ethics and decision-making in public health …1 ethics and decision making in public health dakota...
TRANSCRIPT
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Ethics and Decision Making in Public Health
Dakota County Public HealthPH Ethics Seminar
October 12, 2016
Lisa M Lee, PhD, MA, MSFrank V Strona, MPH
Presidential Commission for the Study of Bioethical Issues
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The findings and conclusions reported here are those of the speaker(s) and do not necessarily represent the official positions of the Presidential Commission for the Study of Bioethical Issues or the US Government.
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4Outline
Define and describe public health ethics Outline ethics skills for all public health
practitioners Describe a method for resolving ethical
dilemmas
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Let’s Get Started
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7Case: Part 1
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• Is this collection and use of public health data ethically justified?
• Why or why not?• Make your case to
your table.
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Public Health Ethics
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10Defining Terms
What is ethics? Bioethics? Public health ethics?
Why do we care about it?
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11Defining Terms
What is ethics? – Consideration of what is right and wrong– Descriptive: What people view as right and wrong– Normative: What we think we ought to do and why– Meta-ethics: How we know what is right
What is bioethics?– Practical ethics applied to health, medicine, science,
and technology
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12Defining Terms
Public health ethics– Moral governance for public health
• Determines what we ought to do– Application of decision making framework
• Determine course of action when values conflict
Other ‘categories’ of ethics apply in public health– Research ethics (Common Rule, IRB)– Professional ethics (Codes of Ethics)
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13Why We Care about Ethics
PHAction
In public health, we act to prevent morbidity and mortality
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14Why We Care about Ethics
PHAction
What we should do
What we are able to
do What we are
permittedto do
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15Operating Ethical Principles: What Should We Do?
Wide array of tangible expectations that guide what public health practitioners should do– Interfere with liberty as little as possible– Ensure benefits outweigh infringement– Infringe on autonomy only as necessary– Be transparent and accountable – Reduce inequities– Reduce harms & burdens– Respect privacy & confidentiality – Use evidence-based interventions– Focus on fundamental causes of disease
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16Public Health Cares about Ethics
Public Health Accreditation Board (PHAB) requires a process for managing ethical issues– Measure 11.1.2.A “The purpose of this measure is to
assess the health department’s policies and process for the identification and resolution of ethical issues that arise from the department’s program, policies, interventions, or employee/employer relations (emphasis added).”
– Dakota County Public Health Ethics Committee (#2102)
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“Should” Considerations in Clinical Medicine & Public Health Practice
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18Our “Patient”: Who Benefits?
Clinical medicine
Patient is the individual Individual benefits Individual orientation Individual consent
Public Health
Patient is the population Population benefits Community orientation Community engagement
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19Our Approach
Clinical medicine
Medical interventions to cure or treat after a condition occurs
Limited number similarly trained professionals
Public Health
Non-medical means (e.g., policy, law, sanitation, behavior change) to prevent illness and promote health
Diverse practitioners
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20Our Ethical Concerns
Clinical medicine Individual liberty,
autonomy, privacy Beneficence,
nonmaleficence Distributive justice
Public Health Respect for persons Interdependence,
interrelatedness Social good, avoiding social
harm Social justice, human rights
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21Moral Governance for Public Health
Heightened focus on autonomy in clinical ethics over past 40 years is incompatible with health needs of a population
Recognition of merits of pluralistic values– Equity– Reciprocity– Common good– Solidarity– Justice
7 Billion Others
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22Moral Governance for Public Health
Dealing with a public good‒ Shifting from individual to collective‒ Shifting from personal moral compass to ethical
decision making
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23Professional Judgment
Professional judgment is the judgment of the profession,
not the professional.
--Jim Swearengen, DVM (Former Senior Director, AAALAC)
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24Ethics Focus in Public Health
Our shift to community requires a shift in our ethical duty‒ Transparency to nurture trust‒ Pluralism to promote collaboration and participation‒ Focus on community to emphasize that good for
community is often best for self
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25Case: Part 2
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26
• What are the public health ethics dimensions of this case?
• Would you do anything differently now (compared with your first response)?
• Would you justify your position differently?
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Ethics Skills for Public Health Professionals
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28Ethics Skills in Practice
What do we need to know how to do? Four skill domains
‒ Identify ethical dimensions‒ Articulate ethical dilemmas‒ Deliberate a path forward‒ Implement and evaluate
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29Ethics Skills in Practice
Identify ethical dimensions in public health‒ Evidence for what we can do and just reasoning for
what we should do‒ Can this vaccine prevent influenza?‒ Should we require all public health staff to be
immunized for seasonal flu?
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30Ethics Skills in Practice
Identify ethical dimensions in public health‒ Ethical questions are different from personal
preferences and cultural customs‒ Should our department implement casual Fridays?‒ Should we promote employees based on how they
dress at work?‒ Ethical questions also differ from legal questions
‒ Should a child who has not been vaccinated be allowed into school?
‒ Should we force parents to vaccinate their children?
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31Ethics Skills in Practice
Identify ethical dimensions in public health‒ What are the values associated with a public health
action or policy?‒ Are values in conflict?
‒ If not, it might be important to communicate the ethical dimensions of decisions to stakeholders
‒ If so, we have an ethical dilemma on our hands
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32Ethics Skills in Practice
Identify ethical dimensions in public health Articulate the ethical dilemma
‒ Need a working knowledge of our underlying values in public health‒ What values motivate our work?
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33Values That Motivate PH Action
Liberal concepts– Autonomy, noninterference, individual liberty, respect for
persons, and rights Collective concepts
– Obligation, producing benefits, preventing harms, protecting trust, confidentiality, population utility, justice, transparency, relationships, equality, participation, and disparities
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34Move Toward Community Solidarity
Need to consider respect for individual autonomy and our obligation to prevent harm and protect community health
Move from values of liberalism in bioethics toward the collective of community and solidarity in public health ethics
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35Ethics Skills in Practice
Identify ethical dimensions in public health Articulate the ethical dilemma
‒ Identify which of these motivations/values are in conflict, for example: ‒ Individual liberty and social good (e.g., movement
restrictions)‒ Equity and justice (e.g., vaccine subsidies)‒ Public beneficence and individual privacy (e.g.,
public health surveillance)
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36Case: Part 3
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• What are the ethical dilemmas in this case (what values conflict)?
• Discuss with your table to come up with a decision about whether and how to move forward with a plan to reduce diabetes in the city.
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38Ethics Skills in Practice
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39Resolving Ethical Dilemmas
Ethics is a social technology, one for which there are no experts. There is only the possibility of conversation, ideally free of factual mistakes and imbued with mutual sympathy.
-- Philip Kitcher, Science in a Democratic Society (2011) p 12.
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40Ethics Skills in Practice
Identify ethical dimensions in public health Articulate the ethical dilemma Deliberate a path forward
– Method to address an open question– Evidence (scientific, lived experience)– Understanding of values at stake– Diverse perspectives– Mutual respect– Principled reason giving
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41Ethics Skills in Practice
Identify ethical dimensions in public health Articulate the ethical dilemma Deliberate a path forward Implement and evaluate
– Gather evidence– Incorporate new information– Ask stakeholders– Make necessary changes or adjustments– Learn lessons– Use as analogous case in the future
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42Ethics Skills in Practice
Four skill domains‒ Identify ethical dimensions‒ Articulate ethical dilemmas‒ Deliberate a path forward‒ Implement and evaluate
Method‒ Reflective, participatory‒ Multidimensional ‒ Open to revision with new information
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Identify values
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44
Thank you!