9
Public Health Ethics and Social Justice in the Community
JOAN KUB
LEARNING OBJECTIVES AND OUTCOMES
Upon completion of this chapter the student will be able to:
Define public health and public health ethics
Differentiate public health ethics from clinical ethics
Describe the ethical tensions inherent in addressing public health problems
Discuss different theoretical approaches and principles used in public health ethics
Apply a public health framework in analyzing the development of a new program or policy
Discuss ethical principles involved in implementing programs and designing policies in the community
As a practicing nurse, you more than likely have experienced situations that involve clinical ethics. In general, clinical ethics focuses on the nurse and other providers’ roles in individual patient/family issues such as confidentiality, privacy, respect, and autonomy. In contrast, public health ethics is concerned with the overall health of communities and populations. Public health also seeks to better understand social inequities in health and to address them using a social justice lens, a responsibility of all nurses as identified in the Code of Ethics (2015). Since public health nursing is a specialty area you may or may not have experienced public health ethical situations.
This chapter discusses the development of the burgeoning field of public health ethics. In doing so it (a) differentiates clinical ethics from public/population health ethics; (b) discusses theoretical foundations and principles of public health ethics; (c) discusses the relevance of human rights and social justice as key to public health ethics; (d) presents one framework for analyzing public or population health decision making; and (e) uses selected public health issues to illustrate the application of theory and principles in the analysis and justification of public health decisions and actions.
CASE SCENARIO
On January 5, 2015, the California Department of Health was notified of a suspected case of measles. The 11-year-old unvaccinated child had visited one of two adjacent Disney theme parks located in Orange County, California. On that same day, six additional suspected measles cases, all of whom had visited the same theme parks from December 17 to 20, were also reported in California and Utah. By February 11, a total of 125 measles cases with a rash occurred from December 28, 2014 to February 8, 2015 (Zipprich et al., 2015). “Among the 110 California patients, 49 (45%) were unvaccinated; five (5%) had 1 dose of measles-containing vaccine, seven (6%) had 2 doses, one (1%) had 3 doses, 47 (43%) had unknown or undocumented vaccination status, and one (1%) had immunoglobulin G seropositivity documented, which indicates prior vaccination or measles infection at an undetermined time” (Zipprich et al., 2015, p. 153). From January 1 to August 21, 2015, 188 people from 24 states and the District of Columbia developed reportable measles. One hundred and seventeen cases (62%) were part of a large multistate outbreak linked to the amusement park in California (Centers for Disease Control and Prevention, 2015a).
This Case Scenario raises several ethical questions that have implications for the health of the public. The key question is whether compulsory mandated measles vaccination that impinges upon individual autonomy, privacy, and liberty is justifiable for reasons of protecting the health of the entire population and realizing public health goals?
Questions to Consider Before Reading On
1. Do you believe compulsory mandated measles vaccination that impinges upon individual autonomy, privacy, and liberty is justifiable for reasons of protecting the health of the entire population and realizing public health goals?
2. Are certain vaccinations mandatory for nurses where you currently work?
Measles is a serious illness with the potential of putting the health of the public at risk with devastating outcomes for individuals and populations. Controversies and tensions exist surrounding concerns about vaccine safety, mandatory school vaccination regulations, suboptimal vaccine coverage, the prevalence of preventable cases of disease, the fairness of exemptions to the law, and liberty/personal rights (Ransom, Swain, & Duchin, 2008). In 2013, the Institute of Medicine report Childhood Immunization Schedule and Safety: Stakeholder Concerns, Scientific Evidence, and Future Studies provided an update on the safety of immunizations for children (Chi, 2014; Institute of Medicine, 2013). Despite this report, it is clear that hesitancy about immunizing children and refusals to immunize children are growing problems, so much so that a study of families in California found that personal belief exemption rates rose by 9.2% from 0.6% in 1994 to 2.3% in 2009 (Richards et al., 2013). This Case Scenario illustrates concerns about individual rights/autonomy versus concern for the overall good of the public.
PUBLIC HEALTH AND PUBLIC HEALTH ETHICS
The field of public health ethics evolved in the early 1980s with the emergence of a number of infectious diseases such as AIDS and severe acute respiratory syndrome (SARS; Knight, 2015; Simón-Lorda, Barrio-Cantalejo, & Peinado-Gorlat, 2015). Debates concerning the relationship of ethics, public health, and human rights surfaced at this time. It became clear that actions required in public health practice are different from actions required in clinical ethics. These differences stem in large part because of the nature of public health.
