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Wednesday, 25 June 2014

Public Health Ethics,Ethical Conflicts, Moral Dilemmas and why is it so hard to tell Right from Wrong?

DrPHealth has looked at public health ethics on a few occasions  July 2011, March 2013  .  Often it helps to look at the same issue with fresh eyes and we were grateful to a group of residents for their analysis of public health ethics.

The presentation went through recent discourses and attempts to establish a solid framework for public health ethics.  Such an endeavor establishes a foundational set of tenets by which public health professionals should have their decisions guided through incorporation of such professional ethics. 

Public Health Ethics: While there is yet concurrence on a public health code of ethics, often included are the biomedical principles of autonomy, beneficence, non-maleficence, and justice.  In some public health versions justice is divided and includes distributive justice, procedural justice, transparency, accountability, and cost effectiveness.  Autonomy is extended to specifically speak to privacy/confidentiality, and within the public health world there is a balancing of harms of benefits across populations sometimes known as utilitarianism.  From that framework one may have the tools to at least begin a discussion.

The Canadian pandemic plan scratched the surface on a response framework ethic and included individual liberty and privacy (autonomy); protection from harm (non-maleficence) and then spoke to other foundational values (an “ethic “) such as the duty to provide care, equity, privacy, proportionality, reciprocity, solidarity, stewardship and trust.  

Two specific other frameworks include Childress (J Law, Medicine and Ethics 30: 169-177) who speaks of key public health ethics do be inclusive of effectiveness (beneficence), proportionality, necessity, least infringement, public justification (justice).   Upshur (CJPH 93: 101-103) spoke of principles for justification of public health interventions to include harm principle (utilitarianism), least restrictive or coercive principle, reciprocity principle, transparency and precautionary.  Similarly Gostin (JAMA 2000 283(23):3118-22) stated that coercion was only justified to avert a harm to others, protect welfare of incompetent persons, and prevent risks to self.

These later frameworks may have benefit in helping guide the actions of the public health practitioner and are driven by ethical outcomes. 

Missing from any ethical framework:  Lacking in any of these frameworks is any consideration, value or principle of the harm to future generations by current actions.  Notably in this omission is the tension that develops in balancing issues involving First Nations where the value of future generations is integral to their life view (ethic). As such, it behooves us to considering expanding existing frameworks with this position in mind.

Professional ethics:  We are also bound by professional ethics established by our professional disciplines.   The CMA, CNA, CDA, CIPHI, Dieticians of Canada, rehab specialists, or a host of other acronymically named organizations purporting to represent the truth of their professional identify, each have established an ethical framework.  Several professions fail to acknowledge the role of their members to the good of society and the public’s health (nursing, medicine and dental are more explicit of such professional roles).  At times the role of the public health professional may be in conflict with that of their professional code of ethics leading to conflicting morals without a clear mechanism of resolution.

Moral dilemmas:  When an individual is faced with a challenge that pits two of their own values against each other, the discordance can lead to considerable angst – sometimes referred to as a moral dilemma.   Grappling with the angst requires access to expertise, strong professional support networks, and a tolerance for ambiguity.

Ethical conflicts: More pointedly though, is that oftentimes public health professionals are faced with conflicts with other just as ethical health professionals, or professionals in other professions who are faced with other values as well.   These situations end up pitting good people against each other who are grounded in their own ethical frameworks.  Such analysis that appreciate the differences between libertarian, liberalism, consequentialism, utilitarian, communitarian, deontological, and a host of other defendable ethical frameworks may not resolve such conflicts, but can form the basis for appreciating the diversity of opinions that may exist. 

While we might like to think that public health trumps all other issues, the reality is that we have yet to argue such a foundational value.  At best we can only hope that by developing a common language we can come to the table and say I respect that your values would have you take this position.  My ethic is such that this is the position that is preferred.  How can we work together to address our conflict?

Good luck.  While ethicists seem confident in their own positions and then can argue the relative virtues of certain courses of action, they all seem to agree that it is not easy.  Expect a tough slog whenever you tread down this path.  However, the ethical public health professional will above all else be able to converse and appreciate some of the ethical principles and issues with which they are faced.

