Public health ethics

Ashok Pandey
MPH/BPH, DGH
NHRC
111/27/18 Ashok Pandey

Introduction
Concept of ethics, importance of ethics in public
health professional, difference between ethics,
rules, regulation and law, brief overview of
history of ethics of public health
Unit 1: Public Health Ethics
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DefinitionsDefinitions
• Ethics
– Is a derivative of the Greek word ethos, meaning customs, conduct, or character
– Is concerned with the kinds of values and morals an individual or society ascribes
as desirable or appropriate
– Focuses on the virtuousness of individuals and their motives
Ethics is the science of morality. It deals with the right or
wrong of any activity.
Research ethics: analysis of moral worth of all the actions
involved in human or animal research.
Ethics: “principles of right conduct”
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Ethics
• Ethics is a discipline that includes the study of
ideals for human conduct for and an
understanding of the normal life in which
actions are judged as right or wrong and
persons and institutions are taken as
praiseworthy and blameworthy

Why Study Ethics in PHWhy Study Ethics in PH
• Many issues of conflict between good of the
individual and good of society
• Immunization, chlorination, fluoridation
• Food fortification
• HIV/AIDs, MDRTB, DOTs vs. DOTS Plus
• Aging and chronic diseases
• Genetically modified foods
• Technology and resource allocation
• Stem cell research
• The Case-for-Action

Ethical Issues in PH
• Responsibility to protect society
• Responsibility to the individual
• Individual vs. community rights
• Government responsibility
• Corporate responsibility
• Right to health care
• Personal responsibility - self care
• Quality of care
• Freedom of choice
• Acting on evidence vs. not acting

Ethical Issues in PH
Routinely in public health, scientific considerations blend
with political and ethical conflicts, and questions of
autonomy, individual rights, coercion, justice,
community, the common good, the norms of research,
and multi-cultural values are central.
In public health today several different types of political
and moral theory overlap, converge, and contend with
one another, including libertarian liberalism, egalitarian
liberalism, utilitarianism, human rights frameworks,
and communitarianism.
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Ethics and Public Health:
Model Curriculum, ASPH,
2003
http://www.asph.org/UserFiles/E
thicsCurriculum.pdf11/27/18 Ashok Pandey

What are Public Health Ethics?
• Public health ethics are principles and values
that guide actions to promote health and
prevent injury and disease among the
population.
• Public health ethics should be distinguished
from biomedical ethics.
- Biomedical ethics often stress the importance of
individual interests of patients.
- Public health ethics emphasize partnership, citizenship,
and community.

• Some scholars have structured public health
ethics in three overlapping ways:
- Professional ethics are concerned with ethical
dimensions of professionalism.
- Applied ethics relate to dynamics of the public
health enterprise itself.
- Advocacy ethics are informed by the single
overriding value of a healthy community.

• Scholars and practitioners disagree on each of
the three forms of public health ethics.
- A code of ethics could clarify the field and provide
guidance regarding ethical dilemmas.
- Some suggest that no single public health
profession exists. It is difficult to find a single set
of values that relates to all public health
professionals.

Contd…
• Moral imperative of PH to ensure and protect the health
of the population and the individual
• Ethical foundations traditionally implicit in PH
• The right to health
• Responsibility from population health
• Renewed awareness of and accountability
• Conflict between individual and community rights
• Effects of doing or not doing public health interventions
or “best practices”
• New issues all the time – disasters, genocide

Moral Reasoning as Guide for Action
• Mandatory and voluntary
• Benefits – for society and individuals
• Do no harm - balance potential good and harm
• Action vs. non action
• Autonomy - right of self determination
• Justice and equity
• Case based approach
• Design and conduct of research
• Application of knowledge
• Conflict of interests – disclosure
• Autonomy - informed consent, confidentiality
• Screening
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When and When Not to Act
• Public (community) right to protection and best available
standards
• Dangers/costs of not acting exceed those of acting
• Judgment, experience, evidence, ethics
• Experience of Good Public Health Practice (GPHP)
• Threats of preventable mortality or risk factors
• Public right to know
• Individual rights
• Balance of contradictions
• Accountability, transparency

Importance of ethics in researchImportance of ethics in research
• Major expansion in health research, technological
advances, newer vaccines and drugs.
• Newer more intrusive interventions: organ
transplantation, stem cells in therapy, cloning.
• Heavy investment, financial interests.
• Many instances of violation.
• Internationalization of research.

Rule
• a statement that tells you what is or is not
allowed in a particular game, situation, etc.
• a statement that tells you what is allowed or
what will happen within a particular system
(such as a language or science)
• a piece of advice about the best way to do
something

Law VS Ethics
Law: Laws are the rules and regulations that are set by the authorities
or government and are must to be followed otherwise penalties and
punishments may be the consequences. Laws are the code of conduct
for the people in a specific area. Laws explain and illustrate people for
what is allowed to do and what is not allowed to do. Laws can be
made and change by authorities according to demand and need for
maintaining specific condition in the society. Laws are must for any
country, workplace or even for a forest.
Ethics: Ethics are the moral values and principles that are adapted
socially from the surrounding. Ethics are the beliefs for wrong and
right in the society characterized by the social and moral actions of the
people. Ethics vary slowly with time depending upon the new
inventions, ideas and information. Ethics may vary from nation to
nation, from culture to culture and from country to country. There is
not any kind of penalty, fine or punishment for not obeying ethics.
Ethics relates to one’s self-respect depending upon his conscience and
self-worth.

