What to do?

4. 8 month child with pneumonia, tested HIV positive. Mom refuses testing for herself, is 6 months pregnant, and states she cannot tell her husband of her possible HIV positive status as he may leave her. What to do?

5. Ethics and Public Health Richard L. Elliott, MD, PhD, FAPA Professor and Director Medical Ethics Mercer University School of Medicine

6. Goals • A brief history of public health • Ethics in medicine vs. public health • Specific issues in public health ethics

8. Edward Jenner 1749-1823 Smallpox vaccine

11. 1854 Cholera outbreak Broad Street, London John Snow, MD1813-1858

12. 1818-1865 Saviour of mothers Ignaz Semmelweis, MD

13. What is Public Health Ethics? • Morality • What is good or right? • Study of virtue(s) • May be study of philosophical abstractions • Ethics • What is good or right in a profession • Emphasis on right actions, not abstractions • Public health ethics • “Public health is what we, as a society, do collectively • to assure the conditions for people to be healthy.” (IOM,1988) • Health promotion and disease prevention of the population • Medical ethics vs. public health ethics • How are they similar? Different? Might they conflict? • Civil rights, liberties vs responsibilities to the community

14. Examples of Ethical Issues in Public Health • Tuskegee • Quarantining • Fluoridation • FDA • Vaccinations • Contact tracing in STD • Toxic sites • Mental health commitment • Commitment of sex offenders • Tarasoff duties with dangerous mentally ill patients • Is there a right to treatment? • Universal health care • In prisons? • Abortion and contraceptive rights • Public lotteries, gambling, and funding education • Physician-assisted suicide • Bioterrorism and civil liberties

15. Values in Public Health • “Greatest good (health) for the greatest number” • Health promotion and disease reduction • Smoking, obesity, vaccinations • Cost/benefit analyses • Economic • Civil liberties • Medical (e.g., vaccination adverse effects)

16. Medical Ethics vs. Public Health Ethics • Medical Ethics Public Health Ethics • Individuals Populations • Autonomy Democratic input • Beneficence Greatest good for the greatest number • Non-maleficence Benefit-risk analyses • Social justice Social justice

17. Ethics as a Common Professional Bond • Much as the Oath of Hippocrates has bound together physicians for over two thousand years, the principles of public health binds together practitioners of public health • Is there an oath for new graduates of public health?

18. Tuskegee • The Tuskegee Study of Untreated Syphilis in the Negro Male • Do whites and blacks differ in disease course? • Treatment planned, cut due to cost • Participation of Tuskegee Institute, black nurse eased fears among men • Macon County Medical Society, mostly black physicians, agreed to deny treatment • Treatment – arsenic, mercury, ASA, iron, spinal taps – perceived as far superior medical care than usually received • Later, men denied free care for syphilis at PHS clinics • Study continued after Nuremberg and declaration of Helsinki (1964) • Expose 1972 ended the study • $10 million settlement • IRBs established • Legacy of mistrust between blacks and whites in research

19. Tuskegee-like Studies? • Nazi experimentation • Hepatitis and Willowbrook State School • Cancer and Jewish Hospital for Chronic Diseases • Cincinnati radiation exposure experiments

20. Where is Tuskegee Today? • Vulnerable populations and research • AIDS in Africa • Is use of a placebo ethical? • Children • Proxy consents

21. National Research Act • Establishment of IRBs to review all federally funded grants involving human subjects • Common Rule (Title 45 Code of Federal Regulations Par. 46 [45 CFR 46]). • In order for persons (or their legally authorized representatives) to give “legally effective informed consent,” the researchers seeking participation must disclose eight elements of information about the study: • 1. a statement that the study involves research, and description of that research and its purposes; • 2. a description of reasonably foreseeable risks; • 3. a description of reasonably expected benefits; • 4. a disclosure of appropriate alternatives; • 5. a statement about maintenance of confidentiality; • 6. an explanation of possible compensation in case of injury, if the study involves more than minimal risks; • 7. information about how subjects can have questions answered; • 8. and a statement that participation is voluntary.

22. Infectious Diseases II • Notification laws – is it ethical to notify the sexual partner of an HIV infected patient of his/her risk? • Why is it permissible to confine a patient infected with TB but not a promiscuous HIV patient ?

23. Health Promotion and Disease Prevention • Smoking bans • On advertising, smoking in public places • Cost of smoking-related diseases and protection from second hand smoke vs. private rights vs. loss of taxes • Bans on certain trans-fat foods • Sex education • Parental rights and responsibilities vs. public good • Ban on marijuana • Helmet laws

24. Environmental Ethics • Global warming • Nuclear power • Disposal of nuclear waste • Lead • Forced evacuation from toxic sites • Are minorities disproportionately affected by waste dumping, waste burning? • Homer, LA and nuclear enrichment site

25. Recognize this?

26. Toxic Waste, the Environment, and Racism • 2007: “Toxic Waste and Racism at 20” • 69% of people living in proximity to a toxic waste site are persons of color • Persons of color are 1.7-2.3 times more likely to live near a toxic waste site than in non-toxic locations

27. Eugenics and Genetic Screening • Eugenics – “improving” population characteristics through governmental manipulation of reproduction • Mentally retarded • Racial • Genetic testing • Voluntary? • Confidential • Insurance reporting?

28. Analyzing an Ethical Issue • What are the facts: science, epidemiology, medicine? • Who are the stakeholders and decisionmakers? • What are the options? • What are the legal constraints: laws, regulations? • What values/ethical principles ought to apply? • What are the conflicts? • What is the recommended decision?

29. References • Association of Schools of Public Health. Ethics and Public Health: Model Curriculum. ASPH.org • American Public Health Association • S Anand. Public Health, Ethics, and Equity. Oxford U Press, 2006 • R Bayer. Public Health Ethics: Theory, Policy, and Practice. Oxford U Press, 2006

30. Case • 8 month child with pneumonia, tested HIV positive. Mom refuses testing for herself, is 6 months pregnant, and states she cannot tell her husband of her possible HIV positive status as he may leave her.

31. History of Ethics in Public Health • Pre-1847 • “Cito, longe, tarde” • 1847 AMA Code of ethics • A physician is “required to expose his health and life for the benefit of the community” • ASPH Ethics curriculum

32. Ethical Principles of Public Health • 1. Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes. • 2. Public health should achieve community health in a way that respects the rights of individuals in the community. • 3. Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members. • 4. Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all. • 5. Public health should seek the information needed to implement effective policies and programs that protect and promote health. • 6. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation.

33. Infectious Diseases • John Stuart Mill “The only purpose for which power can rightfully be exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, both the physical moral, is not sufficient warrant” • Jacobson v. Massachusetts (compulsory vaccination, 1905): Constitution permits states to enact "such reasonable regulations [to] protect the public health and the public safety and" as long as such efforts did not "contravene the Constitution of United States, nor infringe any right guaranteed or secured by that instrument.”

34. Ethical Principles of Public Health (continued) • 7. Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public. • 8. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community. • 9. Public health programs and policies should be implemented in a manner that most enhances the physical and social environment. • 10. Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others. • 11. Public health institutions should ensure the professional competence of their employees. • 12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.