Ruth Gaare Bernheim

Public Health Ethics: The Voices of Practitioners

Public health ethics is emerging as a new field of inquiry, distinct not only from public health law, but also from traditional medical ethics and research ethics. Public health professional and scholarly attention is focusing on ways that ethical analysis and a new public health code of ethics can be a resource for health professionals working in the field. This article provides a preliminary exploration of the ethical issues faced by public health professionals in day-to-day practice and of the type of ethics education and support they believe may be helpful.

Public health ethics. Public justification and public trust.

Viewing public health as a political and social undertaking as well as a goal of this activity, the authors develop some key elements in a framework for public health ethics, with particular attention to the formation of public health policies and to decisions by public health officials that are not fully determined by established public policies. They concentrate on ways to approach ethical conflicts about public health interventions. These conflicts arise because, in addition to the value of public health, societies have a wide range of other values that sometimes constrain the selection of means to achieve public health goals. The authors analyze three approaches for resolving these conflicts (absolutist, contextualist, and presumptivist), argue for the superiority of the presumptivist approach, and briefly explicate five conditions for rebutting presumptions in a process of public justification. In a liberal, pluralistic, democratic society, a presumptivist approach that engages the public in the context of a variety of relationships can provide a foundation for public trust, which is essential to public health as a political and social practice as well as to achieving public health goals.ZusammenfassungUnter dem Gesichtspunkt, dass Public Health eine politische und soziale Unternehmung ist, entwickeln die Autoren einige Schlüsselbegriffe für einen auf Public Health zugeschnittenen ethischen Rahmen. Dabei zollen sie der Entstehung gesundheitspolitischer Strategien und den Entscheidungen von Amtsträgern des öffentlichen Gesundheitswesens besondere Aufmerksamkeit. Ihr Hauptaugenmerk liegt auf Ansätzen zur Lösung ethischer Konflikte bei Public-Health-Maßnahmen. Diese Konflikte treten auf, weil Gesellschaften neben dem Wert der öffentlichen Gesundheit noch eine breite Spanne anderer Werte haben, die manchmal die Auswahl der Mittel, um Ziele der öffentlichen Gesundheit zu erreichen, einschränkt. Die Autoren analysieren 3 Ansätze zur Lösung dieser Konflikte (absolutistisch, kontextualistisch, präsumptivistisch) und argumentieren für die Überlegenheit des präsumptivistischen Ansatzes. Sie erläutern kurz 5 Bedingungen unter denen präsumptive Annahmen in einem Prozess öffentlicher Rechtfertigung nicht annehmbar wären. In einer liberalen, pluralistischen und demokratischen Gesellschaft kann ein präsumptivistischer Ansatz, der die Öffentlichkeit im Kontext verschiedener Beziehungen beschäftigt, ein Fundament für öffentliches Vertrauen legen, was für Public Health als politische und soziale Praxis sowie für die Erreichung von Gesundheitszielen grundlegend ist.

FACTORES SOCIOCULTURALES QUE INFLUYEN EN LA PRÁCTICA DE LA LACTANCIA ENTRE MUJERES DE BAJA RENTA EN FORTALEZA, CEARÁ, BRASIL: UNA PERSPECTIVA A PARTIR DEL MODELO DEL SOL NACIENTE DE LEININGER

Esta investigacion fue desarrollada para analizar los factores socioculturales que pueden influir en la practica de la lactancia entre mujeres de baja renta en Fortaleza, Ceara, Brasil. Este estudio de observacion utilizo la Teoria del Cuidado Cultural de Leininger para identificar y analizar los factores socioculturales clave. El estudio involucro a 12 gestantes y nodrizas. Usando un formulario de observacion creado de acuerdo con el modelo del Sol Naciente (Leininger), fueron llevadas a cabo visitas en los domicilios de las mujeres y observadas sus condiciones de vida. Las observaciones fueron registradas en el formulario y se sacaron fotografias de las condiciones generales de la morada, de la vecindad y del servicio de salud local. Las condiciones de vida son pobres. La mayoria de las casas tiene refrigeracion inadecuada, problemas estructurales y poco espacio. Eso revela la gravedad de las condiciones economicas de los residentes. Las mujeres observadas en general eran autonomas y vivian con por lo menos un miembro de la familia. Los factores que aparentemente ejercian mayor influencia sobre la decision de las mujeres a favor de la lactancia fueron los economicos y familiares. Se espera que los hallazgos de este estudio lleven a intervenciones mas efectivas y culturalmente apropiadas con objeto de aumentar el inicio y la duracion de la lactancia.

