Public Health Ethics (F2024) - Carpiano - PDF

Public Health Ethics Richard M. Carpiano, Ph.D., M.P.H. Professor of Public Policy PBPL 006: Introduction to Public Health © 2024 Richard M. Carpiano; do not distribute 1 or reproduce Roadmap for Lecture Part 1 of a series on public health ethics, p...

Public Health Ethics Richard M. Carpiano, Ph.D., M.P.H. Professor of Public Policy PBPL 006: Introduction to Public Health © 2024 Richard M. Carpiano; do not distribute 1 or reproduce Roadmap for Lecture Part 1 of a series on public health ethics, politics, and policy © 2024 Richard M. Carpiano 2 Public Health Controversies: 5 Major Sources 1. Role of economic market vs. government for health 2. Economic impact 3. Individual liberty 4. Moral and religious opposition 5. Political interference with science © 2024 Richard M. Carpiano 3 Controversy Source #1: Role of economic market vs. government The types of public health policies favored depend greatly on one’s philosophies about the role that public and private institutions should play in public health and health care The appropriate role of government is often controversial Social justice versus market justice © 2024 Richard M. Carpiano 4 Market Justice vs. Social Justice Differences: Market justice: focuses on individual responsibility Social justice: focuses on the common good Raises questions about: the scope of public health importance of economic factors for health Sources of political controversy © 2024 Richard M. Carpiano 5  Reproduced from Shi L, Singh D. Delivering Health Care in America. 3rd ed. Sudbury, MA: Jones and Bartlett Publishers; 2004:59. 6 Characteristics of Market and Social Justice © 2024 Richard M. Carpiano  Reproduced from Shi L, Singh D. Delivering Health Care in America. 3rd ed. Sudbury, MA: Jones and Bartlett Publishers; 2004:59. 7 Implications of Market and Social Justice © 2024 Richard M. Carpiano Controversy Source #2: Economic Impact Public health measures often have a negative economic impact on some segment of society Businesses often resist public health measures because they affect profits Those who must pay may not be the ones who benefit Costs may be short-term, while benefits may be long-term Costs are easier to calculate than benefits © 2024 Richard M. Carpiano 8 Tragedy of the Commons Nice explanation: https://www.youtube.com/watch?v=jSuETYEgY68 Exemplified in many environmental laws Freedom of individuals should be restricted for the well-being of the population Do laws overly restrict “freedom” to pollute? What should be included among protected resources? © 2024 Richard M. Carpiano 9 Controversy Source #3: Individual Liberty Public Health actions often involve limits on personal liberties Paternalism: Interference of a state or an individual with another person, against their will, defended or motivated by a claim that the person will be better off or protected from harm Restrictions to prevent harm to others generally acceptable Harm Principle (J.S. Mill): “Your freedom to swing your fist ends where my nose begins” Paternalism often only acceptable for laws concerning children For protecting individuals from their own actions? © 2024 Richard M. Carpiano 10 Controversy Source #4: Moral & Religious Opposition Concerns: Public health solutions often viewed as promoting immoral behavior (e.g., harm reduction efforts) Sex and reproduction Comprehensive (vs. abstinence-only) sex education, “Sex positivity” Abortion Alcohol and drugs Needle exchange programs, Safe injection sites Such opposition may discourage scientists and funding agencies from conducting research on many important health problems © 2024 Richard M. Carpiano 11 Controversy Source #5: Politics vs. Science Always the possibility of tension Reagan administration: decisions regarding AIDS epidemic George W. Bush administration: criticized for having “made decisions about important public health issues based solely on political considerations, not scientific ones.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5308193/ Obama administration: FDA approvals (e.g., opioid drugs) Trump administration: micro-managing CDC releases Biden administration: COVID-19 mandates/policy, test supply © 2024 Richard M. Carpiano 12 These Create Dilemmas for Public Health What actions can be taken? Most ideal vs. less ideal vs. not ideal What is feasible (practical) vs. ideal given a particular social, cultural, political, historical context? Most importantly: What is the (most) right thing to do? © 2024 Richard M. Carpiano 13 Require Use of Ethical Frameworks 3 Key Frameworks 1. Utilitarianism 2. Deontological (Duty) Ethics 3. Communitarianism Plus Libertarianism The Trolley Experiment is helpful for understanding the first two: https://www.youtube.com/watch?v=bOpf6KcWYyw © 2024 Richard M. Carpiano 14 1. Utilitarianism Focused on maximizing utility (happiness) & minimizing pain Focused on the ends (consequences) and not the motives What is the right (just) action is what secures the greatest good for the greatest number of people Cost-benefit/effectiveness analysis a common tool to assess such utility E.g., Cost of