Difference between ethics, rules, regulation
• Ethics are the moral values and principles that are adapted socially
from the surrounding while Laws are the rules and regulations that
are set by the authorities or government and are must to be
followed otherwise penalties and punishments may be the
consequences.
• Disobeying laws may get you in penalties, fine or punishment but
there are no penalties, fine or punishment for not obeying ethics.
• Laws are made by the competent authorities based upon the ethics
of the society and other demands.
• Laws are must to be obeyed by everyone but ethics are the values
considered to be a positive attitude to follow them.
• Ethics vary slowly with time depending upon the new inventions,
ideas and information while laws can be made and change by
authorities according to demand and need for maintaining specific
condition in the society.

• Ethics are made from moral values of one self or from society and laws
are made with ethics as a guiding principle.
• Ethics vary from area to area but laws vary from state to state.
• Laws are same for everyone in a country but ethics may vary from one city
to another.
• Religion has a direct impact on ethics. It may or may not affect the laws of
an area or country.
• Driving the within speed limits with desire that no one should get accident
or disturbed comes in ethics while driving the car within speed limits due
to getting safe from fine by traffic police is obeying of laws.
• Offering “Salam” when meeting someone is ethical but in army you must
have to salute your senior as it is a law in army.
• Sometimes laws may allow you to do something, means that is legal to do
but your ethics may not let you to do that.

Rule, regulation and Law
Laws are more prescriptive than ethical standards, have been
incorporated into code, and carry greater sanctions or penalties for
failure to comply.
• When ethics and laws appear to be in conflict with each other, the
professional
• counselor must attempt to resolve the conflict in a responsible
manner.
• Because there are greater penalties associated with laws, the
counselor will often follow the legal course of action if there is no
harm to the client.
• Some professional associations have their own ethical standards or
best practice guidelines.
• These codes of ethics and guidelines parallel ACA’s Code of Ethics
but speak more directly to the specialty area

PH Law and Ethics
• Gov’t obligation to protect health of the population
• Power of government to legislate, tax, spend,
regulate, punish
• Restriction of personal and business liberties e.g. seat
belt laws; smoking restrictions vs. human rights
• Economic, social impact of intervention vs. non-
intervention e.g. inequities of the poor and rural
• Laws enacted by legislative bodies
• Court decisions
• Public scrutiny
• Accountability

Individual Rights and PH Ethical Issues
• Right to quality health services
• Provider responsibility to act for benefit of client
• Euthanasia - right to die
• Confidentiality – right to privacy
• Informed consent – right to know
• Birth control – religion vs. individual rights
• Supply and distribution of resources for health
• Incentives - disincentives
• Equity – social, ethnic, regional
• Social solidarity

Groups at Special Risk
• Women
• Children
• Civilians in war and terror situations
• Disaster victims
• Native peoples
• Minority groups
• Prisoners
• Military
• Refugees and internal migrants
• Mentally ill
• Rural vs. urban

Brief overview of history of ethics of
public health

Learning from History

Nazi War Crimes of a
Medical Nature
The Tuskegee
Syphilis Study
The Jewish Chronic
Disease Hospital
Study
The
Willowbrook
Studies
Radiation Tests on
Mentally Impaired
Boys
Most Cited Infamous Cases

Nazi War Crimes
• To ensure supremacy of the Aryan race,
Nazi’s in Germany wanted a secret way of
sterilizing large populations.
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Three Experiments for Sterilization
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1. To sterilize women Dried Plant Juice put into
flour was fed to the general population.
2. Intra-uterine injections of Silver Nitrate to
women, without consent, during routine
physical examinations.
3. Men exposed to sterilizing doses of Radiation
while standing to fill forms without their
knowledge
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• Study to develop an effective
vaccine for Typhus
– Prisoners administered vaccine or placebo and
then injected with blood from patients with typhus
fever. Hundreds Died.
– Survivors served as a "passage group“ to keep
the pathogen alive and virulent
Buchenwald
Concentration Camp

• Horrors of "experiments,“ exposed after
World War II.
• Professional status: Physicians
• Nature of the crimes: Atrocious
• Separate trial
TheThe “Nuremberg
“Nuremberg
Trials”
Trials”

Research Findings of Nazi times not
allowed to be published even today

Tuskegee Syphilis Study
• U. S. A. study to study natural history of
untreated latent syphilis.
• 400 black men with syphilis and 200
controls
• No informed consent.
• Procedures claimed as "Special Free
Treatment.“
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Tuskegee Syphilis Study
• Complications & death rate double in patients
• Penicillin available but subjects were not informed &
treated with it.
• Continued till reported in press in 1972
• An enquiry was held.
• President Clinton apologized profusely to
all concerned in 1997
• U S government still pays millions to surviving
subjects & families
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The Jewish Chronic
Diseases Hospital Study
• 1963, Nature of human transplant rejection
process
• Injection of live cancer cells
• Claimed Consent was taken orally
• Felt documentation as unnecessary
• Patients not informed because it would frighten
the patients unnecessarily