Monday, 23 June 2014

Harm reduction comes of age as both a clinical and prevention service.

One of our favourite blog posts was the analysis of the use of the terms “harm reduction” since the Harper government took power DrPHealth Harm reduction and politics of language June 2012.   It even appears that the government of Canada search engine has been modified to preclude an extension of the analysis by eliminating searches restricted by dates.

Despite the multitude of barriers to harm reduction, use of such services continues to grow at a steady consistent pace.  A BC colleague recently reviewed provincial distribution information noting a consistent annual increase of about 5% per year over the past few years.   For whatever inexplicable reason, such information is not readily available (sic) and would be welcomed to be posted by DrPHealth (email dphealth@gmail.com).

Nonetheless, harm reduction has yet to gain mainstream acceptance as a clinical service.  Perhaps it has quietly been sneaking in the back door. 

A significant obstacle is the language used, with a broad range of activities falling under the single rubric of harm reduction.  Worse, is some people that attempt to redefine fringe clinical services like providing “housing” as a form of harm reduction rather than acknowledging it as a basic prerequisite of health. 

Some key aspects of harm reduction – while often limited to substance use rhetoric, it is sometimes any activity that involves risk for which the risk is being mitigated and not eliminated (seat belts for car occupants, helmets for bikers).  Operationally it seems to also be about an approach that accepts people where they are without judgment or expectation yet this is not part of the definitions in circulation.

Its purposes are many fold.  Initially it was about reducing the spread of transmissible illnesses.  It now includes reducing overdoses, unwanted pregnancy, injuries and illnesses such as liver cirrhosis. Many will see a purpose in harm reduction services as an entry point to develop therapeutic relationships prior to engaging clients in effective definitive treatment.

The tools have also broadened from condoms and needles, to a wide range of materials for which on review there is no taxonomy.  May we at least propose one?

1.       Replacement therapies (methadone, nicotine replacement, alcohol maintenance, other opiate substitues etc.)
2.       Safer materials (condoms, safety gear like helmets, injection supplies, inhalant supplies, naloxone distribution, etc)
3.       Safer environments (safer drug consumption, access in corrections facilities, alcohol tolerant housing etc) 
4.       Population level harm reduction (moving to regulated substances policies, HIV treatment to prevent spread to others)

While the classification is not pure, its purpose is to stimulate the discussion – so please discuss.

On a side note, with the business of harm reduction thriving, a handful of cities are lining up to submit proposals for supervised drug consumption, and for the most part politicians are trying hard to avoid discussions in public forums.   Harper’s   Respect for Communities (DrPHealth review) Act died on the 2013 order paper, only to be inserted into an Act to amend the Controlled Drugs and Substances Act (currently through first reading and known as Bill C-2). (Read the DrPHealth posting on Respect for Communities for what was the predicted course over the past year).

Harm reduction has become an integral component of managing risk, reducing health care system burdens, and part of a continuum of health interventions. While Harper’s government has been effective in muzzling the conversation, those providing the service have done a marvelous job of expanding services as a health intervention and need full commendation for their efforts. 

Well done to those public health workers who have kept the needs of some of the most needy foremost in mind. 

Thursday, 19 June 2014

Celebrating a real live current public health success. Students are making healthier choices.

Either students are learning what questions to not answer on health surveys, or one of the great public health successes of the century is working its way through our schools. 

Yes, many in public health felt that focusing attention on those already engaging in less healthy behaviours was resource intensive and lacked efficacy, so the focus has shifted to raising a healthier generation.

Those efforts are beginning to pay off.  A report of the US  CDC  showing that tobacco smoking in the US is at its lowest level in the past quarter century.  The smoking rates are just one of the gems in the youth behavioural risk surveillance system of the US.  Other good news is that obesity trends are flattening, sexual activity is decreasing, school violence is down almost a half,  and often drug use is decreasing. 

There are a plethora of Canadian resources that further confirm this healthier trend.  CPHO 2011 report  though lacking in key long term trend data. 

