Ethical Issues and Challenges in Public Health

Public health is concerned with preventing disease, prolonging life, and promoting health. Public health is usually viewed as a broad social movement, a way of asserting social justice, value and priority to human life. Public health professionals operate in an ethically complex environment. There are tensions between achieving benefits for whole populations and protecting individual’s rights, also epidemiological data collection can conflict with the right to privacy. Health promotion interventions may be paternalistic or intrusive. Resources for public health also compete with other legitimate demands.

Challenges and Ethical issues in public health

The following are identified challenges and ethical concerns in public health

1) Determining appropriate use of public health authority vis-a-vis economic impacts

2) Making decisions related to resource allocation.

3) Negotiating political interference in public health practice.

4) Ensuring standards of quality of care.

5) Decision-making vis-a-vis questioning the role or scope of public health.

6) Measure and values.

7) Surveillance versus cure.

Brief description of the listed items:

Determining appropriate use of public health authority vis-a vis economic impact: Public health practitioners have substantial authority to limit individuals’ freedom and privacy or to affect the economic viability of businesses in a community. Public health regulations affect the industries (e.g. tobacco), those paying for the public health benefits may not necessarily be the beneficiaries (e.g. regulatory actions for worker safety raising costs to consumers), people may not be willing to pay costs for benefits that would accrue in the long future (e.g. measures to limit global warming) and it is easier to calculate current costs incurred for public health than the benefits that would come later.

Other examples come to mind when determining the appropriate use of public health vis-a-vis economic impact. Studies have shown that several health officers and environmental health workers discussed the complex determinations they must make to decide, for example, when to close a contaminated beach that is an important source of tourism revenue in an area. Nurses and medical directors expressed a similar need to weigh public health gains vis-à-vis restrictions on autonomy when considering partner notification or mandating treatment for infectious diseases. Many more examples can be listed in literature.

Making decisions related to resource allocation: The need to allocate limited public health resources, including program funds, personnel effort, and scarce products, requires practitioners at all levels to make difficult choices among competing programmes and population groups. There may be difficulty apportioning scarce products, such as annual influenza vaccine, despite extant federal guidelines. Many practitioners encounter challenges maintaining adequate staffing levels in clinics or determining how best to spend their own time among competing programmes. Some factors are considered to be inappropriate allocations, such as spending enormous resources in one area in the face of unmet needs in another. There is also the challenge of struggling to determine whether it was best to expend resources today or save resources for future public health needs. For example if many local health departments offered health plans for the uninsured in their communities, it becomes the task of the commissioners, health officers, and others to decide what proportion of the uninsured in their communities should be eligible for the care provided.

Negotiating political interference in public health practice: Negotiating tensions that emerge from political oversight of public health practice proves to be ethically challenging for many practitioners. Individualistic societies resist the notion of public health‘s concern for the collective. Such tensions create pressure to bend the rules or sacrifice best practices.

Some practitioners, for example, struggle with political pressure to allow noncompliance with environmental health regulations by a local politician or prominent constituent. Others have political pressure to perform duties in ways that were inconsistent with scientific evidence or to maintain programmes because they addressed the ―issues of the day‖ rather than the issues of greatest health need in their communities. In this view, politics conserves the broad vision of public health and prefers it to limit into a technical enterprise focusing on controlling communicable diseases and a safety net providing medical care to the indigent. There should be a limit to political pressures for the purpose of improving community health.

Ensuring standards of quality of care: Practitioners experience a strong commitment in ensuring and maintaining quality care across different populations. There is professional obligation to do what is perceived to be ―right, even in the face of resource limitations or program constraints. Previous studies revealed that Practitioners, particularly those providing direct patient care, described the ethical tensions they experienced when compelled to provide lower-quality care to certain populations because of programme rules or limited resources. For example, practitioners in family planning clinics can provide birth control medications only from sample stockpiles and are prohibited from prescribing other medications that may be better suited for their patients. Also, there is a dilemma in cost benefit analysis – the difficulty of valuing life, and values to be assigned for the rich versus the poor.

Decision-making vis-a-vis questioning the role or scope of public health: Practitioners may share a macro level concerns about what the public health system should do and what functions or services it should provide. To some practitioners, the central duty of public health is to provide protection against infectious disease and other health threats for all members of a community; to others, public health properly includes providing safety net services to the most vulnerable. Practitioners sometimes perceive a disconnect between their view of the appropriate mission, role, or scope of public health and the types of services that were being provided in their communities.

The public health practitioner may be involved in deciding which is more needed to attend to between paternalism and libertarianism. Paternalism involves restriction on individual behaviour for protecting their health (e.g. enforcing seat belts) libertarianism claims that the only purpose for which power can be rightfully exercised over any member of a civilized community against the person‘s will is when his act harms others (e.g. regulating drunkenness) and may even make others lose their lives especially when they drive.

The development and application of formal frameworks may be one method of encouraging thorough and rigorous ethical analysis and decision-making. Such tools may help to unmask normative assumptions and may be an important addition to economic or other methods of analysis for decision-making.

Measure and values: Some public health measures are not acceptable on religious and moral grounds, (E.g. sex education and distribution of contraceptives and/or condoms to adolescences). Also, health authorities deciding on values and choices of those they serve (e.g. whether someone should not take the responsibility on behaviour causing ill health such as smokers, alcoholics, promiscuous 41 people),decision on whether to emphasize HIV/AIDS prevention versus anti- retroviral (ARV) therapy in poor countries.

Surveillance versus cure: This involves hoe to deal with sick subjects identified in routine survey/data collection and the extent of providing access of benefits to research subjects.

 Public Health Values

Many academics and practitioners perceive a philosophy of social justice to be foundational in public health. Practitioners in the field of public health have attributed the values underlying their decisions and actions to commitment to the concept of fairness; an important element in any construct of social justice. The term fairness takes on a wide variety of meanings which include equal treatment across population groups, provision of services to those in greatest need, and expectations that individuals pay their fair share for services according to their abilities. Several practitioners have emphasized the importance of having evidence to support programming decisions and of using public dollars efficiently. Others emphasized the importance of respecting individuals’ autonomy or including community values in programme decisions.

These values are not necessarily inconsistent with social justice and utilitarianism, but they nonetheless portray a complex and heterogeneous set of values articulated by practitioners. To be able to practice public health effectively, work through and resolve problems, practitioners may depend almost exclusively on their own experiences and judgment and informal consultation with others.

All professionals in positions of responsibility must make independent judgments during the course of their daily work; however, it is important to consider whether practitioners’ individual moral compasses can suffice when they are responsible for community-level health. Clearly, professional experience—working through ethical challenges in numerous situations over time—builds an arsenal of knowledge and insights on which to base future decisions.

Yet public health goals may call for practitioners to look beyond the realm of their own experiences and moral foundations to ensure that public health outcomes are a just outcome for all involved; that is, that the benefits and burdens of outcomes are equitably distributed in the population.

Utilitarianism alone is unlikely to provide an adequate account of public health ethics, other considerations are necessary. Identifying the sources of ethical tension among public health practitioners may create new opportunities to reduce or manage those tensions. There is the need in building links between ethical analysis and the practical work of public health.