In 1988, the Institute of Medicine (IOM) defined public health as what we, as a society, do collectively to ensure the conditions in which people can be healthy (Institute of Medicine, 1988). The IOM report went on to define the core functions of public health as assessment, assurance, and policy development (Figure 9.1). The American Public Health Association further defined public health by the 10 essential services that help define effective performance (American Public Health Association, n.d.; Table 9.1). Public health seeks to improve the health of communities and populations. It is concerned with not only understanding the causes of disease but first and foremost the prevention of disease. It is often focused on underlying social, economic, and environmental conditions and population-level health interventions, policies, or programs that shift the distribution of health risk.
A five-tier health impact pyramid illustrates the focus of interventions in public health. (Figure 9.2; Frieden, 2010). The broad base focuses on what has now been called social determinants of health (housing, sanitation, nutrition) followed by interventions that change the context for health (clean water, safe roads, eliminating trans fat in foods), followed by protective interventions such as immunizations, followed by direct clinical care and counseling and education. The two top tiers are focused more on individual care and are dependent on individuals changing their behavior. The lowest tier has the greatest potential to change population health, while tier 2 usually consists of the most effective public health actions (Frieden, 2010).
Figure 9.1 Core functions and essential services of public health.
Source: CDC (2016).
Questions to Consider Before Reading On
1. What interventions could nurses implement at each tier in Figure 9.2?
2. What are the ethical implications of these interventions?
PUBLIC HEALTH ETHICS
In 2002, the American Public Health Association adopted a code of ethics for public health practice (Public Health Leadership Society, 2002; Thomas, Sage, Dillenberg, & Guillory, 2002; see Table 9.2). Until that time, public health was guided by medical ethics with the four principles of autonomy, beneficence, nonmaleficence, and justice (Thomas, 2008). Although these principles guide the interactions between individuals and their health care providers, ethical quandaries in public health are concerned with the needs of populations. The moral considerations generally include concerns with . . .
Table 9.1
Ten Essential Public Health Services
1. Monitor health status to identify community health problems. 2. Diagnose and investigate health problems and health hazards in the community. 3. Inform, educate, and empower people about health issues. 4. Mobilize community partnerships to identify and solve health problems. 5. Develop policies and plans that support individual and community health efforts. 6. Enforce laws and regulations that protect health and ensure safety. 7. Link people to needed personal health services and ensure the provision of health care when otherwise unavailable. 8. Ensure a competent public health and personal health care workforce. 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. 10. Research for new insights and innovative solutions to health problems. |
Source: American Public Health Association (n.d.).
Figure 9.2 Five-tier health impact pyramid.
Source: Frieden (2010).
Table 9.2
Principles of Public Health
1. Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes. 2. Public health should achieve community health in a way that respects the rights of individuals in the community. 3. Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members. 4. Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all. 5. Public health should seek the information needed to implement effective policies and programs that protect and promote health. 6. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation. 7. Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public. 8. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community. 9. Public health programs and policies should be implemented in a manner that most enhances the physical and social environment. 10. Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others. 11. Public health institutions should ensure the professional competence of their employees. 12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness. |
Source: Public Health Leadership Society (2002).
producing benefits; avoiding, preventing, and removing harms; producing the maximal balance of benefits over harms and other costs (often called utility); distributing benefits and burdens fairly (distributive justice) and ensuring public participation including the participation of affected parties (procedural justice); respecting autonomous choices and actions, including liberty of action; protecting privacy and confidentiality; keeping promises and commitments; disclosing information as well as speaking honestly and truthfully (often grouped under transparency); and building and maintaining trust. (Childress et al., 2002, pp. 171–172)
Although some of these moral considerations apply to clinical ethics, there are distinct differences between public health ethics and clinical ethics. Clinical ethics is concerned with the individual patient and relationships with individual clinicians. Typical concerns include issues of confidentiality, privacy, respect, and autonomy (Carter, Kerridge, Sainsbury, & Letts, 2012). In contrast, public health ethics is focused on collective thinking and tradeoffs between the well-being of communities and the well-being of individuals (Carter et al., 2012). According to the Canadian Institutes of Health Research (2012), public health ethics differs from traditional bioethics because of its emphasis on moral evaluations related to populations, the realization that “upstream” interventions occur outside the health care system, and the focus on the prevention of illness and disease.