The Willowbrook State Study
(Infectious Hepatitis Study)
• Study of the natural history of Infectious Hepatitis &
effects of "gamma" globulin in preventing it
• All children, Deliberately infected with hepatitis virus
• Extracts of stools from infected individuals.
• Later injections of more purified virus preparations
• Researcher’s claim: Better to be infected under
carefully controlled conditions than otherwise
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Radiation Tests on Mentally Impaired Boys
Fernald State School in Massachusetts.
• 1946 to 1956, 19 boys fed radioactive milk
• Research on Digestive System.
• Researchers from
• Harvard University & Massachusetts
Institute of Technology (MIT)
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Refrigeration Experiment
• 16 mentally disabled patients placed in
refrigerated cabinets
• At 30 degree Fahrenheit (- 1 degree C)
• For 120 hours,
• University of Cincinnati Hospital
• “to study the effect of frigid temperature
on mental disorders”

“Thalidomide Disaster” 1962
Thalidomide withdrawn from the market
after thousands of birth deformities

Ethical Misconduct / Clinical Trials
India & Indians
• Supreme Court of India hauled up two top
biotech companies
– Hyderabad-based Shanta Biotech and
– Bangalore-based Biocon India
• "Openly conducting illegal clinical trials of
Streptokinase on unsuspecting patients“.

Ethical Misconduct
India & Indians
• > 400 infertile women without consent in India 2003
• To study Letrozole induced ovulation.
• Letrozole used globally only for breast cancer
• Complaint in Supreme Court.
• 2001, clinical trial of “Nordihydroguairetic acid”, with
anti-cancer properties by Regional cancer-
treatment center (RCC) in Kerala for a US-based
researcher without consent

Origins of Medical Ethics
• Caraka and Susruta Samhita(400 BC), Ashtanga Hridaya
• Hippocratic Oath (600 AD)- Father of Modern Medicine.
• Founded medical school, developed Oath of Medical Ethics
• Formed basis of recent medical oaths taken by students
before they begin practice of medicine. The chief tenants are:
– honor instructors in medical arts
– pass on the Art only to those bound by the Oath
– practice for the benefit of patients; "do no harm"
– give no deadly medicine or substance to produce abortion
– enter homes for the benefit of the sick
– abstain from mischief and corruption
– doctor-patient confidentiality

AMA Code of Ethics (1846)
• 1st code adopted by a national organization.
• Revised in 1980/2001, currently has following features
– dedication, competence, compassion & respect
– honesty & duty to report fraud or deception
– respect for the law
– respect for the rights of patients & colleagues
– respect for privacy & patient confidentiality
– continued education & consultation with professionals
– freedom of association & environment in practice of Art
– responsibility to make efforts to improve the community

Nuremberg Code (1947)
 A result of post-WWII trial of 23 Nazi doctors for crimes against
humanity committed in the name of research
 German doctors performed experiments under the disguise of
scientific research in Nazi concentration camps where prisoners
were used without concern for their welfare & consent
 Principles
 informed, voluntary consent
 research must be purposeful and necessary for the benefit of society
 research must be based on animal studies or other rational justification
 avoidance, protection from injury, unnecessary physical, mental suffering
 risks to subject shall not be greater than humanitarian importance of
problem
 investigators must be scientifically qualified
 subject may terminate the experiment at any time

Declaration of Geneva (1948)
• This oath was adopted by the World Medical Association after
the atrocities committed in the name of research in WWII Nazi
concentration camps. Key features are:
– service to humanity
– respect and gratitude for instructors
– conscience and dignity in the practice of the Art
– Attention to health of patient, colleagues & traditions of Art
– practice in accordance with laws of humanity, respect for
human life from conception
– duty takes precedence over racial, religious, political or social
prejudices

Declaration of Helsinki (1964)
• Published as response to unethical experiments of Nazis
during WWII
• Revised several times since its publication in 1964
• Latest revision (2000) states- "well-being of human subject
should take precedence over interest of science & society."
• Doctor should only act in the patients best interest
• Health of the patient is the first concern.
• Discusses use of placebo
• Ethics committees have obligation to monitor trials
• To disclose to subjects details of funding & conflicts of
interest.
• Publishers may decline studies not carried out ethically

Codes of Medical Ethics
• 400 BC : Charaka Samhita
• 600 AD : Hippocratic Oath
• 1846 : Code of Medical Ethics, AMA
• 1947 : Nuremberg Code
• 1948 : Universal Declaration of
Human Rights (UN)
• 1956 : Code of Medical Ethics, MCI
• 1964 : Helsinki Declaration
• 2000 : Revised Helsinki Declaration
• 2000 : Delhi Medical Council
Regulations

Guidelines
• 1979 : Belmont Report,USA
• 1980 : Policy Statement, ICMR,India
• 1993 -95 : Genetics, Human tissue, Xeno-
transplantation (Nuffield Council, UK)
• 1982, 1991, 1993 : The WHO / CIOMS guidelines
• 1996 : ICH GCP Guidelines
• 2000 : Revised ICMR guidelines ‘Ethical
guidelines for biomedical research on
human subjects’- India
• 2001 : Draft revised CIOMS Guidelines
• 2001 : Indian GCP Guidelines

Ethical Guidelines - ICMR
• 1980 -1st guidelines; one of earliest in the world
entitled “Policy Statement on Ethical
Considerations involved in research on Human
Subjects”
• 2000- “Ethical guidelines for biomedical research
on human subjects”
• It has been proposed that these guidelines will be
updated periodically with the new developments
in area of Biomedical Sciences

1980 ICMR Guidelines
Policy Statement on Ethical Considerations involved in research on
Human Subjects
 Ethics Committee
 Informed consent
 Clinical trials
 Research on children, mentally
disadvantaged, those with diminished
autonomy
 Traditional Medicine
 Publications

