Ethics in Public Health, Health Care, Health Research and

the Biomedical Sciences

Hatem El-Dabbakeh, DrPH

University College of Ability Development - PRCS

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.

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

What is Public Health Ethics?

• A systematic approach to balancing competing interests and

providing justification for public health policies and decisions.

– Often individual rights of autonomy and privacy v.

community interests and responsibilities

• “Public health law provides authority to place significant

restrictions on individuals; the law describes what public health

can do, Public Health Ethics helps in determining what public

health should do.”

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, DOTs vs. DOTS Plus

Aging and chronic diseases

Genetically modified foods

Technology and resource allocation

Stem cell research

The Case-for-Action

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 for 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 – disasters, genocide

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

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?

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

PH Law and Ethics o Gov’t obligation to protect health of the population

o Power of government to legislate, tax, spend, regulate, punish

o Restriction of personal and business liberties e.g. seat belt laws;

smoking restrictions vs. human rights

o Economic, social impact of intervention vs. non-intervention e.g.

inequities of the poor and rural

o Laws enacted by legislative bodies

o Court decisions

o Public scrutiny

o Accountability

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

Individual and Community PH Ethics Individual Community

• 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

• 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

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

The New Public Health

o Sanitation, environment, infectious disease control

o Managing health systems and resources

o National target e.g. reduce stroke mortality

o Health promotion e.g. food fortification, smoking restriction

o Health education e.g. nutrition, exercise, self-care

o Personal preventive services e.g. hypertension, MI, CHF, diabetes

o Clinical standards, guidelines e.g. AMI, diabetes

o Ambulatory and home care

o Long term care

Principles of the Ethical Practice of Public Health: Code of Ethics

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 for, or work for the empowerment of,

disenfranchised community members, ensuring that the basic

resources and conditions necessary for health are accessible to all

people in the community

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

collaboration and affiliations in ways that build the public’s trust

and the institution’s effectiveness