BC uses the McCreary study  and are repeated every five years and have better trend data with indications that tobacco, drugs and alcohol are all decreasing, along with healthier sexual activity.  Information on bullying is not as robust

Alberta TAYES studies went through a few iterations http://www.albertahealthservices.ca/2382.asp  before being swept into the Alberta Health Services and also showed some wave over wave improvement at least from 2005-2008

Saskatchewan has been discussing a youth survey for several years

Manitoba undertook surveys in 2009 with data released and 2012 (pending) undertaken by Partners in Planning for Healthy Living 

Numerous health units in Ontario have undertaken local youth behavior surveillance surveys

Quebec did a survey back in 1999 and no more recent surveys were noted thought some regions may have undertaken local surveys. 

Atlantic provinces have collaborated on a survey every five years, most recently in 2012 and province specific information can be accessed at New Brunswick, Nova Scotia, Newfoundland and Labrador, (PEI did not participate in the most recent wave).  The surveys also show general positive health trends.

 For the data geeks out there, there is so much data on student health that can be mined and represented.  Here is merely a taste that students are getting healthier and public health should be celebrating one of its great success of the century – well done colleagues. 

Tuesday, 17 June 2014

Guns set to surpass motor vehicle crashes as US cause of death - rather disturbing

One the most disturbing Tweets in some time.  A graphic produced by the US news group Bloomberg based on CDC statistics and tweeted as

Gun related deaths set to surpass automobile deaths in U.S. in 2015. One is on the rise, other is on the decline. From @michaelshermer

The graphic follows, but the message is clear guns have become as big a threat as the traditional motor vehicle, at least in the US.  Much of the change is attributable to improved safety of cars for which the US has been adamant in its expectations of auto manufacturers and  religious at times in enforcement of driving offenses to ensure safety.

How is it that in the face of such evidence, and the contradictions in philosophies behind two deadly human inventions, that the US continues to zealously strive for reductions in the carnage on the roads while just as fervently arguing for the freedom to carry guns and see them misused.

With Canadian gun death rates at one seventh of the US, and road fatalities actually one half the US rate, it will be sometime before the situation becomes comparable.

Worth a diversion to check out country by country death rates by causes at world Life expectancy  There are a handful of causes of death that Canada and/or the US rank globally as high – explore the general trends.     

Sunday, 15 June 2014

Fathers Day - a reflection on the changing Canadian family

Father’s Day – perhaps better known at the opportunity to restock the supplies of ties, which themselves are an antiquated form of torture, a reminder how close our foreparents were to having a noose around their necks for the least of offenses. 

The day has increased in stature, and Hallmark dutifully produces a unique line of appropriate gift cards (with only a slight hint of corporate capitalism to pad their bottom line). 

There is a trend noted in the 2006 and reaffirmed in the botched 2011 National Household survey, of biologic children from non-continuing marriages which are living with their father. Most notable as a trend is that now up to 21% of where children are living with a lone parent, that the lone parent is the father.    

 For new couples, roughly 8% of children are with their biologic father and step mother.  New to the 2011 survey was more detail on blended family situations for which prior comparisons are lacking. 

Statistics Canada has continued their welcomed trend of releasing special day information of relevance, check on the  Fathers Day  iteration. Of particular note is the gross disparity where 80% of Quebec fathers have or intend on taking parental leave, where outside of Quebec this is less than 10%. 

So to the 8.6 Million Canadian Fathers – Happy Fathers Day, you are not alone.  

Monday, 9 June 2014

Megaregions and the future of Canadian health care services

The era of the Megaregions and ‘Big Health’ has arrived.

The first health regions in Saskatchewan had as few as a few thousand people and clearly were not viable.  Over time the number of regions has gradually diminished as the balance between geography and trying to reflect community needs has been juggled by a handful of individuals sitting in provincial capitals. 

This week Nova Scotia announced the dismantling of the district health boards through an eloquent legal slight of hand.  While effectively maintaining the districts, their boards were all dismissed and replaced a single administrator responsible for all health districts.  Nova Scotia health boards dismissed.  

