Ethical Issues in Public Health Practice in Michigan Sarah E. Gollust, Nancy M. Baum, MHS, Susan D. Goold, MD, MHSA, MA, and Peter D. Jacobson, JD, MPH.

Ethical Issues in Public Health Practice in Michigan

Sarah E. Gollust, Nancy M. Baum, MHS, Susan D. Goold, MD, MHSA, MA, and Peter D. Jacobson, JD, MPH

Public Health Systems Research Interest Group

Annual Meeting

June 7, 2008

Background

Academic distinction made between bioethics and public health ethics

Limited empirical evidence on the extent to which public health practitioners experience ethical challenges in daily work

Project Goals

Build empirical base for public health ethics

Identify ethical issues practitioners experience in their daily work

Gain understanding of methods of resolution

Methods

Site selection: 13 local health departments (LHDs) selected for variation in:

Geographic location Population characteristics Governance structure

Recruitment: snowball sampling, starting with health officers at each LHD

Source: Michigan’s Guide to Public Health for Local Governing Entities, November 2006, MALPH

Characteristics of Participating Agencies

Site N per site

County or District

Setting

LHD 1 3 County Urban

LHD 2 3 District Rural

LHD 3 3 County Rural

LHD 4 4 County Urban

LHD 5 5 County Urban

LHD 6 4 County Urban

LHD 7 4 County Rural

LHD 8 3 District Rural

LHD 9 4 County Rural

LHD 10 4 County Rural/Urban

MDCH 6 State N/A

+ 1 City Department Employee and 1 County Commissioner (neither affiliated with sites above)

Occupations of Study Participants

Occupation n

Health Officers 10

Medical/Dental Directors (non-HO) 4

Environmental Health 6

Nursing or Clinic Staff 8

Health Educator 2

Emergency Preparedness 1

Communications/Public Relations 2

Other (LHD employees) 4

County Commissioner/ BOH Member 2

State Employee 6

Total 45

Methods, cont.

Semi-structured, mostly face-to-face interviews with 45 practitioners to identify: Ethical issues faced in practice Underlying values Processes for resolution Demographics and personal exposure to ethics

Qualitative coding and analysis of transcripts

Results

Ease Discussing Ethics

Few practitioners rely on ethical constructs or use the “language” of ethics

No difficulty identifying or discussing ethical issues

Ethical Challenges - 5 Major Themes

1) Appropriate use of public health authorityBalancing public health benefits with individuals’ autonomy or businesses’ economic viability

2) Decisions related to resource allocationChoosing among populations/programs

Allocating scarce resources

Allocating practitioners’ time

5 Major Themes, cont.

3) Political interference in practicePolitics dictates programming, not evidence

Focus on political “issues of the day” rather than community needs

4) Assuring standards of quality care Across different populations

During emergencies

5 Major Themes, cont.

5) Questioning the role or scope of public health

Traditional protection from infectious disease

vs. Safety net

vs. Inclusion of social determinants of health

Public Context

Professional ethics Personnel issues, managing employees Public sector duties Relationships with private sector Conflicts of interest

Public Health Values

Diversity of values, no clear hierarchy or focus across participants Helping the most vulnerable Using public funds efficiently Being consistent Being data-driven Being fair Greatest good for the greatest numbers of people Personal responsibility

Resources Used to Resolve Ethical Challenges

Consultation with colleagues Reliance on personal experience Reliance on personal moral grounding Almost no use of formal frameworks

Discussion

Discussion

Practitioners recognize that their work demands nuanced, ethically-laden decisions

Sense of “doing the right thing” animates practitioners’ daily practice

Discussion

Few differences in major types of ethical issues across practitioners and departments

Practitioners use little formal assistance to process and resolve ethical issues

Creating effective frameworks to assist practitioners will be a challenge

Contribution to Public Health Systems Research

Qualitative research informs the interactive effects of policy and the organizational environment on practice

Identifies how systems-level factors (e.g., funding restrictions) affect practitioners’ daily work

Contribution to Public Health Systems Research

Recognizes that ethical decision-making is an integral part of delivering public health services E.g., decisions allocating resources

May suggest ways to design a system that facilitates ethical decision-making and reduces ethical conflict

Acknowledgements

Greenwall Foundation

Robert M. Pestronk (study consultant)

45 public health professionals for offering us their considerable insights

More information

My email: [email protected] Study publications:

Baum et al. Looking Ahead: Addressing Ethical Challenges in Public Health Practice. Journal of Law, Medicine, and Ethics. 2007; 35(4): 657-667.

Gollust et al. Politics and Public Health Practice: Left and Right Meets Wrong and Right. Journal of Public Health Management and Practice. 2008; Forthcoming.