Ethical Issues in Public Health

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Ethical Issues in Public Health

• Marymount University
• Eileen Sarsfield, PhD, PHCNS-BC

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Objectives

• Describe ethical principles in relation to
  individuals and populations.
• Discuss nursing traditions and documents which
  support social justice in light of the present
  market justice environment.
• Use ethical problem-solving strategies to
  address dilemmas related to care of individuals,
   communities, and populations

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Define Ethics

• The philosophical study of moral values and
  rules.
• The science of human duty in terms of what is
  right and wrong, true or false.

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Ethical Approach to Solving Health Care Dilemmas

• Bioethics- refers to the study of ethics as it
  relates to health and moral dilemmas.
• Ethical dilemma-a situation characterized by
  conflicting rights or obligations.
• (Lundy Janes, 2009)

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Bioethics-The Big Four Principles

• These principles are widely used as a starting
  point for practical decision making in clinical
  professions dealing with individual cases
  (biomedical)
• Autonomy- free choice
• Beneficence-doing good
• Nonmaleficence- do no harm
• Justice- fairness
• Beauchamp Childress (2008) Principles of
  Biomedical Ethics, 6th Edition

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Use in Public Health

• Though the Big Four Principles are primarily
  used in clinical practice addressing individual
  cases, they can be applied on a population level.
• In public health practice, principles such as
  beneficence often carry more weight than the
  principle of autonomy.
• For example, fluoridation of the water programs

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Population-based Ethical Principles In Public
Health

• Consequentialism- What are the goodness or
  badness of the consequences? The consequences of
  a particular action form the basis for any valid
  moral judgment about that action. A form of this
  is
• Utilitarianism the greatest
  happiness/good for the greatest number of
  people. The moral worth of an action is
  determined by its outcome. (John Stuart Mill).
  To a utilitarian the results are paramount.
• Deontology- derives the rightness or wrongness of
  an act from the character of the act itself
  rather than the outcomes of the action. i.e.
  murder is inherently wrong regardless of the
  situation.

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Community / Public Health Ethical Principles cont

• Communitarian ethics - What can I do to make
  society better or does what I am doing improve
  society?
• Beneficence- The obligation to act in ways that
  benefits others
• Justice- fair, equitable, appropriate treatment
  in the light of what is owed to people.
• Egalitarian ethics Stresses equal access to
  important social goods based on giving primacy
  to principles of social justice.

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Principles that Frame the Right to Health Care
Argument

• Often the right to health care is framed within
  the communitarian principle and the principle of
  distributive justice which states that resources
  should be given first to those who need it the
  most.

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The Ethical Principle of Justice

• Social justice the principle that all persons
  are entitled to have their basic needs met
  regardless of economic status, class, gender,
  race, ethnicity, religion, citizenship, age,
  sexual orientation, disability or health. (PHN
  Scope and Standards, 2007)
• Distributive justice- resources should be given
  first to those who need it the most
• Egalitarian justice- equal distribution to
  everyone regardless of need (Socialism)
• Restorative justice payback those previously
  harmed by injustice-i.e. Native Americans

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Social Justice

• We lack benchmarks to determine what is fair
  and what is unfair.
• The construct is difficult to teach, practice or
  model.
• It is a highly personal idea often
  formed/influenced by life experiences.
• In health care it is often interpreted to mean
  there is a collective responsibility for health
  care.

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Nursing and Social Justice

• Nursings traditional ethos rooted in the theory
  of social justice
• Respect for patients
• Caring
• Compassion
• Concern for their well-being
• Concern for the poor and vulnerable

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Nursing's Policy Statements

• Three contemporary documents and statements about
  the meaning of social justice.
• 2001 Code of Ethics for Nurses
• 2004 Scope and Standards of Nursing Practice
• 2010 Nursings Social Policy Statement
• There is an emphasis on individuals rather than
  on populations and the common good.

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Social Justice and Public Health Nursing

• Beauchamp (1976) asserted that the ethical
  foundation of public health is social justice.
• The ANA Scope and Standards of Public Health
  Nursing (2007) uses
• Utilitarianism the greatest happiness/good
  
• for the greatest number of people.
• Using utilitarianism as a guiding principle for
  public health nursing can focus on quantitative
  evaluation justice is considered through the
  lenses of who ever happens to be the majority.

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Market Justice vs. Social Justice in Public Health

• Market justice is increasingly influencing public
  health nursing through the partnering of managed
  care companies and public health agencies.
• Managed cares focus on the medical model, market
  demands, shareholders concerns and the individual
  rather than on the common good is incompatible
  with social justice principles.

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Todays Challenges to Social Justice

• Although public health nurses are champions of
  social justice, their work places embrace
  bureaucracy, standardization, individual care and
  medical models.
• A market driven health care system challenges us
  to study, analyze and discuss social justice.

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Major Ethical Tensions in Public Health

• Individual and Community Rights. Perhaps the
  clearest example of an ethical tension in public
  health is the balancing of individual and
  community rights when a person is discovered to
  have a communicable disease.
• Weighing Benefits, Harms, Risks, and Costs. All
  public health interventions require a balancing
  of benefits versus harms and costs. Vaccination
  campaigns always have an associated risk of harm
  because of adverse reactions to the vaccine.

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Public Health Ethical Dilemmas

• Typhoid Mary
• AKA Mary Mallon

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Public Health and the State Beneficence or
Paternalism?

• The formation and enforcement of public health
  policy is a government function.
• Many public health interventions, such as water
  fluoridation and mass vaccination programs
  certainly have benefits, but respect for autonomy
  may be undermined.
• When the state does something to protect people,
  some may hold different values and feel that the
  state is acting paternalistically toward them.

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Community/Public Health Ethical Decision Making

• Kass Six Step Framework
• What are the public health goals of the proposed
  program?
• How effective is the program in achieving its
  stated goals?
• What are the known or potential burdens of the
  program?
• Can burdens be minimized? Are there alternative
  approaches?
• Is the program implemented fairly?
• How can the benefits and burdens of a program be
  fairly balanced?
• (Lundy Janes, 2009)

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Ethical Decision Making Common Themes or Models

• Clarification of the ethical dilemma- gather data
• Determine if an ethical principle/s can guide the
  decision making process
• Evaluate options- unpack the elements
• Seek advice if possible
• Justify the position and act on it
• (Lundy Janes, 2009)

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Summary

• Nurses have opportunities to participate in
  ethical decision making with individuals,
  families and communities.
• Understanding the principles of ethical theory
  and decision making provides us with a starting
  point and a framework for developing our own set
  of beliefs that will guide us in the practice of
  nursing.