Modern Origins of Public Health Ethics (History)
Miasma and germ theories
Social hygiene
Scientific and PH advances during 19th
-20th
centuries
Government responsibility –local, state and national
Collective bargaining for health benefits
Tragic distortions of social hygiene – eugenics, genocide
Human rights – Nuremberg, Tuskegee, Helsinki
Universal right to health care (Health for All)
Self responsibility (lifestyle) in health
Advancing technology and rising costs
Public awareness and expectations
Pragmatism and science

New Public Health
Individual
Health
Population
Health
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Ethics
LawGovernment
Public
Opinion
Inter
national
standards

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What would your mother tell
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Considerations of ethics and brief
terminology
o Defining the Good, Virtue Ethics, Situation
Ethics, Care Ethics
o Moral worth, types of moral worth
o Paternalism, Plagiarism, Patent right,
Autonomy, Competence and Decisional
Capacity, Truth-Telling , Pluralism and
Healthcare Professionals

Good
Only the Good Will is good without qualification,
independently of what it achieves.
Gifts of nature such as intelligence, qualities of
temperament like courage or perseverance, are often
good but may be used for evil ends unless directed
by a good will.
Gifts of fortune which include riches and health can
also be used for good or ill.
Even moderation and self-control are not good in
themselves but require a good will Happiness is not
the Supreme Good

Forms of ethics
1. Metaethics (what is good? etc)
2. Normative ethics (what should we do?)
3. Applied ethics (how do we apply ethics to work and lives?)
4. Descriptive ethics (what morals people follow)

Virtue ethics
• Ethics isn’t just about acting, but about living
• An action is right if and only if it is what a
virtuous agent would characteristically (i.e.
acting in character) do in the circumstances
– Knowing how to act takes practical wisdom, which
involves experience and insight

What is a virtue?
• Aristotle: a virtue is a state of character by which you
‘stand well’ in relation to your desires, emotions and
choices:
– ‘to feel [desires and emotions] at the right times, with
reference to the right objects, towards the right people, with
the right motive, and in the right way’
• Virtues are traits that are necessary for ‘living well’.

Moral worth
The moral theory known as “the ethics of care”
implies that there is moral significance in the
fundamental elements of relationships and
dependencies in human life.
Normatively, care ethics seeks to maintain
relationships by contextualizing and promoting
the well-being of care-givers and care-receivers
in a network of social relations.

Most often defined as a practice or virtue rather
than a theory as such, "care" involves
maintaining the world of, and meeting the needs
of, yourself and others.
It builds on the motivation to care for those who
are dependent and vulnerable, and it is inspired
by both memories of being cared for and the
idealizations of self.
Moral psychology (the biological and
psychological bases)

Paternalism
• Paternalism: action taken to benefit a person
against his/her will.
– Strong: taking such an action even though the person is
mentally competent.
– Weak: taking such an action when a person is known or
suspected to be incompetent.

Paternalism
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Paternalism

Paternalism
We know what’s best for you.
The state should protect people from themselves.
The state is modeled after the family
Aristotle compared the family to the state, the head of
household to the monarch, the wife, children and slaves to
the subjects

Plagiarism
• Giving Credit Where Credit is Due!

PoliticsNJ, The Pulblis Group, Hoboken, NJ.
http://www.politicsnj.com/plagerism090903.htm.
Plagiarism defined:
The word
“plagiarism”
comes from the
Latin plagiarus
meaning
“kidnapper”

Types of Plagiarism
• Global plagiarism
• Patchwork plagiarism
• Incremental plagiarism

Global Plagiarism
Stealing a speech entirely from a single
source and passing it off as one’s own.

Patchwork Plagiarism
Stealing ideas or language from two or
three sources and passing them off as
one’s own.

Incremental Plagiarism
Failing to give credit for particular parts
of a speech that are borrowed from other
people.

According to the Merriam-Webster Online Dictionary (
http://www.m-w.com), to plagiarize means:
“transitive senses : to steal and pass off (the ideas or
words of another) as one's own : use (another's
production) without crediting the source
intransitive senses : to commit literary theft : present
as new and original an idea or product derived
from an existing source”

Why is plagiarism important? Who really
cares?
Plagiarism is theft of intellectual property.
Plagiarism is cheating.
Plagiarism may result in receiving a failing grade or
zero for the assignment. Plagiarism could result in a
disciplinary referral. Students caught plagiarizing may
be denied admittance to or removal from the National
Honor Society.

Two types of plagiarism:
• Intentional
– Copying a friend’s work
– Buying or borrowing
papers
– Cutting and pasting blocks
of text from electronic
sources without
documenting
– Media “borrowing”without
documentation
– Web publishing without
permissions of creators
• Unintentional
– Careless paraphrasing
– Poor documentation
– Quoting excessively
– Failure to use your own
“voice”

What is a Patent?
A PATENT is a form of:
“Intellectual property” which is a creation of the
human mind that is protected by law. Intellectual
property rights include:
Patents
Copyrights
Trademarks
Trade Secrets

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Why Patent?
• Patenting is Prestigous –
– I did it!
– And I was first!
• Easy Publication – no editors.
• Licensing possibilities.
• Expanded collaborations.
• Commercial advantage over competitors
• Provide valuable trading assets to help assure
freedom to operate

Autonomy
• Ancient Greek politics auto (self)
nomos (governing)

Autonomy
•The individual
•Sovereign self with
positive and negative
rights
•free from interference
•Right to determine one’s
own life

Autonomy
• Underpins many
practices in
contemporary health
care
• Legal practices
premised upon the
right to self-
determination
• Consent
• Confidentiality

Autonomy: for and against
•Sets the boundary to
permissible intervention
•Consent
•Individual rights and
freedoms
•Implies a view of the
‘isolated’ individual
•Under emphasises
relatedness
•Can seem selfish and
superficial
•(Consumer rights and the
free market)

Competence
Competence is the ability to do something
successfully or efficiently.
Competence indicates sufficiency of knowledge and
skills that enable someone to act in a wide variety of
situations. Because each level of responsibility has
its own requirements, competence can occur in
any period of a person's life or at any stage of his or
her career.

