PH Module, Session 1

Public Health Ethics and Health Equity

What is PH Ethics?
“Public health ethics involves a systematic process to clarify, prioritize and
justify possible courses of public health action based on ethical principles,
values and beliefs of stakeholders, and scientific and other information.”
(CDC)

“All the days wherein the plague shall be in him he shall be defiled; he is
unclean: he shall dwell alone; without the camp shall his habitation be”
(Leviticus 13:46)

Isolation of passengers on ships entering Venice and other European cities

for 40 days during the 14th Century
https://www.cdc.gov/os/integrity/phethics/index.htm
Why we need PH ethics
Personal
liberties
and rights

Outcomes
SOCIAL JUSTICE that
benefit the
population
Historical Example
Jacobson v. Massachusetts

Final ruling: “in every well-ordered society charged with the duty of
conserving the safety of its members the rights of the individual in respect of
his liberty may at times, under the pressure of great dangers, be subjected to
such restraint, to be enforced by reasonable regulations, as the safety of the
general public may demand" and that "[r]eal liberty for all could not exist
under the operation of a principle which recognizes the right of each
individual person to use his own [liberty], whether in respect of his person or
his property, regardless of the injury that may be done to others."
Medical vs PH ethics
Medical, clinical, and bioethics focus
• Treatment of disease or injury
• Medical interventions by health professionals
• Individual benefit seeking and harm avoidance
• Respect for individual patients
• Interests of the patient placed over that of the
provider
• Authority based on the prestige and
trustworthiness of the health professional
• Informed consent sought from individual patient
• Justice concerns limited to treating patients equally
and ensuring universal access to health care
Adapted from Ortmann, Barrett et al. 2016
Public health focus
• Prevention of disease and injury
• Range of interventions by various professionals
• Social, community, or population benefit seeking,
and harm avoidance based on collective action
• Relational autonomy of interdependent citizens
• Duty to the community to address health issues
that individuals cannot solve and that require
collective action
• Authority based on law, which is a principal tool of
public health policy for creating health regulations
• Community consent and building a social
consensus through ongoing dialogue and
collaboration with the public
• Central concern with social justice regarding
achievement of health equity
The Institute of Medicine - 1988

“Public health is what we, as a society, do objectively to assure the

conditions in which people can be healthy”.
PH ethics: a balancing act
• Balancing the rights of individuals with positive health outcomes of
communities and populations
• Working in an environment that has a scarcity of resources
• Focusing on health equity as an outcome – rather than health equality
• Working with populations who have different views, beliefs, and values
• Working across different stakeholders, professionals, and communities
PH Ethics: General Ethical Principles
1. Non-maleficence – the obligation to not do harm
2. Beneficence – the obligation to help others
3. Respect for autonomy – the right to self-determination
4. Justice – the fair distribution of health outcomes in a society
• Linked with health equity
Additional values of importance to PH
1. Procedural justice = ensuring public participation and the participation of
affected parties
2. Effectiveness = the programme is effective in protecting public health
3. Privacy and confidentiality
4. Transparency = speaking honestly and truthfully, and disclosing information
5. Trust = building and maintaining public trust
6. Efficiency = the programme is an efficient use of scarce resources
7. Proportionality = the benefits to public health outweigh the infringement of
moral considerations
8. Necessity = there is no alternative programme that is less morally troubling
9. Public justification = degree to which any moral infringements are explained
and justified to the public
10. Least Infringement = the public health action is the least restrictive means
available
Application of an ethical analysis
3-Step Framework1

Step I: Analyse the Ethical Dimensions of the Public Health Issue and
Context
• What are the likely benefits to the population?
• What are the risks, harms, or concerns?
• What are the appropriate public health goals in this context?
• What are the moral norms and claims of stakeholders, and how strong are
they?
1. H Barrett, W Ortmann et al. 2016
Application of an ethical analysis

Step II: Formulate Alternative Courses of Action and Evaluate their Ethical Dimensions
• What are the short- and long-term options, given the assessment of the public health issue and
context in Step I?
• What are the ethical dimensions and tensions of each option?
o Utility: Does the public health action produce the best balance of benefits over harms and
other costs?
o Equity and Justice: Is health equity advanced? Are the benefits and burdens distributed fairly
(distributive justice)? Is there appropriate public participation, including the participation of
affected parties (procedural justice)?
o Respect for Individual and Community Interests: Does the public health action respect self-
determination and human rights, as well as civic roles and community values (e.g.,
trustworthiness)
Application of an ethical analysis

Step III: Provide Justification for a Particular Public Health Decision

• Effectiveness: Is the public health action likely to be effective?
• Proportionality: Will the probable benefits of the action outweigh the
infringed moral considerations?
• Necessity: Is the action necessary (i.e., will overriding a conflicting ethical
norm achieve an important public health goal)?
• Least Infringement: Is the public health action the least restrictive means
available?
• Public Justification: Can decision makers offer public justification in the
political and cultural context that stakeholders, the public, and those most
affected find acceptable?
Case Study

Adapted from H Barrett, W Ortmann et al. 2016

Health Equity

https://www.youtube.com/watch?v=tZd4no4gZnc
Health Equity

https://www.youtube.com/watch?v=MmxS2ZdjmJY&t=69s
 Discuss the following questions

Public What is the ethical question?

Health Ethics What are the relevant facts (scientific and social)?

Group
Exercise Who or what could be affected by the way the
question gets resolved?

What are the relevant ethical considerations?