Transcript Ethical Issues in Public Health

Ethical Issues in
Public Health
Marymount University
Eileen Sarsfield, PhD, PHCNS-BC
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Objectives
 Describe
ethical principles in relation to
individuals and populations.
 Discuss nursing traditions and
documents which support social justice
in light of the present market justice
environment.
 Use ethical problem-solving strategies to
address dilemmas related to care of
individuals, communities, and
populations
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Define Ethics
The
philosophical study of
moral values and rules.
The science of human duty in
terms of what is right and
wrong, true or false.
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Ethical Approach to Solving
Health Care Dilemmas
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Bioethics- refers to the study
of ethics as it relates to health
and moral dilemmas.
Ethical dilemma-a situation
characterized by conflicting
rights or obligations.
(Lundy & Janes, 2009)
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Bioethics-The Big Four Principles
These principles are widely used as a
starting point for practical decision making
in clinical professions dealing with
individual cases (biomedical):
 Autonomy- free choice
 Beneficence-doing good
 Nonmaleficence- do no harm
 Justice- fairness
Beauchamp & Childress (2008) Principles of Biomedical Ethics, 6th Edition
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Use in Public Health
 Though
the “Big Four” Principles are
primarily used in clinical practice
addressing individual cases, they can be
applied on a population level.
 In public health practice, principles such
as beneficence often carry more weight
than the principle of autonomy.
 For example, fluoridation of the water
programs
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Population-based Ethical
Principles In Public Health
Consequentialism- What are the goodness or
badness of the consequences? The consequences
of a particular action form the basis for any valid
moral judgment about that action. A form of this is:
Utilitarianism “the greatest happiness/good
for the greatest number of people”. The moral
worth of an action is determined by its
outcome. (John Stuart Mill). To a utilitarian –the
results are paramount.
 Deontology- derives the rightness or wrongness
of an act from the character of the act itself rather
than the outcomes of the action. i.e. murder is
inherently wrong regardless of the situation.
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Community / Public Health
Ethical Principles cont…
 Communitarian
ethics - What can I
do to make society better or does what
I am doing improve society?
◦ Beneficence- The obligation to act in ways that
benefits others
◦ Justice- fair, equitable, appropriate treatment in
the light of what is owed to people.
 Egalitarian
ethics – Stresses equal
access to important social goods; based
on giving primacy to principles of social
justice.
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Principles that Frame the
Right to Health Care
Argument
◦ Often the right to health care is
framed within the communitarian
principle and the principle of
distributive justice which states that
resources should be given first to
those who need it the most.
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The Ethical Principle of Justice
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Social justice: the principle that all persons
are entitled to have their basic needs met
regardless of economic status, class, gender,
race, ethnicity, religion, citizenship, age, sexual
orientation, disability or health. (PHN Scope and
Standards, 2007)
Distributive justice- resources should be
given first to those who need it the most
 Egalitarian justice- equal distribution to
everyone regardless of need (Socialism)
 Restorative justice – payback those
previously harmed by injustice-i.e. Native
Americans
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Social Justice
We lack benchmarks to determine what is
“fair” and what is “unfair”.
 The construct is difficult to teach, practice
or model.
 It is a highly personal idea often
formed/influenced by life experiences.
 In health care it is often interpreted to
mean there is a collective responsibility
for health care.
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Nursing and Social Justice
 Nursing’s
traditional ethos rooted in
the theory of social justice:
Respect for patients
Caring
Compassion
Concern for their well-being
Concern for the poor and vulnerable
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Nursing's’ Policy Statements
Three contemporary documents and
statements about the meaning of social
justice.
 2001 Code of Ethics for Nurses
 2004 Scope and Standards of Nursing
Practice
 2010 Nursing’s Social Policy Statement
 There is an emphasis on individuals rather
than on populations and the common good.
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Social Justice and Public
Health Nursing
Beauchamp (1976) asserted that “the ethical
foundation of public health is social justice”.
 The ANA Scope and Standards of Public Health
Nursing (2007) uses:
Utilitarianism “the greatest happiness/good
for the greatest number of people”.
 Using utilitarianism as a guiding principle for
public health nursing can focus on quantitative
evaluation; justice is considered through the
lenses of who ever happens to be the majority.
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Market Justice vs. Social
Justice in Public Health
Market justice is increasingly influencing
public health nursing through the
partnering of managed care companies
and public health agencies.
 Managed care’s focus on the medical
model, market demands, shareholders
concerns and the individual rather than
on the common good is incompatible
with social justice principles.
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Today’s Challenges to Social
Justice
 Although
public health nurses are
champions of social justice, their
work places embrace bureaucracy,
standardization, individual care and
medical models.
 A market driven health care system
challenges us to study, analyze and
discuss social justice.
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Major Ethical Tensions in
Public Health
Individual and Community Rights. Perhaps
the clearest example of an ethical tension in
public health is the balancing of individual and
community rights when a person is discovered
to have a communicable disease.
 Weighing Benefits, Harms, Risks, and
Costs. All public health interventions require a
balancing of benefits versus harms and costs.
Vaccination campaigns always have an associated
risk of harm because of adverse reactions to
the vaccine.
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Public Health Ethical
Dilemmas
Typhoid Mary
AKA Mary Mallon
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Public Health and the State:
Beneficence or Paternalism?
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The formation and enforcement of public
health policy is a government function.
Many public health interventions, such as
water fluoridation and mass vaccination
programs certainly have benefits, but respect
for autonomy may be undermined.
When the state does something to protect
people, some may hold different values and
feel that the state is acting paternalistically
toward them.
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Community/Public Health:
Ethical Decision Making
Kass Six Step Framework:
 What are the public health goals of the
proposed program?
 How effective is the program in achieving its
stated goals?
 What are the known or potential burdens of
the program?
 Can burdens be minimized? Are there
alternative approaches?
 Is the program implemented fairly?
 How can the benefits and burdens of a
program be fairly balanced?
(Lundy & Janes, 2009)
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Ethical Decision Making:
Common Themes or Models
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Clarification of the ethical dilemmagather data
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Determine if an ethical principle/s can
guide the decision making process
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Evaluate options- unpack the elements
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Seek advice if possible
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Justify the position and act on it
(Lundy & Janes, 2009)
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Summary
Nurses have opportunities to participate
in ethical decision making with individuals,
families and communities.
 Understanding the principles of ethical
theory and decision making provides us
with a starting point and a framework for
developing our own set of beliefs that will
guide us in the practice of nursing.
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