Decisional Capacity
Decisional capacity is the ability to consent to or
refuse care. It is closely related to competence,
which can only be determined in a court of law

Truth-telling
Truth-telling, or veracity, can be defined as the
avoidance of lying, deception, misrepresentation,
and non-disclosure in interactions with patients
or relevant to patient care.
Being honest with research participants about
their diagnoses is a relatively new addition to the
ethics of health care.

Pluralism
a situation in which people of different social
classes, religions, races, etc., are together in a
society but continue to have their different
traditions and interests
: the belief that people of different social classes,
religions, races, etc., should live together in a
society

PLURALISM
• Pluralism views interest
groups as aggregating
the preferences of their
members and working
to maximize those
preferences in a political
arena characterized by
conflict.
• Pluralism accepts that
interest groups are
motivated primarily by
a shared conception of
the public.

Ethical pluralism
• The claim that there are not just one single good for human
beings, but many.
• The varieties of good may lead to conflicts in values, but it
does not mean that the values are subjective.
• Some values are important only for people of a certain group,
which are recognized but not held by other people.
• The list of values may include:
– Freedom, justice, equality, harmony, solidarity, love, friendship,
fidelity, naturalness, utility, affluence…

Thin morality
• Ethical pluralism allows that there are a few
basic moral principles that all cultures should
follow.
• But beyond these principles, each culture can
have its own value system, provided that it
does not violate the higher moral principles.
• It means that:
– Thin morality is the same everywhere.
– Thick morality is valid only for people in the same
community.

Application: liberal pluralism
• Liberalism:
– the political doctrine which advocates the values
of freedom of thought, the rule of law, market
economy, and limitations on power of the state.
• Liberal pluralism:
– the liberal doctrine which advocates the co-
flourishing of value-systems in society, provided
that people with different moral values do not
harm each other.

Healthcare Professionals
Health professionals maintain health in humans
through the application of the principles and
procedures of evidence-based medicine and
caring.
Health professionals study, diagnose, treat and
prevent human illness, injury and other physical
and mental impairments in accordance with the
needs of the populations they serve.

They advise on or apply preventive and curative
measures, and promote health with the ultimate
goal of meeting the health needs and expectations of
individuals and populations, and improving
population health outcomes.
They also conduct research and improve or develop
concepts, theories and operational methods to
advance evidence-based health care.
Their duties may include the supervision of other
health workers
(adapted from ILO 2008; WHO 2010; Gupta 2011).

Public Health professionals
Medical Doctors
Nursing Professionals, including Public Health Nurses
Midwifery Professionals, including Public Health Midwives
Dentists
Pharmacists

Patients, Society and Healthcare
Professionals ethics
o Health care professionals as their patients' friend
o Equalities in cultural and linguistic
o Confidentiality
o Conflicts of interest
o Consent
o Health care professionals as citizens
o Health professionals and their lives

Health care professionals as their
patients' friend
‘Professionalism’ is under increasing scrutiny
across the health and social care professions,
with many of the issues that emerge later in
people’s careers being linked to a broad range
of behaviours distinct from their technical
ability.

professionalism’ found in existing measures,
which were:
– adherence to ethical practice;
– effective interactions with patients and service
users;
– effective interactions with staff; and
– reliability, and commitment to improvement)
which illustrate the behavioural focus of many
of these approaches.

Equalities in cultural and linguistic
CLAS (Culturally and Linguistically Appropriate
Services) in Health and Health Care is basically to
implement the proper tools and policies to ensure
that everyone gets the best health care possible
regardless of what culture they come from or what
language they speak.
The Principal Standard essentially summarizes the
mission statement of the blueprint, which is, as
mentioned earlier, to make sure everyone gets the
care they deserve regardless of certain cultural and
linguistic differences.

“Communication and Language Assistance,”
covers everything regarding what organizations
would need to do in order to provide patients
with the communication and linguistic
assistance they need to receive proper care.
Language assistance means more than just
working with interpreters. It means providing
important written and multimedia materials in
the most common languages in the area.

•Promote exactly what their theme says,
through establishing goals, conducting
assessments of the implementation of the
standards, and more
•Makes sense as communities are always
growing and changing both culturally and
linguistically.
•Community to make sure all services, practices,
and policies are appropriate based on the
cultural and linguistic diversity of the
community.

Privacy vs. Confidentiality
Privacy
• About people
• Sense of being in
control of access that
others have to
ourselves
• a Right to be Protected
Confidentiality
• Extension of privacy
• About identifiable data
• an Agreement about
maintenance and who
has access to
identifiable data
• HIPAA - protects patients
from inappropriate
disclosures of "Protected
Health Information" (PHI)

Definitions
• Privacy – about people and our sense of being in
control of others access to ourselves or to
information about ourselves with others.
• Confidentiality – treatment of identifiable,
private information that has been disclosed to
others; usually in a relationship of trust and
with the expectation that it will not be divulged
except in ways that have been previously
agreed upon.