The prevention imperative is evident, for example, in current global HIV/AIDS policy discussions. Although the initial focus of HIV/AIDS policy was focused on individual behavior and ensuring access to biomedical treatment, public health efforts are now focused on a combination of behavioral, structural, and biomedical prevention strategies (Meier, Brugh, & Halima, 2012).The behavioral approaches include not only traditional educational and motivational approaches but also community normative approaches. The aim of structural approaches is to change the social, economic, political, and environmental factors that influence HIV risk and vulnerability. The biomedical approaches involve technological interventions not solely dependent on behavior change (Meir et al., 2012).
Question to Consider Before Reading On
1. What are some of the identified public health needs in your community?
THEORETICAL FOUNDATIONS AND PRINCIPLES OF PUBLIC HEALTH ETHICS
Within both clinical and public health ethics, it is important to examine the theory and principles guiding normative behavior. Theories that are particularly pertinent to public health ethics are utilitarianism, deontology, libertarian theories, and communitarianism. These theories have been described in earlier chapters but often have particular relevance to public health. Utilitarianism, for example, is often used to justify public health interventions supporting the belief that the most ethical course of action is the one that produces the greatest good for the greatest number (Buchanan, 2008). The moral worth of actions using utilitarianism is based on their contributions to overall “utility” (Mill & Bentham, 1987). Utilitarianism often utilizes economic approaches such as cost–benefit analyses or cost-effectiveness analyses to guide decision making in public health (Faden & Powers, 2008). Deontology is the theory proposed by Kant that begins with the premise that human beings have the capacity for reason and are worthy of respect and dignity. Therefore, human beings have a duty to respect the dignity of other human beings and humans should not be treated as a means to an end (Misselbrook, 2013). In public health, appeals to the avoidance of stigmatization of vulnerable groups such as individuals with HIV have been used to guide moral decision making within the public realm (Dean, 2014). Libertarian theory is concerned with ensuring that public policies do not violate human rights or rights to property influencing tax policies (Faden & Powers, 2008). Communitarianism is a social philosophy concerned with a collective reflection on shared values and what is good for society. Communitarians examine the ways shared good or values are formed, transmitted, justified, and enforced (Etzioni, 2006). Communitarian ethics can be used in examining the allocation of scarce resources and rationing of care or resources in time of need (Etzioni, 2011) or in the development of infectious disease policies (Cheyette, 2011).
PRINCIPLES OF PUBLIC HEALTH ETHICS
The principles that have particular relevance to our discussion of public health ethics are paternalism, human rights, and social justice.
Paternalism Versus Autonomy
Distinguishing clinical ethics from public health ethics is often concerned with identifying when paternalistic interventions that override individual autonomy are justified (Buchanan, 2008). Paternalism is described by Schickle as the interference with a person’s autonomy by performing an act or agreeing to perform an act without the consent of that person with the intention of improving or preventing a decline in the welfare of that person (Schickle, 2009).
Discussions of paternalism often relate back to a 1905 single Supreme Court case, Jacobson v. Massachusetts. The court found:
The liberty secured by the Constitution of the United States to every person within its jurisdiction does not impart an absolute right in each person to be, at all times and in all circumstances, wholly freed from restraint. There are manifold restraints to which every person is necessarily subject for the common good. (Supreme Court of the United States, decided February 20, 1905, cited by Buchanan, 2008)
In thinking about communicable diseases, overriding individual rights or autonomy for purposes of controlling infectious diseases is often justified. Tuberculosis, for example, is a classic example when individual patients have been “quarantined” in the past to ensure a cure and to protect others from the disease. This is an example of John Stuart Mill’s theory of liberty and “harm principle” that is invoked to control risk and to control infectious diseases. This is justified since an individual poses a significant harm to others and therefore liberty-limiting interventions are supported (Gostin & Gostin, 2009).
In cases of infectious diseases, it is easier to justify what appear to be paternalistic public health interventions. Today we are not only concerned about infectious diseases, however, but also the growing public health emphasis on noncommunicable diseases. The key question is whether any public health intervention can rightfully infringe upon individual autonomy. Childress and colleagues defined five “justificatory conditions” when this could occur. These criteria include (a) effectiveness, (b) proportionality, (c) necessity, (d) least infringement, and (e) public justification. An intervention or policy must show evidence of realizing its goal, being necessary for the accomplishment of the goal, and justifiable by public health agents. In addition, it is essential to show that the public health benefits outweigh the infringed moral considerations (proportionality) and the public health agents seek to minimize and attain the least infringement of general moral considerations (Childress et al., 2002).
Question to Consider Before Reading On
1. Recall a recent incident of communicable or noncommunicable disease. Did the interventions proposed and/or implemented meet the criteria defined by Childress et al. (2002)?
CASE SCENARIO (CONTINUED)
