Public Health Ethics: Cases Spanning the Globe

Abstract

Public health ethics can be seen both as the application of principles and norms to guide the practice of public health and as a process for identifying, analyzing, and resolving ethical issues inherent in the practice of public health. Public health ethics helps us decide what we should do and why. Although the practice of public health has always considered ethical issues, the emergence of public health ethics as a discipline is relatively new. Although rooted in bioethics and clinical and research ethics, public health ethics has many characteristics that set it apart. The defining characteristics are its focus on achieving social goods for populations while respecting individual rights and recognizing the interdependence of people. Currently there are few practical training resources for public health practitioners that consider ethical issues and dilemmas likely to arise in the practice of public health. In public health ethics training, we have found it advantageous to use cases to illustrate how ethical principles can be applied in practical ways to decision making. The use of cases encourages reflection and discussion of ethics, reinforces basic ethical concepts through application to concrete examples, highlights practical decision making, allows learners to consider different perspectives, and sensitizes learners to the complex, multidimensional context of issues in public health practice. The case-based approach (known as casuistry) contrasts with the theoretical approach to considering moral principles, rules, and theories. By describing scenarios, cases allow the learner to use ethical principles in the context of a realistic situation that sheds light on ethical challenges and illustrates how ethical principles can help in making practical decisions. This casebook comprises a broad range of cases from around the globe to highlight the ethical challenges of public health. For those new to public health ethics, Section I introduces public health ethics. Chapter 1, “Public Health Ethics: Global Cases, Practice, and Context” by Ortmann and colleagues, summarizes basic concepts and describes how public health ethics differ from bioethics, clinical ethics, and research ethics. The chapter also includes an approach for conducting an ethical analysis in public health. In Chap. 2, “Essential Cases in the Development of Public Health Ethics,” Lee, Spector-Bagdady, and Sakhuja highlight important events that shaped the practice of public health and explain how practitioners address and prevent ethical challenges. Section II is organized into chapters that discuss the following public health topics: • Resource allocation and priority setting • Disease prevention and control • Chronic disease prevention and health promotion • Environmental and occupational public health • Vulnerability and marginalized populations • International collaboration for global public health • Public health research We have invited some of the leading writers and thinkers in public health ethics to provide an overview of the major ethical considerations associated with each topic. The topic overviews offer the authors’ perspectives about applicable ethical theories, frameworks, and tools and draw attention to the cases that follow. The cases are meant to highlight the ethical issues in practice. Each represents the work of authors from around the globe who responded to a solicitation from the U.S. Centers for Disease Control and Prevention. We worked with the authors to ensure that each case included a concise articulation of a public health situation that raises ethical tensions, challenges, or concerns that require decisions or recommendations from public health officials or practitioners. The cases are presented in a standard format that includes a background, case description, discussion questions, and references. However, we also allowed for variation in the amount of detail provided in each section and the approach used to set up the case. Our goal was to include just enough contextual information to orient the reader who is not an expert in the case topic. We include the case setting, population, or intervention in question, legal or regulatory landscape, and questions to stimulate discussion on core ethical issues. Each case—although fictionalized—is as realistic as possible to reflect the ethical challenges that public health practitioners face daily. Sometimes the cases were based on actual or composite events. In these instances, the case details were modified to exclude identifying information that could be considered private, sensitive, or disputable by others involved in the case. We deliberately did not attempt to provide a resolution or solution for the cases. Often in public health practice, there is no single correct answer. Instead, ethical analysis in public health is a process to identify the ethical dimensions of the options available and to arrive at a decision that is ethically justifiable, through deliberation and consideration of relevant facts, values, and contexts. The cases and other writings in this book represent the opinions, findings, and conclusions of the authors and do not necessarily reflect the official position, views, or policies of the editors, the editors’ host institutions, or the authors’ host institutions. We decided which topic category to place the case in to best distribute the cases across chapters. However, you may note that some cases cross topic areas and could just as easily have been included in another chapter. This casebook is written for public health practitioners, including frontline workers, field epidemiology trainers and trainees, and managers, planners, and decision makers with an interest in learning about how to integrate ethical analysis in their day-to-day public health practice. However, the casebook will also be useful to instructors in schools of public health and public health students as well as to academic ethicists who can use the book to teach public health ethics and distinguish it from clinical and research ethics. Our hope is that the casebook will increase awareness and understanding of public health ethics and the value of ethical analysis in public health practice in all of its forms. This includes applied public health research; public health policy development, implementation, and evaluation; and public health decision making in national and international field settings and training programs. By emphasizing prospective practical decision making, rather than just presenting a theoretical academic discussion of ethical principles, we hope this casebook will serve as a useful tool to support instruction, debate, and dialogue about the nature of ethical challenges encountered in public health practice and how to resolve these challenges. We recommend discussing the cases in small groups and using the discussion questions, the ethical framework described in Chap. 1, and the information provided in the topic area overview sections as a starting place for exploring the ethical issues reflected in the cases. The ultimate goal of case-based learning is to develop skills in ethical analysis and decision making in daily public health practice. The ethical framework provides a convenient tool for putting our ideas into practice.