What is a Conflict of Interest?
A potential conflict exists when there is a
possibility that an individual’s outside financial
interests could directly and significantly affect
the individual’s professional actions or decisions.

What is a conflict of interest?
• A conflict of interest (COI) occurs when the
obligations of an employee to the WIC Program are
influenced or compromised by self-interest, a prior
commitment, competing loyalties, or an inability to
be objective, and that which may or may not result in
a financial gain.

conflict of interest is…
•
 An alternate or proxy acting on behalf of more than
one WIC family.
 Enrolling a family member or friend into WIC.
 Issuing WIC food instruments to a family member or
friend.
 Influencing WIC participants on where to shop or not
shop.

conflict of interest is…
 Favoritism toward any vendor.
 WIC employee or their spouse being the owner of a
WIC authorized vendor.
 Receiving benefits from a vendor.

INFORMED CONSENT

Voluntary informed consent is the agreement
given by a well-informed person who:
Has received the necessary information
expressed in spoken words and in writing;
Has adequately understood the information; and
Has made the choice to participate (or not
participate) without coercion.
VOLUNTARY INFORMED CONSENT

CONCEPT OF INFORMED COSENT
˚ Medical advances should not require some
people to sacrifice their health and rights for the
good of all.
˚ Informed consent is a process which is designed
to empower the individual to make a voluntary
informed decision regarding participation in the
research.
˚ Voluntary consent means that the participants
were able to consent, were not being coerced to
do the study and understood the risks and
benefit involved.

Informed Consent
˚ Informed consent is a key instrument in protecting
the right.
˚ Procurement of consent ensures human dignity of
the participants and also shows respect for them.
˚ Informed consent is one of the primary ethical
principles governing human subject research.
˚ Informed consent assures that prospective
research subjects will understand the nature of
the research and can knowledgeably and
voluntarily decide whether or not to participate

Informed Consent
˚ The fundamental ethical duty of respect for
persons requires that we do not act against a
person’s wishes, and thus genuine consent to
participate in research must be obtained.
If the consent is taken below age 18 years is know
as ASSENT CONSENT

Health care professionals as citizens
There was no single definition of
professionalism; rather it is a concept that can
mean different things to different people, in
different contexts.
This complexity was linked to the diversity of
the sources and influences which lead to
individuals’ perceptions of professionalism.

“It’s everything really, it’s the way from the
minute you get to the station to the minute
you get home, it’s the conduct of work.”
‘Professionalism’ then is not perceived as an
absolute, but constructed in the interaction of
individual and context.

1 The health professional’s own beliefs
about the nature of clinical problems.
2 The health professional’s estimate of
the probability of the hypothesis and
disease.
3 The seriousness and treatability of the
disease.
4 Personal knowledge of the patient.

5 The health professional’s stereotypes.
• Stereotypes are sometimes seen as problematic and as
confounding the decision-making process.
• Most meetings between health professionals and patients
are time-limited and consequently stereotypes play a
central role.
• Stereotypes reflect the process of ‘cognitive economy’
and may be developed according to a multitude of factors
such as how the patient looks/talks/walks or whether they
remind the health professional of previous patients.
• Without stereotypes, consultations between health
professionals and patients would be extremely time-
consuming.

Example: Health belief and help seeking

Health professionals and their lives
Many behavioural and attitudinal descriptions of professionalism, such as
those reflecting empathy and caring, framed it as an expression of
fundamental, inherent qualities on the part of the professional.
When talking about this personal level of construct, with professionalism as a
‘part of the self’, there were many references to people’s own moral and ethical
codes, their ‘core beliefs’ (such as a belief in helping people) or their
‘standards’ (such as standards of ‘decent behaviour’ and how people treat each
other), underpinning practice.
In this way professionalism was seen by both educators and students as
‘intrinsic’, referring to qualities which may be innate or at least pre-existing,
exemplified by statements such as ‘you have it or you don’t’ and ‘you should
just know’.

Health professionals and their lives
• Occupational role
• Impression: Professionalism, time
consciousness, ….
• Clear communication: Listening, empathy, …
• Respect the rights of patient
• Level of confidence
• Etc.

Influence of Social Factors
• Treatment recommendations of relatives
• Economic level
• Social and cultural acceptance of the
treatment recommended by the health
professional
• Impact of care giver
• Etc.

Ethics is a topic that covers questions relating to
•what kinds of lives we should lead,
•what counts as a good society,
•what actions are right and wrong,
•what qualities of character we should develop and
•what responsibilities humans have for each other and the
ecosystem.
In the context of research, ethics as a subject area traditionally
covers topics such as the overall harms and benefits of research,
the rights of participants to information, privacy, anonymity, and
the responsibilities of researchers to act with integrity

Ethical justice and right
Ethics is a code of thinking and behavior governed by a
combination of personal, moral, legal, and social
standards of what is right.
Although the definition of "right" varies with situations
and cultures, its meaning in the context of a community
intervention involves a number of guiding principles
with which most community activists and service
providers would probably agree

• Respect people as ends, not means: consider and treat
everyone as a unique individual who matters, not as a number
in a political or social or clinical calculation.
• Respect participants' ability to play a role in determining
what they need. Don't assume that professional staff or
program planners necessarily know what's best for a
community or individual.
• Respect everyone's human, civil, and legal rights. This
encompasses such issues as non-discrimination and cultural
sensitivity.
• Do what is best for everyone under the
circumstances. You're not necessarily going to be able to help
everyone all the time, but you can try to get as close as
possible.

