What to do?

What to do?

8 month child with pneumonia, tested HIV positive. Mom refuses testing for herself, is 6 months pregnant, and states she cannot tell her husband of her possible HIV positive status as he may leave her.

RICHARD L. ELLIOTT, MD, PHD, FAPAPROFESSOR AND DIRECTOR

MEDICAL ETHICSMERCER UNIVERSITY SCHOOL OF MEDICINE

Ethics and Public Health

Goals

A brief history of public healthEthics in medicine vs. public health Specific issues in public health ethics

Edward Jenner

1749-1823

Smallpox vaccine

John Snow, MD1813-1858

1854

Cholera outbreak

Broad Street, London

Ignaz Semmelweis, MD

1818-1865

Saviour of mothers

What is Public Health Ethics?

Morality What is good or right? Study of virtue(s) May be study of philosophical abstractions

Ethics What is good or right in a profession Emphasis on right actions, not abstractions

Public health ethics “Public health is what we, as a society, do collectively to assure the conditions for people to be healthy.”

(IOM,1988) Health promotion and disease prevention of the population Medical ethics vs. public health ethics

How are they similar? Different? Might they conflict? Civil rights, liberties vs responsibilities to the community

Examples of Ethical Issues in Public Health

Tuskegee Quarantining Fluoridation FDA Vaccinations Contact tracing in STD Toxic sites Mental health commitment Commitment of sex offenders Tarasoff duties with dangerous mentally ill patients Is there a right to treatment?

Universal health care In prisons?

Abortion and contraceptive rights Public lotteries, gambling, and funding education Physician-assisted suicide Bioterrorism and civil liberties

Values in Public Health

“Greatest good (health) for the greatest number”

Health promotion and disease reduction Smoking, obesity, vaccinations

Cost/benefit analyses Economic Civil liberties Medical (e.g., vaccination adverse effects)

Medical Ethics vs. Public Health Ethics

Medical Ethics Public Health Ethics

Individuals PopulationsAutonomy Democratic inputBeneficence Greatest good for

the greatest number

Non-maleficence Benefit-risk analyses

Social justice Social justice

Ethics as a Common Professional Bond

Much as the Oath of Hippocrates has bound together physicians for over two thousand years, the principles of public health binds together practitioners of public health

Is there an oath for new graduates of public health?

Tuskegee

The Tuskegee Study of Untreated Syphilis in the Negro Male Do whites and blacks differ in disease course?

Treatment planned, cut due to cost Participation of Tuskegee Institute, black nurse eased fears

among men Macon County Medical Society, mostly black physicians,

agreed to deny treatment Treatment – arsenic, mercury, ASA, iron, spinal taps –

perceived as far superior medical care than usually received Later, men denied free care for syphilis at PHS clinics Study continued after Nuremberg and declaration of Helsinki

(1964) Expose 1972 ended the study $10 million settlement IRBs established Legacy of mistrust between blacks and whites in research

Tuskegee-like Studies?

Nazi experimentationHepatitis and Willowbrook State SchoolCancer and Jewish Hospital for Chronic

DiseasesCincinnati radiation exposure experiments

Where is Tuskegee Today?

Vulnerable populations and researchAIDS in Africa

Is use of a placebo ethical?

Children Proxy consents

National Research Act

Establishment of IRBs to review all federally funded grants involving human subjects

Common Rule (Title 45 Code of Federal Regulations Par. 46 [45 CFR 46]).

In order for persons (or their legally authorized representatives) to give “legally effective informed consent,” the researchers seeking participation must disclose eight elements of information about the study:

1. a statement that the study involves research, and description of that research and its purposes;

2. a description of reasonably foreseeable risks; 3. a description of reasonably expected benefits; 4. a disclosure of appropriate alternatives; 5. a statement about maintenance of confidentiality; 6. an explanation of possible compensation in case of injury, if the study

involves more than minimal risks; 7. information about how subjects can have questions answered; 8. and a statement that participation is voluntary.

Infectious Diseases II

Notification laws – is it ethical to notify the sexual partner of an HIV infected patient of his/her risk?

Why is it permissible to confine a patient infected with TB but not a promiscuous HIV patient ?

Health Promotion and Disease Prevention

Smoking bans On advertising, smoking in public places Cost of smoking-related diseases and protection

from second hand smoke vs. private rights vs. loss of taxes

Bans on certain trans-fat foodsSex education

Parental rights and responsibilities vs. public goodBan on marijuanaHelmet laws

Environmental Ethics

Global warming Nuclear power

Disposal of nuclear waste

LeadForced evacuation from toxic sitesAre minorities disproportionately affected by

waste dumping, waste burning? Homer, LA and nuclear enrichment site

Recognize this?

Toxic Waste, the Environment, and Racism

2007: “Toxic Waste and Racism at 20”69% of people living in proximity to a toxic

waste site are persons of colorPersons of color are 1.7-2.3 times more likely

to live near a toxic waste site than in non-toxic locations

Eugenics and Genetic Screening

Eugenics – “improving” population characteristics through governmental manipulation of reproduction Mentally retarded Racial

Genetic testing Voluntary? Confidential

Insurance reporting?

Analyzing an Ethical Issue

What are the facts: science, epidemiology, medicine?

Who are the stakeholders and decisionmakers?What are the options?What are the legal constraints: laws,

regulations?What values/ethical principles ought to apply?What are the conflicts?What is the recommended decision?

References

Association of Schools of Public Health. Ethics and Public Health: Model Curriculum. ASPH.org

American Public Health AssociationS Anand. Public Health, Ethics, and Equity.

Oxford U Press, 2006R Bayer. Public Health Ethics: Theory, Policy,

and Practice. Oxford U Press, 2006

Case

8 month child with pneumonia, tested HIV positive. Mom refuses testing for herself, is 6 months pregnant, and states she cannot tell her husband of her possible HIV positive status as he may leave her.

History of Ethics in Public Health

Pre-1847 “Cito, longe, tarde”

1847 AMA Code of ethics A physician is “required to expose his health and life

for the benefit of the community”

ASPH Ethics curriculum

Ethical Principles of Public Health

1. Public health should address principally the fundamental causes of disease and 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.

Infectious Diseases

John Stuart Mill “The only purpose for which power can rightfully be exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, both the physical moral, is not sufficient warrant”

Jacobson v. Massachusetts (compulsory vaccination, 1905): Constitution permits states to enact "such reasonable regulations [to] protect the public health and the public safety and" as long as such efforts did not "contravene the Constitution of United States, nor infringe any right guaranteed or secured by that instrument.”

Ethical Principles of Public Health (continued)

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 competence of their employees.

12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.