This document discusses three case studies related to public health ethics and provides background information on relevant ethical principles and frameworks. The case studies involve: 1) a community health initiative on teenage pregnancy, 2) a proposal to strengthen laws against homelessness, and 3) the use of "sin taxes" to influence health behaviors. Background information is presented on ethical theories like egalitarianism, libertarianism, and theories of justice. Principles of public health ethics and frameworks for analyzing issues of social and economic justice are also defined.

1. · Write a response as directed to each of the three case studies
and save the document.
1- Analyze the ethical implications of a community health
initiative to decrease the rate of teenage pregnancy by means of
health education in the public schools. This community takes
pride in its schools and is comprised of multiple ethnic,
immigrant, religious and social groups. Use the following
ethical principles in your analysis: autonomy, beneficence,
nonmaleficence and justice.
Egalitarian
• The view that everyone is entitled to equal rights and equal
treatment. Ideally, each person has an equal share of the goods
of society, and it is the role of government to ensure that this
happens. The government has the authority to redistribute
wealth if necessary to ensure equal treatment. Thus egalitarians
support welfare rights—that is, the right to receive certain
social goods necessary to satisfy basic needs. These include
adequate food, housing, education, and police and fire
protection. Both practical and theoretical weaknesses are
inherent in egalitarianism.
Libertarian
• The libertarian view of justice advocates for social and
economic liberty. While egalitarianism lacks incentives for
individuals, libertarianism emphasizes the contribution and
merit of individuals (Beauchamp & Childress, 2013).
• Limited role of government

2. Liberal democratic
Attempts to develop a theory that values both liberty and
equality
• Based on Rawl’s Theory of Justice and the “veil of
ignorance.” Behind this veil, people (or their representatives)
are unaware of social position, race, culture, doctrine, sex,
endowments, or any other distinguishing circumstances (Rawls,
2001). This is known as the original position and is an exercise
to address the inequalities and bargaining advantages that result
from birth, natural endowments, and historical circumstances.
Without these inequalities, all people are free and equal and can
work together as citizens to decide what is fair and therefore
just. Once impartiality is guaranteed, Rawls suggests all
rational people will choose a system of justice containing the
following two principles:
• Each person has the same claim to a fully adequate scheme of
equal basic liberties, and this scheme is compatible with the
same scheme of liberties for all.
• Social and economic inequalities are to satisfy two conditions:
first, they are to be attached to offices and positions open all
under conditions of fair equality of opportunity; and second,
they are to be to the greatest benefit to the least advantaged
members of society (the difference principle).
Box 7.2
Ethical Principles
Respect for autonomy: Based on human dignity and respect for
individuals, autonomy requires that individuals be permitted to
choose those actions and goals that fulfill their life plans unless
those choices result in harm to another.
Nonmaleficence: Nonmaleficence requires that we do no harm.
It is impossible to avoid harm entirely, but this principle

3. requires that health care professionals act according to the
standards of due care, always seeking to produce the least
amount of harm possible.
Beneficence: This principle is complementary to
nonmaleficence and requires that we do good. We are limited by
time, place, and talents in the amount of good we can do. We
have general obligations to perform those actions that maintain
or enhance the dignity of other persons whenever those actions
do not place an undue burden on health care providers.
Distributive justice: Distributive justice requires that there be a
fair distribution of the benefits and burdens in society based on
the needs and contributions of its members. This principle
requires that, consistent with the dignity and worth of its
members and within the limits imposed by its resources, a
society must determine a minimal level of goods and services to
be available to its members.a"
2- You are a public health nurse committed to supporting health
and equity in all policies. Imagine that you are working in a
community with a large number of homeless people. The
climate is mild, and the people live openly in the street and
parks. A proposal is to come before the city council to
strengthen the vagrancy ordinance in order to promote tourism.
As a community health nurse working with the homeless, you
have been asked to provide testimony. What will your position
be and how will you defend it ethically? Use specific principles
in the Principles of the Ethical Practice of Public Health (Box
7.4 in Chapter 7 of Stanhope and Lancaster, 2020) as you
support your testimony.
"Box 7.4
Principles of the Ethical Practice of Public Healtha
1. Public health should address principally the fundamental
causes of disease and

4. requirements for health, 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 and work for the
empowerment of disenfranchised community members, aiming
to ensure that the basic resources and conditions necessary for
health are accessible to all.
5. Public health should seek the information needed to
implement effective policies and programs that protect and
promote health.
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.
10. Public health institutions should protect the confidentiality
of information that can bring harm to an individual or
community if made public. Exceptions must be justified on the
basis of the high likelihood of significant harm to the individual
or others.
11. Public health institutions should ensure the professional
competencies of their employees.
12. Public health institutions and their employees should
engage in collaborations and affiliations in ways that build the

