An introduction to ethical issues in public health practice and research I gave to master students in the Public Health Institute in Sudan -- My Home Country. This was on Jan. 5, 2012.

1. Public Health Institute (Khartoum, Jan. 5, 2012)
Ghaiath M. A. Hussein
Assistant Professor of Bioethics
Faulty of medicine, King Fahad Medical City
Riyadh, Saudi Arabia
Email: ghaiathme@gmail.com
Phone: 00966566511653

2.  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?
Public Health Institute (Sudan)

3. Public Health Institute (Sudan)

4. Public Health Institute (Sudan)

5.  The expressive level (unanalyzed expressions or
feeling that, by themselves, don’t provide
reasons or justification)
 The pre-reflective level (justification via
law, religious tenets, social values, codes of
ethics, etc.; accepted uncritically)
 The reflective level (reasoned ethical
argument/defense based on ethical
principles, rules, virtues, values to which we
consciously subscribe; justification provided)
Thomas J and Waluchow W, 1998
Public Health Institute (Sudan)

6.  It is the process we need to go through to reach a
decision about an ethical issue.
 It helps us to differentiate:
 Values and ethical principles
description of the way the world is; an actual state
of affairs (“is”)
judgment about the way things should be
(“ought”).
they are meant to guide actions. Key
values in bioethics have corresponding (e.g., principle of
respect for autonomy)
Public Health Institute (Sudan)

7. What is Public Health about?
What is ethics/bioethics?
What is Public Health Ethics?
What is an ethical issue?
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8.  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 Health Institute (Sudan)
Public

9.  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.
Public Health Institute (Sudan)

10.  A system of moral principles or standards
governing conduct.
 a system of principles by which human actions
and proposals may be judged good or bad, right
or wrong;
 A set of rules or a standard governing the
conduct of a particular class of human action or
profession;
 Any set of moral principles or values recognized
by a particular religion, belief or philosophy;
 The principles of right conduct of an individual.
(UNESCO/IUBS/Eubios Living Bioethics Dictionary version 1.4)
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11.  It is derived from Greek bio- life and ethicos
moral.
 The science/art that aims at
identification, analysis, and resolution of the
ethical issues in almost any field that is
related to human life and health.
Public Health Institute (Sudan)

12. ▪ deciding what we should do (what
decisions are morally right or acceptable);
▪ explaining why we should do it (how do we
justify our decision in moral terms); and
▪ describing how we should do it (the method
or manner of our response when we act on our
decision).
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13. Clinical Ethics
Bioethics Research ethics
Resource
Allocation ethics
Business ethics
Public Health
Environmental ethics
Ethics ethics
Nursing ethics
Social ethics
Organizational other
ethics
IT ethics
Other
Public Health Institute (Sudan)

14.  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
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16.  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?
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17. Public Health Institute (Sudan)

18.  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)
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19. Public Health Institute (Sudan)

20. Disproportional
burden Resource
allocation
Consent
Public
engagement
Sub-optimal
products Loss of
COI property Access Restricted Confiden Professiona
Surveillance
(®Tamiflu, vaccin &work to care movement tiality l duty
(research?)
e) hours
Inequalities
Trials (review)
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21. Philosophical Religious Guiding Principles
• Deontological • Islamic ethics & • Utility
• Utilitarian (act & jurisprudence • Efficiency
rule) (Purposes of Law • Liberty
• Rights-based ‘Sharia’)
• Transparency
• Virtue • Christian ethics
• Participation
• Casuistry • Review and
• Social-contract revisability
• Principlism • Effectiveness
• Fairness
• Reciprocity
• Solidarity
Public Health Institute (Sudan)

22.  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 (Sudan)
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binding legal rights

23.  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
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24.  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
Public Health Institute (Sudan)

25.  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.
Public Health Institute (Sudan)

26. Fast track
review
Urgent
Prior approval
Research
Not urgent RECs
Research or
‘practice’?
Implement
policy
Ethics
Practice
considered?
Add ethical
considerations
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27. Source of tension Suggested ethical/practical
approach
Differences in -Local (national) deliberation
guiding -Regional meetings
references/principles -Unifying/Uniforming int’l ethical guidance
to include local sources
Scarcity of resources -Develop a fair decision-making process
-Prior priority setting standards & guidance
Urgency -Prior planning
-‘Ethical drills’
-‘Fast track’ review mechanism
-On-call ethicist
Public Health Institute (Sudan)

28.  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!
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29. Questions & Discussion
Public Health Institute (Sudan)
Feel free to contact:
Ghaiath Hussein
Assistant Professor of Bioethics
Faulty of medicine, King Fahad
Medical City
Riyadh, Saudi Arabia
Email:
ghaiathme@gmail.com
Phone: 00966566511653

30.  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
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