Ethics And Decision-making In Public Health (presentation .

1Ethics and Decision Makingin Public HealthDakota County Public HealthPH Ethics SeminarOctober 12, 2016Lisa M Lee, PhD, MA, MSFrank V Strona, MPHPresidential Commission for the Study of Bioethical Issues

2The findings and conclusions reported here are thoseof the speaker(s) and do not necessarily represent theofficial positions of the Presidential Commission forthe Study of Bioethical Issues or the US Government.

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Outline Define and describe public health ethics Outline ethics skills for all public healthpractitioners Describe a method for resolving ethicaldilemmas4

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6Let’s Get Started

Case: Part 17

8 Is this collection anduse of public healthdata ethicallyjustified? Why or why not? Make your case toyour table.

9Public Health Ethics

Defining Terms10 What is ethics? Bioethics? Public health ethics? Why do we care about it?

Defining Terms11 What is ethics?––––Consideration of what is right and wrongDescriptive: What people view as right and wrongNormative: What we think we ought to do and whyMeta-ethics: How we know what is right What is bioethics?– Practical ethics applied to health, medicine, science,and technology

Defining Terms12 Public health ethics– Moral governance for public health Determines what we ought to do– Application of decision making framework Determine course of action when values conflict Other ‘categories’ of ethics apply in public health– Research ethics (Common Rule, IRB)– Professional ethics (Codes of Ethics)

Why We Care about EthicsIn public health, we act to prevent morbidityand mortalityPHAction13

Why We Care about EthicsWhat weare able todoWhat weshould doPHActionWhat wearepermittedto do14

Operating Ethical Principles: What Should We Do? 15 Wide array of tangible expectations that guidewhat public health practitioners should do–––––––––Interfere with liberty as little as possibleEnsure benefits outweigh infringementInfringe on autonomy only as necessaryBe transparent and accountableReduce inequitiesReduce harms & burdensRespect privacy & confidentialityUse evidence-based interventionsFocus on fundamental causes of disease

Public Health Cares about Ethics16 Public Health Accreditation Board (PHAB)requires a process for managing ethical issues– Measure 11.1.2.A “The purpose of this measure is toassess the health department’s policies and process forthe identification and resolution of ethical issues thatarise from the department’s program, policies,interventions, or employee/employer relations (emphasisadded).”– Dakota County Public Health Ethics Committee (#2102)

17“Should” Considerations in ClinicalMedicine & Public Health Practice

Our “Patient”: Who Benefits?Clinical medicinePublic Health Patient is the individualIndividual benefitsIndividual orientationIndividual consent18Patient is the populationPopulation benefitsCommunity orientationCommunity engagement

Our Approach19Clinical medicinePublic Health Medical interventions tocure or treat after acondition occurs Non-medical means (e.g.,policy, law, sanitation,behavior change) to preventillness and promote health Limited number similarlytrained professionals Diverse practitioners

Our Ethical ConcernsClinical medicine Individual liberty,autonomy, privacy Beneficence,nonmaleficence Distributive justice20Public Health Respect for persons Interdependence,interrelatedness Social good, avoiding socialharm Social justice, human rights

Moral Governance for Public Health21 Heightened focus on autonomy in clinical ethicsover past 40 years is incompatible with healthneeds of a population Recognition of merits of pluralistic values–––––EquityReciprocityCommon goodSolidarityJustice7 Billion Others

Moral Governance for Public Health22 Dealing with a public good‒ Shifting from individual to collective‒ Shifting from personal moral compass to ethicaldecision making

Professional JudgmentProfessional judgment is thejudgment of the profession,not the professional.--Jim Swearengen, DVM(Former Senior Director, AAALAC)23

Ethics Focus in Public Health24 Our shift to community requires a shift in ourethical duty‒ Transparency to nurture trust‒ Pluralism to promote collaboration and participation‒ Focus on community to emphasize that good forcommunity is often best for self

Case: Part 225

26 What are the publichealth ethics dimensionsof this case? Would you do anythingdifferently now(compared with your firstresponse)? Would you justify yourposition differently?

