identification of unrecognized disease using test, examinations
or other procedure that can help disease or disease precursor in apparently
WELL person
Function Reduce morbidity & mortality
Ethical Issue Informed consent - principle of respect for individuals’ freedom
- giving information about the procedure, meaning
of a positive or negative test result, potential risks
and benefits before undergo screening
Privacy and confidentiality – minimize risks e.g. stigma
Risks or harm – false-positive or false-negative will give ‘labelling’
effect and the psychologic impact (anxiety) of the
test result or diagnosis
Potential benefits – early detection of the disease and treatment effective
Allocation of public resources for screening
16

17. SLO
• Evolution of public health ethics
• Common ethical issues and situations related to public health –
please include the followings in your discussion :
ethical issues related to :
• public health surveillance, emergency response and outbreak investigation
• Health promotion and disease prevention
• Public health screening programs
• How these common issues could cost severe consequences
• Methods of prevention or controlling these ethical problems
17

18. Ethical Issues in Social Media ( SM ) Research
for Public Health
• vehicle for surveillance, delivery of health interventions, recruitment to trials,
collection of data, and dissemination. However, the networked nature
• -cause ETHICAL ISSUE
• CONCERN : 1. privacy .anonymity and confidentiality
authenticity
2.the rapidly changing SM environment
3.informed consent
3. recruitment, voluntary participation,
and sampling
minimizing harm
4.a data security and management
18

19. paternal discrepancy
• Public health consequences of PD: affect far more than 1 in 25
families. Given an average of two children per family, more families
will be affected within just a single generation
19

20. Ethical issues in public health surveillance
• overviews on surveillance ethics are limited in scope and in how
transparently they derived their results.
• constitutes an unjustified infringement of privacy or autonomy
rights although it allows the production of a more
complete and reliable data set [3–5]. Especially in the
context of HIV/AIDS: data collection from valunerable population and
might lead to stigmatism
20

21. Ethical Challenges of Big Data in Public Health
• Digital epidemiology, also referred to as digital disease detection
(DDD),electronic data sources that emerged with the advent of
information technolog
• global real-time data, DDD promises accelerated disease outbreak
detection, and examples of this enhanced timeliness in detection
• This dynamic environment generates various ethical challenges that
relate not only to the value of health for individuals and societies, but
also to individual rights and other moral requirements
21

22. SLO
• Evolution of public health ethics
• Common ethical issues and situations related to public health –
please include the followings in your discussion :
ethical issues related to :
• public health surveillance, emergency response and outbreak investigation
• Health promotion and disease prevention
• Public health screening programs
• How these common issues could cost severe consequences
• Methods of prevention or controlling these ethical problems
22

23. Ethical issues related to :
Public health surveillance, emergency response and
outbreak investigation
• Privacy and confidentiality of health information – information
dissemination/ hacked, including misinformation (misinfodemic)
• Cybersecurity
• Confidentiality
• Fact-checking
• Balanced against possible risks and
harms – surveillance data should not
be collected if not going to used
• Judicial collection of data
23

24. Ethical issues related to :
Public health surveillance,
emergency response and
outbreak investigation
Privacy: Ambulance/ MOH cars in front of a house
Confidentiality:
• Patient’s address and contacts are shared with teams
• Timely information to public via mass media - SARS, H1N1
Social media - Facebook
Autonomy: Do patients have right to say no to outbreak investigation?
Stigma: Quarantine at airport
• Ensure confidentiality - prevent sharing to social media,
• Legislation (PCDA 1988)
• Adequate dissemination of information - quarantine/ disease is not a stigma
24

25. 25

26. Ethical issues related to: Health promotion and
disease prevention
• Need of voluntary participation – community empowerment
• Avoidance of excessive incentives
• Justice – related issues
• Need for sensitivity to ethnic and cultural habits, avoid ‘top-down’
planning
• Avoid conflicts of interest
• To present facts about health hazards or health opportunities in a
truthful way
• Avoid distorting the facts
26

27. Ethical issues related to: Public health
screening programs
• Informed consent
• respect for individuals’ freedom
• information about the procedure, meaning of a +ve or -ve test result,
potential risks & benefits
• Privacy and confidentiality
• minimize risks e.g. stigma
• Risks or harm
• avoid ‘labelling’ effect and adequate information to reduce the
psychologic impact (anxiety) of the test result or diagnosis
27

28. 28

29. References
1. Steven S. Coughlin. Ethical issues in epidemiologic research and public health
practice, 2006. Available online: https://ete-
online.biomedcentral.com/track/pdf/10.1186/1742-7622-3-16?site=ete-
online.biomedcentral.com
2. Ortmann., L. W., et al, 2016. Public Health Ethics: Global Cases, Practice, and
Context. Available online: https://www.ncbi.nlm.nih.gov/books/NBK435780/
3. Abbasi, M., et al, 2017. The evolution of public health ethics frameworks:
systematic review of moral values and norms in public health policy. Available
online: https://link.springer.com/article/10.1007/s11019-017-9813-y#Tab1
4. Barrett, H. D., Ortmann, W. L., Dawson, A., Saenz, C., Reis, A., & Bolan, G.
(2016). Public Health Ethics: Cases Spanning the Globe (Public Health Ethics
Analysis Book 3) (1st ed. 2016 ed.). Springer.
29