1. Ethical Issues in Public Health
Marymount University
Eileen Sarsfield, PhD, PHCNS-BC

2. 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

3. The philosophical study of moral values and rules.
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.

4. 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)

5. 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

6. 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

7. 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.

8. 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.

9. 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.

10. 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

11. 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.

12. Nursing and Social Justice
Nursing’s 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

13. 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 Nursing’s Social Policy Statement
There is an emphasis on individuals rather than on populations and the common good.

14. 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.

15. 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 care’s focus on the medical model, market demands, shareholders concerns and the individual rather than on the common good is incompatible with social justice principles.

16. Today’s 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.

17. 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.

18. Public Health Ethical Dilemmas
Typhoid Mary AKA Mary Mallon

19. 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.

20. 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)

21. 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)

22. 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.