Transcript Learning Objective 3.1 - Global Health Training Centre

WHO Training Manual
Ethics in epidemics, emergencies and disasters:
Research, surveillance and patient care
Learning Objective 3.1
Identify possible harm and benefit to individuals
and communities resulting from public health
practice and surveillance
Outline
1. Writing Exercise 1
2. Introduction
a) Potential Benefits & Harms
b) Minimising harms
3. Writing Exercise 2
4. Reading and discussion – Swine flu
5. Case Study – sexually transmitted infections
6. Summary
Suggested
time (total
105 min)
Activity
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0-5
(5 min)
6-25
(20 min)
26-30
(5 min)
31-35
(5 min)
36-50
(15 min)
51-60
(10 min)
61-70
(10 min)
71-100
(30 min)
101-105
(5 min)
Writing and
discussion
introducti
on
Writing
Reading
Group
discussion
Class
discussion
Slide
presenta
tion
Case
Summary
study and and
discussion conclusion
Harm in public health
Often viewed as a tension between the
individual and the population.
For example, the harm of violating privacy
must be weighed against the benefit of
public health.
Ethical justification usually requires an
estimation of the probability and magnitude
of the resulting harm.
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Identifying harm
 If harm is something that negates or diminishes
health, the WHO definition of health suggests that
harm could be:
– Physical
– Mental
– Social
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Psychosocial aspects
 Elaborate on the potential types of harm that could
arise within each of these three areas of health.
 What other dimensions of a person are included
within the psychosocial model of human well-being?
 The following diagram provides one answer:
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material
biological
social
well-being
spiritual
emotional
mental
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cultural
Adapted from Williamson & Robinson, Intervention 2006;4(1):4-25
Psychosocial harm
 Public health and humanitarian responses have
traditionally focused on medical, biological and
material needs.
 As psychosocial needs are increasingly recognised
and addressed, the potential for psychosocial harm
needs to be acknowledged and responded to.
 Use the Case Study to identify examples of various
types of psychosocial harms based on the previous
slide’s diagram.
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Moral harm
 The violation of ethical principles, moral virtues and
an individual’s conscience can lead to what is called
moral distress. The sort of harms arising from
mishandled ethical dilemmas could include:
–
–
–
–
–
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Injustice
Dishonesty
Distrust
Loss of respect, either for self or others
Debilitating guilt
One final harm
 Predicting and balancing the potential harms of
various options is always difficult.
 However, a decision not to act, or to allow the status
quo to continue, also runs the risk of allowing harm.
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 ‘Indeed, it remains our ethical obligation to use the
data we collect for public health benefit; not using the
data for improving health must be justified.’
– Lee et al. American Journal of Public Health 2012;102(1):42
 What could be the harm in not using such data?
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Minimising harm in surveillance
 Collect the minimum amount and simplest data to
meet the surveillance goals.
 Engage early with the individuals, families or
communities, especially with sensitive data or
vulnerable populations, including on communication
strategies for findings.
 Use rigorous data protection procedures.
 Act on new evidence as soon as possible.
 Promote transparency, inclusiveness and openness.
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Intervention Ladder
Eliminate choice, e.g. quarantine.
Restrict choice, e.g. make specific vaccinations compulsory.
Guide choices through disincentives, e.g. making vaccination a
requirement for children before enrolment in school.
Guide choices through incentives, e.g. offering free health
screening along with vaccination.
Guide choices through changing the default policy, e.g.
requiring questions about vaccinations at primary care visits.
Enable choice, e.g. provide public programs or facilities.
Provide information, e.g. public information campaign.
Do nothing or just monitor the situation.
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Adapted from Nuffield Council on Bioethics, 2007
Case Study
Records from the sexually transmitted infection (STI) clinic at the largest
general hospital in a southern African country indicate that the segment of
the population self-ascribed as “coloured” has twice as many cases of
STIs as the segment that is self-ascribed as “black”. By contrast, for
almost all other conditions seen in the hospital’s outpatient department,
the number of cases of a disease in each racial and ethnic group is
proportional to that group’s percentage of the general population. Even
after controlling for socioeconomic status, this distinction in the
distribution of STIs remains.
Before the country’s independence, government officials assigned
individuals to one of four racial categories – black, white, coloured, and
Asian. Since independence, an individual’s membership to one of these
racial groups, or a new alternative, “other,” is self-ascribed. Authorities
may investigate an individual’s self-categorization if they suspect them of
self-identifying to a racial group to accrue some particular benefit.
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Case Study
Dr Chingana, director of the STI clinic, believes that the disproportionate
rate of cases in people who have identified themselves as “coloured”,
compared with those who have identified as being “black”, reflects
differences in each group’s biological susceptibility to these diseases: he
is, however, unsure of the underlying mechanism responsible. Dr
Chingana develops a survey designed to link STI symptoms with a variety
of risk factors, including race and ethnicity. He presents his protocol to his
institution’s research ethics committee for approval.
Ms Johnson, a community representative on the committee who selfidentifies as coloured, objects to the inclusion of race as a targeted factor
in the survey. She contends that a finding of higher rates of STI cases in
the coloured population will only serve to reinforce these deeply held
prejudices. Further, she is sceptical of the notion that being coloured
might increase one’s risk of contracting an STI and probes for further
explanation. Do the bacteria behave differently in coloured people? Is
their anatomy different?
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Case Study
Dr Chingana argues that this question is critical to the study. Moreover,
the findings might point to further research that could aid in the
development of programmes for STI control aimed at reducing the high
rate of infection among coloured people.
As used here, “race” refers to a group of people connected by common
descent or origin.
“Ethnicity” here refers to the culture and/or collective identity shared by a
group of people of common descent or origin.
Source: Cash R, Wikler D, Saxena A, Capron A, eds. Casebook on Ethical Issues in
International Health Research. Geneva: World Health Organization, 2009, p. 62.
.
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For Discussion
 How might the different types of harms identified in
the Case Study be minimised?
 How could (or should) these different types of harms
be prioritised in public health surveillance?
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Sources
 Cash R, Wikler D, Saxena A, Capron A, editors (2009) Casebook on
Ethical Issues in International Health Research. Geneva: World Health
Organization; 62
(http://whqlibdoc.who.int/publications/2009/9789241547727_eng.pdf).
 Lee LM, Heilig CH, White A (2012) Ethical justification for conducting
public health surveillance without patient consent. American Journal of
Public Health 102(1):38-44.
 Nuffield Council on Bioethics (2007) Public health: the ethical issues.
London (http://www.nuffieldbioethics.org/public-health).
 Williamson J, Robinson M (2006) Psychosocial interventions, or
integrated programming for well-being? Intervention 4(1):4-25.
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Acknowledgements
Chapter author
O’Mathúna, Dónal, School of Nursing and Human
Sciences, Dublin City University, Dublin, Ireland
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