Ethical role of the Community
• develop community acceptance and preparedness
• anticipate and mitigate stigma associated with trial
• raise awareness about the role community based organizations
can play before, during and after trials
• facilitate clinical trial recruitment
• incorporate prevention education and training programs for
specific vulnerable populations
• develop strategies for promotion and distribution
• advocate for investment in research and development

6
• Corporate Culture
• Organizational Policies
• Individual Responsibility
– Discretion
– Relevancy
– Accuracy
– Fairness
– Timing
Ethical role of the Community

132
Social Responsibility
• Organization’s obligation to make
choices and take actions that will
contribute to the welfare and
interests of society and organization
• Being a good corporate citizen
• Difficulty in understanding – issues
can be ambiguous with respect to
right and wrong

1
Communication Ethics
I think that failures in ethics and
integrity here are less excusable than
errors in performance.
- Frank Cary, Former Chairman IBM

2
Why won’t we talk about it?
• Fear of imposing morality on others
• Not related to the bottom line
• The “it depends” philosophy
Communication ethics is
a way of understanding
and communicating
what is “right” and
what is “wrong” in
research and practice.

4
Ethical Dilemmas
• Secrecy
• Whistleblowing
• Leaks
• Apology
• Rumors & Gossip
• Lying
• Euphemisms
• Ambiguity

Respect ethics
 Respect for Persons
 Beneficence/Non-Maleficence
 Justice/Non-Exploitation

Respect for Persons
Autonomy
 Says that each individual:
 Is unique and free;
 Has the right and capacity to decide;
 Has value and dignity; and
 Has the right to informed consent.
Protection for vulnerable persons
 Special protections must be in place for those whose
decision–making capacity is impaired or diminished,
whether due to physical or social factors

Language of Professional Ethics
In general, the field of professional ethics is the study of the
principles and standards that underlie a profession’s
responsibilities and conduct.
It examines the ethical dilemmas and challenges met by
practitioners of a profession, the way in which professionals
organize and develop ethical standards for members of their
profession, and how these standards are applied in everyday
practice.

“A term designating one or more of
(1)the justified moral values that should govern the work of professionals;
(2)the moral values that actually do guide groups of professionals, whether
those values are identified as
a)principles in codes of ethics promulgated by professional societies or
b) actual beliefs and conduct of professionals; and
(1)the study of professional ethics in the preceding senses, either
i)normative (philosophical) inquiries into the values desirable for
professionals to embrace, or
ii) descriptive (scientific) studies of the actual beliefs and conduct of groups of
professionals.

Cultural ethics
Culture reflects the moral values and ethical norms
governing how people should behave and interact with
others.
Ethical Culture is a religion centered on ethics, not
theology, whose mission is to encourage respect for
humanity and nature and to create a better world.
Members are committed to personal ethical
development in their relationships with others and in
activities involving social justice and environmental
stewardship

• We believe all individuals have inherent worth and dignity, the
potential to grow and change, a responsibility to strive for
ethical growth, and a responsibility to create a better world.
• As an Ethical Community we are all part of something that
transcends the individual experience and are enriched through
our relationships with others. As such, we have
responsibilities to each other, to the Society, and to the
community.

Code of conduct of public health professional

Individual Liberty
In Britain, as long as we do
not break the law, we can
live as we choose to and
have our own opinions about
things.

Mutual Respect
We might not always agree
with other people, but we try
to show respect for their
thoughts and feelings.
We can give respect to others
and we can expect other
people to show us respect.

Mill’s Harm (aka Liberty)
Principle
• ‘The only purpose for
which power can be
rightfully exercised
over any member of a
civilized, against his
will, is to prevent harm
to others. His own
good, either physical
or moral, is not a
sufficient warrant.’

What about self-regarding
actions?

‘Harm’
• ‘Harm’ means harm to our interests.
• The interests that count here are those that ought to be
considered to be rights, those interests ‘which society ought
to defend me in the possession of’.
• Which interests should be rights is decided by utility, ‘but it
must be utility in the largest sense, grounded on the
permanent interests of a man as a progressive being.
• These permanent, progressive interests include freedom, the
pursuit of truth, and the development of individual character.

‘Pursuing our own good in our
own way’

Negative freedom
• There are many causes for
someone’s inability to do
something:
– Genetics
– Episodic
– Dispositional
– Decision-based
– Resource-based
– Legality

Coercion
• Freedom is not being coerced.
• Coercion involves someone else intentionally
constraining my actions.
• Everyone who is not coerced is equally free.

Berlin
• We need freedom to develop
our faculties to conceive and
pursue our own ends.
• Freedom is absence of
coercion, but the extent of our
freedom depends on which
opportunities are available to
us, especially their importance.

Positive freedom
• Liberty must enable activity in order to be
worthwhile; the final end is a better life.

Individual positive freedom
• If someone is unable to take advantage of
opportunity, their freedom is worthless; therefore,
the value of freedom itself requires that we help
them.
• Taylor: people need developed faculties and
sufficient resources
• Berlin: but we can’t dictate what counts as ‘rational’,
or this is paternalism

Rousseau: Collective positive
freedom
• Freedom is living
under rules you have
created yourself. So
we need to decide
social rules together.
Breaking those rules is
then, in fact, ‘unfree’.

