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EMPHNET Ethical principles and theories and the core professional public health values Ghaiath M. A. Hussein MBBS, MHSc. (Bioethics), PhD Researcher Email : [email protected] Regency Palace hotel, Amman, Jordan 15-19 June, 2014
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EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Dec 04, 2014

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Healthcare

Ghaiath Hussein

This is a series of presentations I gave in the Eastern Mediterranean Public Health Network (EMPHNET)'s Public Health Ethics (PHE) course that was held in Amman in June 2014.
This presentation outlines the main philosophical approaches to medical ethics and public health ethics.
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Page 1: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

EMPHNET

Ethical principles and theories and the core professional public health values

Ghaiath M. A. HusseinMBBS, MHSc. (Bioethics), PhD Researcher

Email :.ghaiathme@gmail com

Regency Palace hotel, Amman, Jordan15-19 June, 2014

Page 2: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Module’s objectives

• Differentiate between the main ethical theories

• Identify key ethical principles and values relevant to public health practice and research

• Present a moral argument on an ethical issue related to public health based on the ethical theories and values

Page 3: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Module’s Outline

• How do we (as humans and public health practitioners) tell right from wrong?–Philosophical approaches–Religious approach

• Examples of the main ethical issues– Informed consent– Conflicts of interest – Resource allocation

Page 4: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

How to approach an ethical issue?

Set of ethical

standards

Proper case

analysis

Modality of decision

making

Follow-up of the

decision

Page 5: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Ethical Guidance in PHE

Philosophical

•Deontological •Utilitarian (act &

rule)•Rights-based

•Virtue •Casuistry

•Social-contract•Principlism

Religious

•Islamic ethics & jurisprudence (Purposes of Law ‘Sharia’)

•Christian ethics•Jewish Ethics

•?Oriental Philosophies (Buddhist, Confucian, etc.)

Guiding Principles

• Utility• Efficiency • Liberty • Transparency • Participation • Review and

revisability• Effectiveness • Fairness• Reciprocity• Solidarity

Page 6: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Deontology & Rights-based ethics

• Deontology : – 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.

• Rights-based ethics: – involves a larger number of principles and is

addressed more to the actions of institutions and governments, e.g. Universal Declaration on Bioethics and Human Rights, (UNESCO) in October 2005. It provides more binding legal rights

Page 7: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Consequentialism (utilitarianism)

• 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

Page 8: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Feminist ethics and Casuistry Feminist ethics: (Ethics of Care) commitment to

correcting male biases (e.g. women’s subordination is morally wrong) and that the moral experience of women is as worthy of respect as that of men.

Casuistry: The greatest confidence in our moral judgments resides not at the level of theory, where we endlessly disagree, but rather at the level of the case, where our intuitions often converge without the benefit of theory.

Page 9: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Virtue ethics

It emphasizes the virtues, or moral character (not duties or consequences)

Someone in need should be helped. Agree?

Page 10: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

“Contractarianism”: Social Contract Theory

Agreement (or consent) of all individuals subject to collectively enforced social arrangements shows that those arrangements have some normative property (e.g. legitimate, just, obligating, etc.). (http://plato.stanford.edu/entries/contractarianism-contemporary/)

1. Political theory: claims that legitimate authority of government must derive from the consent of the governed, where the form and content of this consent derives from the idea of contract or mutual agreement.

2. The moral theory: claims that moral norms derive their normative force from the idea of contract or mutual agreement.

Page 11: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Rawl’s theory of Justice

Rawl’s (Theory of Justice), requires two main conditions for this ‘contract’:1. Equality of moral persons: Each person is rational,

self-interested and have an equal right to the most extensive total system of equal basic liberties.

2. Veil of ignorance : morally adequate principles of justice are those principles people would agree to in an original position which is essentially characterised by this veil of ignorance.

