1. TH Tulchinsky MD MPH Braun School Public Health 16 November 2010
Ethics in Public Health, Health Care, Health Research and the Biomedical Sciences
TH Tulchinsky MD MPH
Braun School Public Health
16 November 2010

2. Ancient Origins of PH Biblical Principals
Pikuah nefesh - sanctity of human life
Tikun olam – Biblical - repair the world
Ancient India and China - sanitation
Ancient Greece
Hippocratic oath - do no harm
Healthy body-healthy mind
City states
Religion – Charity, after-life

3. Medieval
The Church - Religious institutions, relieve suffering, care of the poor
Aristocracy – noblesse oblige
Universities – royal charters
Cities – royal charters, municipal government sanitation, hospitals
Guilds – mutual benefit “friendly” societies
Leprosy
Pandemics - undefined
The Plague

4. Modern Origins of Public Health Ethics
Miasma and germ theories
Social hygiene
Scientific and PH advances during 19th-20th centuries
Government responsibility –local, state and national
Collective bargaining for health benefits
Tragic distortions of social hygiene – eugenics, genocide Human rights – Nuremberg, Tuskegee, Helsinki
Universal right to health care (Health for All)
Self responsibility (lifestyle) in health
Advancing technology and rising costs
Public awareness and expectations Pragmatism and science

5. Ten Achievements of Public Health of the 20th Century
Control of infectious disease
Vaccination
Motor vehicle safety
Safer workplaces
Decline in deaths coronary heart disease, strokes
Safer and healthier foods
Healthier mothers and babies
Family planning
Fluoridation of drinking water
Recognition of tobacco as a health hazard
MMWR, 1999

6. Ethics in Epidemiology
Ethics is a branch of philosophy that deals with distinctions between right and wrong – with the moral consequences of human actions.
The ethical principles that arise in epidemiologic practice and research include:
Informed consent
Confidentiality
Respect for human rights
Scientific integrity
Last JM [ed]. A Dictionary of Epidemiology. Fourth Edition. 2000

7. Ethics, Values, and Mission Statements in Epidemiology
Core values - fundamental ethical and basic scientific values support mission and purpose of the profession
Epidemiologic mission is to acquire new scientific information needed to maintain, enhance, and promote the public's health
Different opinions about core values
Values in the profession may gradually evolve over time e.g. euthanasia
Core values in epidemiology are closely related to core values in the broader field of public health.
"Values define us as a group of public health professionals; values drew many of us into public health”.
Coughlin SS. Epidemiologic Review. 2000;22:

8. Moral Reasoning as Guide for Action
Mandatory and voluntary
Benefits – for society and individuals
Do no harm - balance potential good and harm
Action vs. non action
Autonomy - right of self determination
Justice and equity
Case based approach
Design and conduct of research
Application of knowledge
Conflict of interests – disclosure
Autonomy - informed consent, confidentiality
Screening
Coughlin S. Emerging Themes in Epidemiology, 2006

9. Ethical Issues in PH
Routinely in public health, scientific considerations blend with political and ethical conflicts, and questions of autonomy, individual rights, coercion, justice, community, the common good, the norms of research, and multi-cultural values are central. In public health today several different types of political and moral theory overlap, converge, and contend with one another, including libertarian liberalism, egalitarian liberalism, utilitarianism, human rights frameworks, and communitarianism.
Ethics and Public Health: Model Curriculum, ASPH, 2003

10. New Public Health: Individual and Population Health
Public health = utilitarian, paternalistic, social and legal responsibility to protect the public health, community orientation, accountability, universal, governmental responsibility
Individual Health
Bioethics = human rights, civil liberties and individual autonomy approach, medicalized system, confidentiality, privacy,
personalized

11. Ethics in PH
Moral imperative of PH to ensure and protect the health of the population and the individual
Ethical foundations traditionally implicit in PH
The right to health
Responsibility fro population health
Renewed awareness of and accountability
Conflict between individual and community rights
Effects of doing or not doing public health interventions or “best practices”
New issues all the time – diasters, genocide

12. When and When Not to Act
Public (community) right to protection and best available standards
Dangers/costs of not acting exceed those of acting
Judgment, experience, evidence, ethics
Experience of Good Public Health Practice (GPHP)
Threats of preventable mortality or risk factors
Public right to know
Individual rights
Balance of contradictions
Accountability, transparency

13. Why Study Ethics in PH
Many issues of conflict between good of the individual and good of society
Immunization, chlorination, fluoridation
Food fortification
HIV/AIDs, MDRTB, DOTs vs. DOTS Plus
Aging and chronic diseases
Genetically modified foods
Technology and resource allocation
Stem cell research
The Case-for-Action

14. Basic Questions Does society’s responsibilities = paternalism?
Does freedom of individual = rejection of responsibility of the state in health?
Do we need informed consent for all PH interventions?
Do individual rights over-ride social responsibility? E.g. AIDS contact tracing
“Precautionary Principle” = must prove zero risk of an new medication or PH intervention?
Equity in health?
Adequacy of funding and its allocation?