27Ethics Skills for Public HealthProfessionals

Ethics Skills in Practice What do we need to know how to do? Four skill domains‒‒‒‒Identify ethical dimensionsArticulate ethical dilemmasDeliberate a path forwardImplement and evaluate28

Ethics Skills in Practice29 Identify ethical dimensions in public health‒ Evidence for what we can do and just reasoning forwhat we should do‒ Can this vaccine prevent influenza?‒ Should we require all public health staff to beimmunized for seasonal flu?

Ethics Skills in Practice30 Identify ethical dimensions in public health‒ Ethical questions are different from personalpreferences and cultural customs‒ Should our department implement casual Fridays?‒ Should we promote employees based on how theydress at work?‒ Ethical questions also differ from legal questions‒ Should a child who has not been vaccinated beallowed into school?‒ Should we force parents to vaccinate theirchildren?

Ethics Skills in Practice31 Identify ethical dimensions in public health‒ What are the values associated with a public healthaction or policy?‒ Are values in conflict?‒ If not, it might be important to communicate theethical dimensions of decisions to stakeholders‒ If so, we have an ethical dilemma on our hands

Ethics Skills in Practice32 Identify ethical dimensions in public health Articulate the ethical dilemma‒ Need a working knowledge of our underlying valuesin public health‒ What values motivate our work?

Values That Motivate PH Action33 Liberal concepts– Autonomy, noninterference, individual liberty, respect forpersons, and rights Collective concepts– Obligation, producing benefits, preventing harms,protecting trust, confidentiality, population utility, justice,transparency, relationships, equality, participation, anddisparities

Move Toward Community Solidarity Need to consider respect for individualautonomy and our obligation to prevent harmand protect community health Move from values of liberalism in bioethicstoward the collective of community andsolidarity in public health ethics34

Ethics Skills in Practice35 Identify ethical dimensions in public health Articulate the ethical dilemma‒ Identify which of these motivations/values are inconflict, for example:‒ Individual liberty and social good (e.g., movementrestrictions)‒ Equity and justice (e.g., vaccine subsidies)‒ Public beneficence and individual privacy (e.g.,public health surveillance)

Case: Part 336

37 What are the ethicaldilemmas in this case(what values conflict)? Discuss with your tableto come up with adecision about whetherand how to moveforward with a plan toreduce diabetes in thecity.

Ethics Skills in Practice38

Resolving Ethical Dilemmas39Ethics is a social technology, one for which there are noexperts. There is only the possibility of conversation,ideally free of factual mistakes and imbued with mutualsympathy.-- Philip Kitcher, Science in a Democratic Society (2011) p 12.

Ethics Skills in Practice Identify ethical dimensions in public health Articulate the ethical dilemma Deliberate a path forward––––––Method to address an open questionEvidence (scientific, lived experience)Understanding of values at stakeDiverse perspectivesMutual respectPrincipled reason giving40

Ethics Skills in Practice Identify ethical dimensions in public healthArticulate the ethical dilemmaDeliberate a path forwardImplement and evaluate––––––Gather evidenceIncorporate new informationAsk stakeholdersMake necessary changes or adjustmentsLearn lessonsUse as analogous case in the future41

Ethics Skills in Practice Four skill domains‒‒‒‒Identify ethical dimensionsArticulate ethical dilemmasDeliberate a path forwardImplement and evaluate Method‒ Reflective, participatory‒ Multidimensional‒ Open to revision with new information42

43Identify values

44Thank you!

Public Health Cares about Ethics. 16 Public Health Accreditation Board (PHAB) requires a process for managing ethical issues – Measure 11.1.2.A “The purpose of this measure is to assess the health department’s policies and process for the . identification . and. resolution . of ethical issues that arise from the department’s program .