Being free
• Berlin: Rousseau understands freedom only
collectively - but this only works if people
identify with society as strongly as Rousseau
wants. We need freedom from collective
decisions too.
• But how much of ‘pursuing our own good in
our own way’ actually depends on others?

Performance Character
• Commitment to
continuous
improvement
• Goal setting
• Work ethic
• Determination
• Self-confidence
• Initiative
• Creativity
Moral/Ethical Character
• Respect
• Responsibility to others
• Love (Compassion)
• Humility
• Integrity
• Justice
• Moral courage

Performance Character:
Doing Our Best Work

You must discover what you are
made for, and you must work
indefatigably to achieve excellence
in your field of endeavor.
If you are called to be a street-
sweeper, you should sweep streets
even as Michelangelo painted or
Beethoven composed music.
—Martin Luther King, Jr.

What is Evidence?
• In the context of evidence based practice this is
research published in professional and academic
journals and systematic reviews of research found in
databases of evidence (such as Cochrane).
• ‘ Knowledge derived from a variety of sources that
has been found to be credible’ (Higgs & Jones 2000)

168
Example:
Injury Prevention

169
Definition of
Evidence-Based Public Health
“the conscientious, explicit, and judicious
use of current best evidence in making
decisions about the care of communities and
populations in the domain of health
protection, disease prevention, health
maintenance and improvement.”

170
Definition of
Evidence-Based Public Health, cont.
“the development, implementation, and
evaluation of effective programs and policies
in public health through application of
principles of scientific reasoning, including
systematic uses of data and information
systems, and appropriate use of behavioral
science theory and program planning
models.”

171
Evidence-Based Practice
• Requires integrating practitioner expertise
with the best evidence from systematic
research.
• Involves finding and selecting resources that
are credible, relevant, and applicable to
practice.

172
Process of
Evidence-Based Practice
1. Define the problem: convert information
needs into focused questions.
2. Find the best evidence from the literature.
3. Critically appraise the evidence for validity
and relevance.
4. Apply the evidence to practice.
5. Evaluate the results.

173
Why Evidence-Based Practice?
• So much information,
too little time
• Need high quality,
filtered information to
make informed decisions
• Value of scientific knowledge for
decision making
• Decisions should not be based only on
intuition, opinion or anecdotal information

174
Need for Evidence-Based Public Health
• Government downsizing - limited resources
• Need to justify actions and demonstrate
benefits of public health interventions
• Decisions often made by politicians with
limited health backgrounds

175
Character is
destiny.
—Heraclitus


The Roles of Ethics in Resource Allocation
• Health economics provides a range of measures to help in
deciding whether to allocate resources to a particular area or
another. Cost-benefit analyses distill the “cost” and the
“benefit” into purely dollar terms. However, students are
introduced to other concepts such as cost effectiveness, in
which the value of a particular program is expressed not in
dollar terms, but rather in terms of health outcomes such as
life years gained.
• One reason for using a cost-effectiveness approach is that we
value health so highly and hesitate to view it in purely dollar
terms. Good resource allocation decisions must involve more
than a money-based analysis; they must reflect what society
thinks is worth investing in.

This is where ethics can contribute. Ethics provides a
framework for examining and ordering our values.
We can value things such as respect for personal
autonomy, doing no harm, value for money, or
privacy. If enough individuals value the same things
in the same way, we can determine a general set and
ranking of community values. (At the same time,
ethical values are not universal and what is
considered highly important, e.g., respect for
autonomy, will depend on culture, time, and place.)

• Almost all health resource allocation decisions have ethical consequences
because they promote particular values while minimizing others. Indeed,
ethical norms are so embedded in resource allocation decisions that we can
take them for granted. For example, will we prefer to fund preventive
measures or cures? Will we prefer to put more resources into fighting
diseases that affect the young or those that affect the elderly? Is “life years
gained” the most important outcome? Knowing how well a particular
resource allocation aligns with a society’s priorities can help decision
makers gauge how acceptable it is going to be to that community.
• Therefore students are also taught ethics, in particular the trade-off
between ethics and efficiency when making resource allocation decisions.
Although we value efficiency, sometimes we might prefer to fund a
program that is less efficient because it reflects something more important
to us. Ethics sets out a systematic way to tease out these elements.

• Once students are introduced to the fundamentals of common (Western) ethical theories, they
apply them to examples taken from health systems around the world. Consider, for example,
co-payments. Western cultures generally place great value on individual rights and self-
determination (autonomy). Understanding this, private health insurers often allow subscribers
more choice of treatments or physicians in return for higher co-payments. It is thought that, by
making individuals responsible for a share of their health costs, they will more thoroughly
investigate all possible treatment options and prices. In this way, patients enjoy more choice
while being delegated more responsibility for their health care. Conversely, there is the risk of
“moral hazard” if there are no co-payments. In essence, if individuals don’t have to pay for
their own health care they’re more likely to have treatments they don’t really need.
• Another example of resource allocation decisions studied in the health care economics course
is the public and private insurance arrangements in Canada and Australia. Both countries
provide universal health coverage, but their structures reveal different approaches to defining
“universal.” In Canada, the law establishes a universal maximum on coverage. Private insurers
are generally prohibited from covering any services that are also publicly covered. In other
words, if procedure A is publicly covered then there is only one waiting line—and everyone
who wants that procedure joins that line.

Thank you

Public health ethics

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