vaccination per each child saves $X in hospitalization cost for that disease © 2024 Richard M. Carpiano 15 2. Deontological (Duty) Ethics Focused on the motive of an action (the means, not the ends) Using reason as a means to guide moral behavior develop principles that can be universalized (used categorically/every time and not situation-specific) that we should do as we would want to be done by/treated Rawls: “Veil of ignorance” thought experiment for a just society: https://www.youtube.com/watch?v=A8GDEaJtbq4 © 2024 Richard M. Carpiano 16 3. Communitarianism Focused on the importance of society in articulating the good life for individuals how shared conceptions of what is good are formed, transmitted, justified, and enforced Acknowledges moral weight of the community while still enabling freedom Recognizes that people: approach their circumstances from particular social identities (citizenship, family tie, community resident) are embedded in obligations based on solidarity, loyalty, historic memory, religious faith have obligations/moral ties that people haven’t chosen © 2024 Richard M. Carpiano 17 How Does Public Health Balance the Rights of Individuals with the Needs of Society? Focus of responsibility differs by the type of risk Self-imposed risk: Risk an individual knowingly and willingly takes on through his or her own actions Wearing a helmet on a motorcycle Imposed risk: Risk to individuals and populations that is out of their direct control Exposure to environmental toxins from a factory © 2024 Richard M. Carpiano 18 No one perspective is always right E.g., Auther reading about COVID-19 Examples: Vaccination policy Water fluoridation Mosquito spraying HIV anti-retrovirals Abortion © 2024 Richard M. Carpiano 19 Public Health Ethics Emphasizes “social” or “public” values reflected in overlapping concepts like: Solidarity Reciprocity Stewardship capture importance of community and duty to take action in the name of population well-being. Different from typically libertarian ethics values like: Autonomy Privacy Anti-paternalism Individual rights and liberties (though still important) © 2024 Richard M. Carpiano 20 What Bioethical Principles Are Used to Address Public Health Issues? A code of ethics has been prepared through the Public Health Leadership Society to guide public health practitioners when making decisions and taking action © 2024 Richard M. Carpiano 21 Principles of the Ethical Practice of Public Health Public health should: 1. address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes 2. achieve community health in a way that respects the rights of individuals in the community 3. have its efforts be developed and evaluated through processes that ensure an opportunity for input from community members © 2024 Richard M. Carpiano 22 Principles of the Ethical Practice of Public Health (cont’d) Public health should: 4. 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. seek the information needed to implement effective policies and programs that protect and promote health © 2024 Richard M. Carpiano 23 Principles of the Ethical Practice of Public Health (cont’d) Public health institutions should: 6. 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. act in a timely manner on the information they have within the resources and the mandate given to them by the public © 2024 Richard M. Carpiano 24 Principles of the Ethical Practice of Public Health (cont’d) Public health programs and policies should: 8. incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community 9. be implemented in a manner that most enhances the physical and social environment © 2024 Richard M. Carpiano 25 Principles of the Ethical Practice of Public Health (cont’d) Public health institutions should: 10. protect the confidentiality of information that can bring harm to an individual or community if made public 11. ensure the professional competence of their employees 12. engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness Modified from Public Health Leadership Society. Principles of the ethical practice of public health. Version 2.2. 2002. http://phls.org/CMSuploads/Principles-of-the-Ethical-Practice-of-PH-Version-2.2-68496.pdf. Accessed March 25, 2017. © 2024 Richard M. Carpiano 26 Applying Bioethical Principles to Protecting Individuals Who Participate in Research The Belmont Report defines the rights of research subjects and outlines 3 basic ethical principles: 1. Respect for persons: Autonomy, protect those with diminished autonomy E.g., children, people who are developmentally disabled, incarcerated persons 2. Beneficence: Do no harm, maximize possible benefits and minimize possible harms 3. Justice: Fairness in distribution of benefits and risks © 2024 Richard M. Carpiano 27  Applying Bioethical Principles to Protecting Individuals Who Participate in Research (cont’d) Institutional review boards (IRBs) must approve most human research before it can begin Created to ensure ethical conduct of research Uses the framework set forth by the Belmont Report to review research proposals © 2024 Richard M. Carpiano 28 Questions? © 2024 Richard M. Carpiano 29