Page 12: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Principlism

• Principle-Based Theories–Principlism 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)

Page 13: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

The ‘4 principles’ model

• Autonomy: respect humans' ability to choose,

• Beneficence: Do Good for others,• Nonmaleficence (Do No Harm), & • Justice

Page 14: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Islamic Approach to Ethical Analysis and Decision Making

Islamic Bioethics

Page 15: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Main Sources1) The Koran 2) The Sunna

Secondary Sources1) Unanimous agreement of Islamic jurists (Ijmaa) 2) Acceptance by the majority of trusted scholars (Rayul Jomhour) 3) Measurement/Analogy (Qiyas)4) Remediation (Maslaha), (Istishab)

Sources of Islamic Morality

Page 16: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

The five purposes of Sharia are to preserve person’s:1. Religion2. Soul3. Mind4. Wealth and5. Progeny

All Islamic legislations came to achieve these goals.

Goals of Islamic Regulations

Page 17: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

What is Islamic Bioethics?It is the methodology of

defining, analysing and resolving the ethical issues that arise in healthcare practice, or research;

based on the Islamic moral and legislative sources (Koran, Sunna & Ijtihad); and

aims at achieving the goals of Islamic morality (i.e. preservation of human’s religion, soul, mind, wealth & progeny )

Page 18: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

1. The principle of Intention (Qasd): Each action is judged by the intention behind it

2. The principle of Certainty (Yaqeen): Certainty can not be removed by doubt

3. The principle of Injury/Harm (Dharar): Injury should be relieved; An individual should not harm others

or be harmed by others An injury is not relieved by inflicting or causing a harm of the same degree Prevention of harm has priority over pursuit of a benefit of equal worth the lesser harm is committed

Major Fiqhi Principles

Page 19: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

4. The principle of Hardship (Mashaqqat): Difficulty calls forth ease, Necessity (Dharuraat) legalizes the prohibited

5. The principle of - Custom or precedent (Urf): Custom is recognized as a source of law on which legal rulings are based unless contradicted specifically by text from the main

legislative sources, i.e. Koran and Sunna.

Major Fiqhi Islamic Principles (2)

Page 20: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

The five major Fiqhi principles and their main ‘sub-principles’

Page 21: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

What is your ‘favourite’ theory? Why?

Page 22: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Guiding ethical principles

• 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

Page 23: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Guiding ethical principles (2)

• 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

Page 24: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

EXAMPLES OF PRACTICAL IMPLEMENTATION OF THESE THEORIES

Page 25: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Informed Consent

• Definition(s): –Autonomous authorization of a medical

intervention…by individual patients/participants” (Beauchamp and Faden, 2004)

– It's the practical expression of patient's autonomy, and the respect for him/her personality

Page 26: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Disclosure

VoluntarinessCapacity

Conditions for informed consent

Page 27: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Conditions for FIC

1. Disclosure: This refers to the process during which the health care provider or researcher provides information about the proposed intervention or research to the participant.

2. Capacity: Refers to the presence of a group/set of functional abilities a person needs to possess in order to make a specific decisions (Griso and Applebaum, 1998). These include: to UNDERSTAND the relevant information, & to APPRECIATE the relatively foreseeable consequences of the various available options available.

3. Voluntariness: Refers to a participant’s right to make participation decisions free of any undue influence.

Page 28: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Conflict of interests

• What is an interest?• Examples of interests:– Financial interests–Career and Academic interests– Social interests

• How to manage COIs?Your thoughts?

Page 29: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

What is an interest?• An interest may be defined as a commitment,

goal, or value held by an individual or an institution.

• Examples include a research project to be completed, gaining status through promotion or recognition, and protecting the environment. Interests are pursued in the setting of social interactions.

Page 30: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

What is COI?• COI exists when two or more contradictory

interests relate to an activity by an individual or an institution.

• Conflicts of interest are “situations in which financial or other personal considerations may compromise, or have the appearance of compromising, an investigator’s judgement in conducting or reporting research.” AAMC, 1990

Page 31: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

What is COI? Cont.

• “A conflict of interest in research exists when the individual has interests in the outcome of the research that may lead to a personal advantage and that might therefore, in actuality or appearance compromise the integrity of the research.”

NAS, Integrity in Scientific Research

Page 32: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Rationing and Resource allocation

Page 33: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Exercise… Share this cake FAIRLY

Page 34: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Back to theories!!• Utilitarianism:– Theory: resources being allocated to less expensive

treatments or services that provide the greatest benefit.

– Practice: QALY.• Equity and Distributive Justice– Theory: “equals should be treated equally, and

unequals treated unequally in proportion to the relevant inequalities”. The need not only the benefit gained from an intervention.