Workshop on Public Health Law and Ethics I & II: The Challenge of Public/Private Partnerships (PPPs)

he issue of public health ethics has received T much attention in recent years and is seen as a new field, distinct fiom medical ethics. Faculty from the University of Virginia, Johns Hopkins School of Public Health, Georgetown University, the University of Minnesota, and others received a grant from the Greenwall Foundation to examine this new field of public health ethics and identi@ the unique principles that distinguish it fiom the study of medical ethics. In the course of that study, which included exploring the field with public health practitioners, a number of distinguishing ethical principles emerged. The moral principles appropriate for public health officials included producing benefits; avoiding, preventing and removing harms; producing a maximum balance of benefits over harms; and distributing benefits and burdens fairly. Ensuring public participation also emerged as a key principle in public health ethics, as did respecting autonomous choices and actions, and protecting privacy and confidentiality. Transparency and building and maintaining trust were also key moral considerations for practitioners. The values emerging from the practice of public health provide a different perspective than that expressed in traditional medical ethics. Focus groups involving members of the National Association of County and City Health Officials (NACCHO), the Association of State and Territorial Health Officials (ASTHO), and the Centers for Disease Control and Prevention (CDC) were included in the exploration of practitioners’ views. In the focus groups, ethical needs were assessed and key ethical challenges were Michael R. Reich, Jody Henry Hershey, George E. Hardy, Jr., James E Childress,

Public Health Accreditation and Metrics for Ethics: A Case Study on Environmental Health and Community Engagement

As public health departments around the country undergo accreditation using the Public Health Accreditation Board standards, the process provides a new opportunity to integrate ethics metrics into day-to-day public health practice. While the accreditation standards do not explicitly address ethics, ethical tools and considerations can enrich the accreditation process by helping health departments and their communities understand what ethical principles underlie the accreditation standards and how to use metrics based on these ethical principles to support decision making in public health practice. We provide a crosswalk between a public health essential service, Public Health Accreditation Board community engagement domain standards, and the relevant ethical principles in the Public Health Code of Ethics (Code). A case study illustrates how the accreditation standards and the ethical principles in the Code together can enhance the practice of engaging the community in decision making in the local health department.

Public Health Ethics: Global Cases, Practice, and Context

Introducing public health ethics poses two special challenges. First, it is a relatively new field that combines public health and practical ethics. Its unfamiliarity requires considerable explanation, yet its scope and emergent qualities make delineation difficult. Moreover, while the early development of public health ethics occurred in a western context, its reach, like public health itself, has become global. A second challenge, then, is to articulate an approach specific enough to provide clear guidance yet sufficiently flexible and encompassing to adapt to global contexts. Broadly speaking, public health ethics helps guide practical decisions affecting population or community health based on scientific evidence and in accordance with accepted values and standards of right and wrong. In these ways, public health ethics builds on its parent disciplines of public health and ethics. This dual inheritance plays out in the definition the U.S. Centers for Disease Control and Prevention (CDC) offers of public health ethics: “A systematic process to clarify, prioritize, and justify possible courses of public health action based on ethical principles, values and beliefs of stakeholders, and scientific and other information” (CDC 2011). Public health ethics shares with other fields of practical and professional ethics both the general theories of ethics and a common store of ethical principles, values, and beliefs. It differs from these other fields largely in the nature of challenges that public health officials typically encounter and in the ethical frameworks it employs to address these challenges. Frameworks provide methodical approaches or procedures that tailor general ethical theories, principles, values, and beliefs to the specific ethical challenges that arise in a particular field. Although no framework is definitive, many are useful, and some are especially effective in particular contexts. This chapter will conclude by setting forth a straightforward, stepwise ethics framework that provides a tool for analyzing the cases in this volume and, more importantly, one that public health practitioners have found useful in a range of contexts. For a public health practitioner, knowing how to employ an ethics framework to address a range of ethical challenges in public health—a know-how that depends on practice—is the ultimate take-home message.