Public Health Service Ethics New Tools for Planning and Implementation Mark E White, MD, FACPM

Objective Introduce you to tools of public health ethics Give examples of how you may use them Summarize results of meetings

Take Home Messages Public health ethics come from you and your society Public health ethics are tools for planning and implementation You must assert your views Consider the views of others openly in planning Use public health ethics to make the world a better place

Why Bother with Ethics? Explicitly considering ethical perspectives in planning allows you to make fairer, more effective and efficient decisions Openly discussing ethics makes it easier to build consensus, even with those who disagree

Every decision has an ethical dimension

8 20th Century Global Health Ethics The Golden Rule: If you take the king’s gold, you take the king’s rules (funders dictate ethics) Individualistic ethics Communitarian ethics

Public Health Practice Improving a specific population’s health by making systematic interventions based on Science Management Consensus building Ethics Examples: surveillance, outbreak investigations, program implementations, evaluations

9 Public Health Program Cycle Planning Advocacy & Consensus Building Implementation Monitoring & Evaluation Justification

10 Where Ethics Can Help Planning Consensus Building Implementation Monitoring & Evaluation Justification Clarify priorities, assumptions and targets Persuade, advocate Clarify progress towards objectives Advocate, persuade Open, fair processes

18 Common Ethical Issues Prioritizing services (science based, fair) Distributing services fairly geographically and socially (fair, effective) Follow up on recommendations of studies (duty) Restrict freedom (quarantine)

7 What are Ethics Anyway? Values: “health is good” Principles are goals: “Help others as you would like to be helped” Processes: clarify, prioritize, justify possible courses of action Based on ethical principles, values of stakeholders scientific information From Drue Barrett, CDC, 2007

Values Come From You Better population health: “Everyone can live healthy, productive lives” Social justice: “Everyone treated fairly” Equity: “Everyone gets an equal chance” Solidarity: “We are in this together.” Duty: “Health workers should take care of people with flu. Autonomy People usually list several, including:

17 Principles of Public Health Ethics Based on value of justice Inclusiveness/solidarity Duty/Professionalism “Health workers risk their lives fighting avian influenza” Science

Organizational Ethics: Principles & Processes Contribute to Public Health Public Health Ethical principles Accountability Transparency Efficiency Effectiveness

Public Health Based on justice Population is patient Rights of community > individuals Do the most good for the most people Protect all, including minorities Don’t restrict freedom unless absolutely necessary

Research Ethics Based on autonomy/individual rights Usually coercive Protect interests of subjects Assumes no benefit to subjects Assumes possible harm to subjects Very high standards of proof, documentation

Clinical Ethics Based on autonomy/individual rights Usually coercive Protect autonomy of patients Privacy Patient must approve Provider works for pateint

Why not Combine Ethics? Public Health aims to improve the health of populations Clinical practice and research aim to improve health of individuals Public health ethics most useful in planning and implementing interventions Public health ethics are tools, rarely coercive

15 Putting Perspectives Together Cultural relativism: Cup half empty: nobody agrees completely Cup half full: everybody agrees on some things Problem: Western individualists have driven the discussion so far Opportunity: Engage Middle Eastern, Asian, Latin American, African cultures You must speak out for your values!

Relative Importance of Principles

Take Home Messages Public health ethics come from you Public health ethics are tools for planning and implementation You must assert your views Consider the views of others openly in planning Use public health ethics to make the world a better place

Thank You