– Practice: ensure that those in poorest health, or greatest need

Page 35: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Back to the principles!!

• Autonomy:– individuals have a right to determine/choose what is in their

own best interest• Beneficence/Non-maleficence:– Healthcare providers should act in the interest of their

clients/patients and NOT to harm them• ‘distributive’ Justice/fairness:– All groups have an equal right to health services regardless

of race, gender, age, income, or any other characteristic.

Page 36: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

In practice…• What does resource allocation affect? How?

Breadth•the population

covered?•application of criteria

•means-testing (e.g., excluding those with higher incomes),

•employment (e.g., excluding self-

employed people) ,•excluding people from

eligibility (e.g., those who do not meet certain requirements),

•or by allowing people to opt out.

Scope•Which services?•excluding services

from the benefits package

•effectiveness,•comparative

effectiveness,•cost-effectiveness,•health technology

assessments (HTAs),•clinical guidelines or

quality assurance

Depth•extent or cost share to

which services are covered

•selective charges (co-payments) for inefficient services,

•reduced charges for especially valuable ones (value-based insurance design)

Page 37: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

THEORETICAL MODELS FOR RESOURCE ALLOCATION

Ezekiel J. Emanuel" Justice and Managed Care: Four Principles for the Just Allocation of Health Care Resources,” Hastings Center Report 30, no. 3 (2000): 8-16. Daniels N, Sabin JE. The ethics of accountability in managed care reform. Health Aff (Millwood) 17[5], 50-64. 1998

Page 38: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Emanuel’s Justice and Managed Care

• Improving Health Should Be the Primary Goal:– The allocation of health care resources should aim at and be justified by

the improvement in people's health• Patients and Members Should Be Informed:

– Patients/community should be informed about the allocation of health care resources and the underlying data and justification for the allocation.

• Patients and Members Should Have the Opportunity to Consent. – Patients/community should be given the opportunity to consent to the

allocation of health care resources that will affect them. • Conflicts of Interest Should Be Minimized:

– People entrusted to allocate health care resources should not make allocating decisions under conditions that could reasonably be expected to be influenced by direct, personal financial benefits or penalties.

Page 39: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Accountability for Reasonableness (Daniel & Sabin)

Condition DescriptionRelevance • Priority setting decisions must rest on reasons

(including evidence and principles) that fair-minded participants (stakeholders) can agree are relevant

• These can involve managers, clinicians, patients, and consumers in general (three key foci are underlined)

Publicity Priority setting decisions and their rationales must be publicly accessible

Appeals The priority setting process must include a mechanism for revising decisions in light of further evidence or principles that other stakeholders might contribute

Enforcement There must be voluntary or public regulation of the process to ensure that the first three conditions are met

Page 40: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Let’s give it a thought!

• 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?

Page 41: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

References

• APHA Code of ethics: http://www.apha.org/NR/rdonlyres/1CED3CEA-287E-4185-9CBD-BD405FC60856/0/ethicsbrochure.pdf

• Childress, James F. Et al., Public Health Ethics: Mapping the Terrain, Journal of Law, Medicine and Ethics, 30 (2002): 170-178.

• Daniels, N. and J. E. Sabin (2008). "Accountability for reasonableness: an update." BMJ 337.

• Alex Friedman (2008). “Beyond Accountability for Reasonableness”. Bioethics 22 (2), 101–112. Doi:10.1111/J.1467-8519.2007.00605.X

Page 42: EMPHNET-PHE Course: Module02: ethical principles and theories and the core professional public health values

Readings

• Verity C and Nicoll A. Consent, Confidentiality, and the threat to public health surveillance. BMJ. 324: 1210-1213. May 2002.

• Myers et al. Privacy and Public Health at Risk: Public Health Confidentiality in the Digital Age. AJPH. 98(5): 793-801. May 2008.

• O’Neil O. Informed Consent and Public Health. Phil. Trans. R. Soc. Lond. B (2004) 359, 1133–1136.

• MacQueen K and Buehler J. Ethics, Practice, and Research in Public Health. AJPH. 94(6): 928-931. June 2004.

• Miller, TE. Sage, WM. “Disclosing physician financial incentives.” JAMA. 281 (15):1424-1430. April 1999.