Nancy M. Baum

“Listen to the People”: Public Deliberation About Social Distancing Measures in a Pandemic

Public engagement in ethically laden pandemic planning decisions may be important for transparency, creating public trust, improving compliance with public health orders, and ultimately, contributing to just outcomes. We conducted focus groups with members of the public to characterize public perceptions about social distancing measures likely to be implemented during a pandemic. Participants expressed concerns about job security and economic strain on families if businesses or school closures are prolonged. They shared opposition to closure of religious organizations, citing the need for shared support and worship during times of crises. Group discussions elicited evidence of community-mindedness (e.g., recognition of an extant duty not to infect others), while some also acknowledged strong self-interest. Participants conveyed desire for opportunities for public input and education, and articulated distrust of government. Social distancing measures may be challenging to implement and sustain due to strains on family resources and lack of trust in government.

Ethical Issues in Public Health Practice in Michigan

OBJECTIVES We sought to ascertain the types of ethical challenges public health practitioners face in practice and to identify approaches used to resolve such challenges. METHODS We conducted 45 semistructured interviews with public health practitioners across a range of occupations (e.g., health officers, medical directors, sanitarians, nurses) at 13 health departments in Michigan. RESULTS Through qualitative analysis, we identified 5 broad categories of ethical issues common across occupations and locations: (1) determining appropriate use of public health authority, (2) making decisions related to resource allocation, (3) negotiating political interference in public health practice, (4) ensuring standards of quality of care, and (5) questioning the role or scope of public health. Participants cited a variety of values guiding their decision-making that did not coalesce around core values often associated with public health, such as social justice or utilitarianism. Public health practitioners relied on consultations with colleagues to resolve challenges, infrequently using frameworks for decision-making. CONCLUSIONS Public health practitioners showed a nuanced understanding of ethical issues and navigated ethical challenges with minimal formal assistance. Decision-making guides that are empirically informed and tailored for practitioners might have some value.

Laypersons’ Choices and Deliberations for Mental Health Coverage

Insurance coverage for mental health services has historically lagged behind other types of health services. We used a simulation exercise in which groups of laypersons deliberate about healthcare tradeoffs. Groups deciding for their “community” were more likely to select mental health coverage than individuals. Individual prioritization of mental health coverage, however, increased after group discussion. Participants discussed: value, cost and perceived need for mental health coverage, moral hazard and community benefit. A deliberative exercise in priority-setting led a significant proportion of persons to reconsider decisions about coverage for mental health services. Deliberations illustrated public-spiritedness, stigma and significant polarity of views.

Politics and public health ethics in practice: right and left meet right and wrong.

As public health practitioners are no doubt aware, public health practice and politics are closely linked. Although theoretical discussion of the emerging field of public health ethics has been rich, scholars have paid little attention to the relationship between ethical issues and politics in public health practice. We conducted semistructured interviews with 45 public health practitioners across a range of occupations (eg, health officers, medical directors, sanitarians, nurses, educators, and commissioners) working at 12 local health departments across Michigan and the state health department. Practitioners were asked to describe the ethical issues they faced in their daily practice. Ethical issues that resulted from the political environment emerged as one major category of ethical issues our interviewees described. This article illustrates how political issues engender ethical challenges in 4 main areas: public health agenda-setting, political pressures, political conflicts with best practices, and the scope of public health practice. The findings suggest that politics and public health ethics intrinsically intersect, because political pressures and priorities often impose ethical challenges that practitioners negotiate in their daily work.

Bacterial Pneumonias during an Influenza Pandemic: How Will We Allocate Antibiotics?

We are currently in the midst of the 2009 H1N1 pandemic, and a second wave of flu in the fall and winter could lead to more hospitalizations for pneumonia. Recent pathologic and historic data from the 1918 influenza pandemic confirms that many, if not most, of the deaths in that pandemic were a result of secondary bacterial pneumonias. This means that a second wave of 2009 H1N1 pandemic influenza could result in a widespread shortage of antibiotics, making these medications a scarce resource. Recently, our University of Michigan Health System (UMHS) Scarce Resource Allocation Committee (SRAC) added antibiotics to a list of resources (including ventilators, antivirals, vaccines) that might become scarce during an influenza pandemic. In this article, we summarize the data on bacterial pneumonias during the 1918 influenza pandemic, discuss the possible impact of a pandemic on the University of Michigan Health System, and summarize our committees guiding principles for allocating antibiotics during a pandemic.

Drawing From Freirian Empowerment Methods to Develop and Use Innovative Learning Maps: Increasing Enrollment of Uninsured Children on Detroit's Eastside

In 2001, virtually every child on Detroits eastside was eligible for health coverage, yet approximately 3,000 children remained uninsured. The primary aim of the Eastside Access Partnership (EAP), a community-based participatory research collaboration, was to increase enrollment of uninsured children in state programs. To achieve this aim, one of the approaches that EAP is using is the innovative Learning Map© titled Choosing the Healthy Path, which was developed in collaboration with Root Learning, Inc. Although Learning Maps were originally developed to assist corporations in implementing strategic change, their integration of visualization and interactive dialogue incorporates Freirian principles of empowerment education, making them a viable option for providing meaningful learning opportunities for community residents. This article presents the collaborative process involving the University of Michigan, local community-based organizations, community members, and Root Learning consultants to develop a visual map that enables community residents to understand and overcome the barriers that prevent them from obtaining health insurance for their children.

Deliberative Procedures in Bioethics

Deliberative procedures can be useful when researchers need (a) an informed opinion that is difficult to obtain using other methods, (b) individual opinions that will benefit from group discussion and insight, and/or (c) group judgments because the issue at hand affects groups, communities, or citizens qua citizens. Deliberations generally gather non-professional members of the public to discuss, deliberate, and learn about a topic, often forming a policy recommendation or casting an informed vote. Researchers can collect data on these recommendations, and/or individuals’ preexisting or post hoc knowledge or opinions. This chapter presents examples of deliberative methods and how they may inform bioethical perspectives and reviews methodological issues deserving special attention.

Where are we in the rationing debate

Improved tools and public participation can inform fair systems

ACA Exchange Competitiveness In Michigan: Affordable Care Act Competitiveness

The expansion of Medicaid and the creation of the Health Insurance Marketplace has provided greater access to health insurance coverage for many Michigan residents. To date, Michigans Health Insurance Marketplace has seen relative success, in part due to the presence of multiple regional insurance carriers and the states embrace of managed care in its Medicaid program in the 1990s. This report examines the conditions in Michigans exchange market and analyzes its experience to date with carrier participation, pricing, and provider networks.

Implementing the collaborative care model as part of a countywide initiative

This column describes the planning and implementation of an integrated behavioral health project which was facilitated and endorsed by a developing accountable health community, the Washtenaw Health Initiative (WHI). The WHI is a voluntary countywide coalition of academic, community, health system, and county government agencies dedicated to improving access to high-quality health care for low-income, uninsured, and Medicaid populations. When lack of access to mental health services was identified as a pressing concern, the WHI endorsed pilot testing of collaborative care, an evidence-based treatment model, in county safety-net clinics. Challenges, outcomes, and relevance of this initiative to other counties or regional entities are discussed.