15. Old-New Battles UK Variolists oppose vaccination vs. smallpox C19th
US Opposition to public health departments in 1920s
UK GPs oppose immunization with pertussis (1980s) and MMR (2002+)
AMA opposes to national health insurance 1920s +
Civil rights vs. HIV control, 1980s US
Anti-fluoridation 1950s to present
Resistance to innovations e.g. MMR, Hib, Pap smear
Anti-food fortification in Europe
Anti-genetic engineering of food in Europe

16. PH Ethical Issues Responsibility to protect society
Responsibility to the individual
Individual vs. community rights
Government responsibility
Corporate responsibility
Right to health care
Personal responsibility - self care
Quality of care
Freedom of choice
Acting on evidence vs. not acting

17. PH Law and Ethics Gov’t obligation to protect health of the population
Power of government to legislate, tax, spend, regulate, punish
Restriction of personal and business liberties e.g. seat belt laws; smoking restrictions vs. human rights
Economic, social impact of intervention vs. non-intervention e.g. inequities of the poor and rural
Laws enacted by legislative bodies
Court decisions
Public scrutiny
Accountability

18. Individual Rights and PH Ethical Issues
Right to quality health services
Provider responsibility to act for benefit of client
Euthanasia - right to die
Confidentiality – right to privacy
Informed consent – right to know
Birth control – religion vs. individual rights
Supply and distribution of resources for health
Incentives - disincentives
Equity – social, ethnic, regional
Social solidarity

19. Groups at Special Risk Women Children
Civilians in war and terror situations
Disaster victims
Native peoples
Minority groups
Prisoners
Military
Refugees and internal migrants
Mentally ill
Rural vs. urban

20. Individual and Community PH Ethics
Sanitation
Herd immunity
Universal access
Education
Gatekeeper function
Mandatory reporting
Case follow-up
Resources for health
Cost containment
Equity
Minority and special groups
High risk groups
Individual
Personal hygiene
Immunization
Right to health care
Self care
Choice of provider
Right to know
Right to die
Confidentiality
Privacy
Informed consent
Patients Bill of Rights

21. Public Health: “the Slippery Slope”
1920’s-1930’s: Eugenics movement
1930’s-1940’s: Mass sterilization of "defectives" in United States and Sweden.
’s: Mass murder of “defectives” in Germany (750,000)
1940’s: Quarantining as pretext for ghettos by Nazis
1940s: Concentration camps, human experimentation
1940s: The Holocaust (6 million Jews and others)
1946 – Nuremberg Trials

22. Landmarks on Individual Rights: the Biomedical Model
Focus on individual informed consent
Concern of exploitation and abuse of the individual
Eugenics and forced sterilization
Concentration camp medical “experiments” - Nuremberg trials
Helsinki declaration
Tuskegee experiment
Declaration of human rights
Health for All

23. Nuremberg Code 1946 Nazi experiments and industrialized murder
Doctors found guilty and executed
Set new conditions for research
Subjects must have:
Right to knowledge of purpose and effects of experiment
Right of voluntary consent
Right to end participation
Scientist in charge responsible for:
Scientific basis or validity of the hypothesis
To terminate experiments likely to cause injury, disability, death

24. Universal Declaration of Human Rights, 1948
Article 25.
Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services etc.

25. Helsinki Declaration 1964 World Medical Assembly 1964 to present
Privacy and integrity of individual protected
Adequate informed consent
Research for valid scientific benefits
Accepted scientific principles
Benefits outweigh risks
Publication
Protect control group
Individual well-being vs. needs of science and society

26. Tuskegee Experiment Tuskegee, Mississippi Duration 1932-1972
Conducted by US Public Health Service
To observe the natural history of syphilis
Group of black men
Treatment with penicillin available (1942)
Failed to provide information to subjects
Unethical (possibly criminal) behavior
New standards resulted
Apology by President Clinton 1996
Continues to influence sectors of US public in response to public health initiatives

27. Health for All WHO definition of health, 1948
Alma Ata, 1978 Health for All
Health care as a universal human right
Government responsibility
Wide acceptance
Important to help shift priorities
Still unfulfilled
Health targets
Priorities and cost-benefit decisions

28. Changing Concepts of Disease
1960s – Ivan Illitch and McKeowan – medical care of little value; health gains result of sanitary and nutritional adavances
1970s – Marc Lalonde Health Field Concept: genetic, environment (physical and social), lifestyle and medical factors in health
Evidence of risk factors for disease e.g. smoking, diet exercise e.g. smoking and Framingham studies
Blaming the victim vs. self responsibility?
Health targets US Surgeon General and WHO

29. New Public Health Individual Health Population Health
Law
Government
Ethics
New Public Health
Public Opinion
Inter
national standards
Individual
Health
Population
Health

30. The New Public Health
Sanitation, environment, infectious disease control
Managing health systems and resources
National target e.g. reduce stroke mortality
Health promotion e.g. food fortification, smoking restriction
Health education e.g. nutrition, exercise, self care
Personal preventive services e.g. hypertension, MI, CHF, diabetes
Clinical standards, guidelines e.g. AMI, diabetes
Ambulatory and home care
Long term care

31. Tasks of the ASPHER Ethics Working Group
Develop overall ethical standards of ASPHER EUPHA and member organizations
Develop ethical standards for public health practice
Develop curricula for undergraduate, masters and PhD level studies of PH
Promote research and publication in ethical issues in PH

32. Summary
Government responsibility to legislate, tax, regulate and enforce for the public health
Protection and pro-active services for the weak, the needy, for equity and social solidarity
Ethical considerations
Rights of society
Rights of individuals
Responsibility of individuals
Informed consent for research
Precaution vs. inertia
Importance of New Public Health

33. What would your mother tell you to do?
Which is the Right Way?
What would your mother tell you to do?