Alberta dissolved health regions into a single megaregion and have yet to recover or develop an effective operating modality.   With BC now at five regional authorities, Saskatchewan at 12, Manitoba 5 (reduced from 11 late last year), Ontario with 14 LHINs, Quebec at 18, New Brunswick 2,  Newfoundland at 4, (PEI, Yukon, Nunavut also have single boards, NWT has 8) the number  of 67 has gradually diminished over the last decade with a starting position in the hundreds nationally. 

While some provinces also have tertiary level services combined into a provincial health authority or equivalent, even these are getting rolled into the megaregions as politicians recognize the high costs of tertiary services can be mitigated by better primary and secondary services. 

Somewhere someone should be asking two questions

1.       What is the ideal set of size parameters for a health region?
2.       Who is making these decisions on amalgamation and why?

On the first question, New Zealand argued in the 90’s that the ideal population was in the one million mark, and based on performance of many health boards they may have been close in their number.  Given Nova Scotia is just shy of the 1 Million mark perhaps the recent decision makes sense.

The bigger questions is why?  Yes there is a small amount of money to be gleamed by reducing boards and by marginally reducing administrations (although this is questionable).   The developing question is how the health regions now interact with the Ministries of Health.  Or, what exactly are the Ministries of Health now doing?  

As the trend continues we can expect Health regions is be limited to implementation and delivery of services and the buffer between the consumer and the politician, Ministries of Health will not just monitor quality but also increasingly be responsible for program development. By controlling the size and function of the Health regions, Ministers of Health effectively are distanced from the problems at the patient bed or clinic room, but fully in control of what is happening.  It is all about limiting the political liability of health as there is limited political currency to be gained in health. 

Communities are merely been given lip service, non-government organizations are used to fill in on the fringe activities that are politically unpalatable, and the family is being left behind in standardized protocols.  Big “H” health has arrived, driven by the triple bottom lines that include finances, quality and effectiveness of care, and supposed concern about employees.  

Through this the need to modernize public health remains.  Vested in tradition and seeking long term benefits the current public health models lack comparability against waiting times, complication rates, and payback value of less than four years.  

The elephant in all this is the future of primary health care and delivery of physician services.  One can expect these to begin to be rolled into the Megaregions in order to have an even better grasp on the continuum of health services.  This despite the active resistance to such change by the medical community. 

Fasten your seatbelts, the rapidity of change will be increasing, with those not strapped in will be left standing in the sidelines and left behind and unable to influence the direction of the future health system.

Friday, 6 June 2014

Sex and Dying: Health, law and politics

Two stories trending this week with the common theme being governments attempting to provide parameters around health issues.

Nationally, the conservatives have released a trial balloon on the revised criminal code sections related to exchanging money for sex.   This on the heels of a survey of 31,000 Canadians on whom the slimest of majorities (56%) indicated they felt buying sex should be illegal, while of the same group 2/3rds indicate that the sale of sex should not be illegal. Depending on who you read, the government was advised that the survey might well be contrary to current policy directions.

The house was required by the December Supreme court decision to revise sections of the criminal code found not constitutional in December 2013, (see DrPHealth Dec 23, 2013).  One year was provided as grace for the government to response.  Presumably after which the offending sections of the criminal code would be considered not in force. 

Now, when the right leaning National Post writes an editorial denounces the proposed legislation, one can feel confide this balloon was full of lead.  National Post on legal changes  . Given it took 6 months to float this balloon, and the clock is ticking, the government may end up defaulting and not addressing the issues or watch for the sections to be covered off omnibus legislation that the Harper regieme has become renowned for sneaking past Canadians.

Only a few hundred kilometers away, Quebec’s new left leaning Liberal government has been the first to meander into the fray of euthanasia and has adopted an “act respecting the end of life”, and to the credit of Premier Couillard, this is a piece of legislation that has cross party support.  National Post May 30

Expect this one to end up in front of the Supreme Court

Hmmmm – so who is setting health policy in Canada these days? government or the judiciary?