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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.

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