5. public’s trust and the institution’s effectiveness.
aA section of the Public Health Code of Ethics is presented.
Reprinted with permission from the Public Health Leadership
Society: Public health code of ethics, 2002, American Public
Health Association (APHA). Available at http://phls.org.
Commonalities exist between the Code of Ethics for Nurses
With Interpretative Statements and the Public Health Code of
Ethics. Both codes provide general ethical principles and
approaches that are enduring and dynamic. They require nurses
and public health personnel to think and act in accordance with
the underlying ethics of their profession. Of note, they each
encourage evidence-based and collaborative approaches for the
betterment of health. Although the two codes do not specify
(nor should they specify) details for every ethical issue, other
mechanisms such as standards of practice, ethical decision-
making frameworks, and ethics committees provide further
guidance. Nevertheless, these two codes address most
approaches to ethical justification, including traditional and
emerging ethical theories and principles, humanist and feminist
ethics, virtue ethics, professional-individual and/or community
relationships, and advocacy. Many websites provide further
information on codes of ethics and other ethical concerns in
public health; all can be accessed through the WebLinks section
of this book’s Evolve website. Some of them are noted in the
Additional Resources feature at the beginning of the chapter."
3- The article by Green is an excellent example and discussion
of the pros and cons of “Sin Taxes”. As a public health nurse
discuss your views on the use of “sin taxes” in general to
change health behaviors. Use specific values in the “Contrast of

6. Social Justice and Market Justice as an Advocacy Framework
Table” (Table 7.3 in Chapter 7 of Stanhope and Lancaster,
2020) in your discussion.
"Box 7.3
Case Study: Autonomy and Distributive Justice
Amelia Lewis, a 31-year-old African American woman with
multiple mental health diagnoses, has been monitored in the
local mental health system for over 10 years. She is the mother
of Tyesha, who is three years old. Multiple agencies have
monitored Ms. Lewis and her little girl, who live in a sparsely
furnished apartment in subsidized housing. A guardian handles
all of Ms. Lewis’s financial affairs. Ms. Lewis’s relationship
with the father of Tyesha has deteriorated, and he does not live
with her.
Ms. Lewis has issues of trust, and she is often suspicious of the
care providers who come to her home. She does rely on some of
the professionals with whom she interacts on a weekly or
biweekly basis. She is both cognitively delayed and suffers
from schizophrenia. Her developmental level places her at a
stage at which her own needs are her primary focus, and this is
not expected to change; her interaction with Tyesha is
perfunctory, involving little outward affection. She is unable to
understand that Tyesha is not capable of self-care and that her
three-year-old child will not always obey when Ms. Lewis
instructs her to do something. Tyesha’s needs, level of
functioning, and cognitive development are quickly surpassing
her mother’s ability to cope. Frustration and misunderstanding
ensue when Ms. Lewis thinks that Tyesha does not listen to her,
and encouragement and parent education have done little to
improve the situation as Tyesha gets older and more assertive.
This has made toilet training, provision of an appropriate diet,
and other aspects of child care problematic.
Many services besides those for mental health are involved to
help this family of two cope. There is concern about abuse or
neglect of Tyesha due to Ms. Lewis’s lack of understanding of

7. how to be a parent. Supplemental Security Income provides
monetary support because of her mental disability, and they
have Medicaid coverage for their health care needs, as well as
food stamps and modest financial assistance through Temporary
Assistance for Needy Families (TANF). Ms. Lewis cannot
currently work and take care of her child due to her mental
disability. Before Tyesha’s birth, Ms. Lewis held a job and
maintained self-care, but the care of Tyesha has precluded her
managing employment at this time. Child Protective Services is
also monitoring Ms. Lewis’s situation to determine to what
extent she can meet the needs of her child. Ms. Lewis attends a
local program to complete her General Education Development
(GED), which provides child care during the day. Though Ms.
Lewis is not expected to complete her GED, this program
provides structured time for Tyesha three times a week. The
child is considered developmentally normal at this time, and an
infant development program monitors her progress on
developmental issues. The Child Health Partnership, an agency
that addresses the needs of challenged families, provides regular
visits, family support, and parenting education, and the GED
teachers make regular home visits to check on Ms. Lewis and
Tyesha. Ms. Lewis thinks things are going just fine.
The Child Health Partnership nurse is concerned about this
family and thinks that some permanent resolution of the
situation is inevitable. There is minimal coordination of
services, and there is no “lead agency” in the family’s care.
Choose one of the ethical decision processes or one set of code
of ethics discussed in the chapter, and discuss and debate these
questions:
1. Should the nurse involved in the Child Health Partnership
program initiate any action to try to coordinate the work of the
many agencies involved with this family?
2. Who has a professional responsibility to determine when the
mother can no longer cope with the developing child?

8. 3. Whose needs, Ms. Lewis’s or Tyesha’s, should take
precedence?
4. Using one of the ethics decision processes, analyze the role
of the nurse in this situation. For example, considering the
utilitarian ethics decision process, decide if it is morally right
for you to take the child away from the mother. If you do this,
what are the implications for the mother, the child, and the
community? What would be the possible consequences of
removing the child? Of not removing the child? What principles
can best guide your decision making? What possible moral
dilemmas will you experience?
5. Safety is a core concept of public health nursing. Using two
of the six quality and safety competences (patient-centered care
and safety) for nurses identified in the Quality and Safety
Education for Nurses (QSEN) work, develop a plan of action for
the nurse who is caring for this family.
Primary prevention
Use the Code of Ethics for Nurses to guide your nursing
practice.
Secondary prevention
If you are unable to behave in accordance with the Code of
Ethics for Nurses (e.g., you speak in a way that does not
communicate respect for a client), take steps to correct your
behavior.
Tertiary prevention
If you have treated a client or staff member in a way that is
inconsistent with ethics practices, seek guidance on other
choices you could have made."