Health ethics in practice :

key issues and challenges

 What are key ethical issues in public
health?
An important set of issues concerns
the relationship between the liberty of the individual
and
broader societal concerns. Other important issues
include
such things as equity, solidarity, social justice,
reciprocity,
and trust.

• public health ethics is a strong commitment to collective action as a

means of protecting individuals and the public from harm and
promoting the highest attainable standard of health.
 What are key ethical issues in public
health?

Individuals have a right to privacy and to freedom of

movement. However, because infectious disease
threatens the health and welfare of others, it may be
legitimate to restrict people’s privacy and liberty in
order to protect others in the community.

• How far may governments go in limiting privacy and freedom of

movement in the name of infectious disease control?
For example,
• With the outbreak of severe acute respiratory syndrome (SARS) in
2002–2003, health officials in both Asia and North America relied on
strategies such as closing schools, cancelling social gatherings, and
quarantining people suspected of being infected. In retrospect, it
became clear that some of these strategies were more extensive than
necessary to address the public health crisis. Yet, where outcomes are
uncertain and potentially catastrophic, liberty-restricting actions may
well be justified by values such as solidarity and reciprocity, provided
that the restrictions are informed by evidence, proportionate to the
threat (see “Proportionality” in the glossary of terms), carried out
humanely and limited to the immediate crisis at hand
Treatment and prevention

Much public health practice and policy is founded on the idea

that prevention is better than waiting for harm to develop and
then focusing on treatment.

The argument in favour of prevention can be a financial

one (it is cheaper), a practical one (when prevention is
possible, why wait to intervene until the disease actually
develops?) or a moral one (a focus on prevention may
reduce overall suffering).
Treatment and prevention

At the same
time, when resources are limited, devoting greater attention
to prevention may take away needed resources from
treatment.

Determining how to allocate scarce resources

between prevention and treatment can therefore raise
difficult
ethical issues related to distributive justice.
 For example,
• scientists working in disease prevention have recently
determined that providing antiretroviral therapy to
people infected with HIV may significantly lower the
risk that they will transmit the virus to uninfected
sexual and needle-sharing partners. However, this
approach may lead to the use of antiretroviral therapy
in persons who do not need it for their own clinical
benefit. Should the provision of antiretroviral therapy
to those who would get sicker or even die without it
take priority over the provision of medication for the
purpose of reducing the risk of transmission? What are
the global obligations to meet the needs of nations
facing these difficult trade-offs?
 Health promotion and equity
• Ill-health related to chronic disease is rising across the world. A large part of
this disease burden is caused by so-called lifestyle choices, such as smoking
tobacco, drinking alcohol, overeating, and not exercising enough. What
ethical obligations do governments have to try to change such behaviour?
For example, we know that smoking is harmful and linked to the death and
suffering of millions of people each year. It is also a deeply entrenched, often
addictive, behaviour. At the same time, autonomous adults generally have
the right to engage in risky behaviour, as long as their actions do not put
other people directly at risk. In this context, to what extent do governments
have an ethical obligation to adopt policies that reduce the harm resulting
from smoking? Should governments use the tax system to deter individuals
from starting or continuing to smoke? Is it acceptable to place limits on the
advertising of tobacco products? Is it appropriate for governments to seek
• to influence the cultural and social factors that may lead some people to
take up smoking? Similar issues arise in other contexts, such as the use of
alcohol and the excessive consumption of unhealthy foods.
What are key ethical issues in clinical
care?

Most health practitioners want to do what is best for their

patients. Non-maleficence (“first do no harm”), beneficence
(doing good) and trust are fundamental ethical principles
at the heart of clinical care.

Health practitioners also

seek to ensure that patients are given adequate
information,
are consenting to treatments and procedures voluntarily,
and have the capacity to understand and appreciate
the potential benefits and risks of the care they receive.

Some common challenges in clinical ethics are outlined next;.

 For example,

• When, if ever, should a clinician’s professional

opinion or treatment recommendation take
precedence over a patient’s right to make a
voluntary and free decision to accept or reject
treatment? Is paternalism (i.e. acting to bring
about something for another individual’s own
good) ever permissible?
 For example,

• What criteria should be used to assess whether

a patient has the capacity to make his or her
own decisions about treatment? How much
preparation and information should a surrogate
or proxy have before making a health decision
for someone else?
 What are key ethical issues in clinical
care?
• Other important ethical issues in clinical care relate to privacy and
confidentiality. These are longstanding values in many cultures.
Privacy and confidentiality should be protected, first because there is
wide agreement that people have the right to control who has access
to their person or to information about them. Secondly, the ability to
provide high quality medical care depends on patients feeling free to
communicate fully and truthfully with their caregivers. Furthermore,
individuals could face stigmatization and discrimination if certain
medical information, such as about sexually transmitted diseases or
mental illness, is not carefully protected. Respecting privacy and
confidentiality carries special importance in an era of electronic
medical records.
 What are key ethical issues of health
organizations and systems?
• Ethical issues arise in the governance and management of health
institutions and systems, particularly where there are competing
stakeholder needs and values. Some examples are given next.

• In some cases, these issues may highlight the challenge of resolving tensions
between different ethical values, such as efficiency, equity and choice. The
decisions made may have significant implications for patients, families, clinicians,
and other key stakeholders.
 For example,
• Resource allocation across health services and
programmes. How should priorities be set to
ensure that resources are allocated fairly and
appropriately to meet the community’s health
needs? How much priority should be given to
disease prevention as opposed to treatment?
In a public health crisis, such as an influenza
pandemic, who should have priority access to
vaccines, drugs, and hospital services? Because
normal health care systems may cease to
function during a severe public health crisis,
efforts should be made to achieve consensus
on these questions in advance.
 For example,
• Corporate partnerships and philanthropic
fundraising. In the face of scarce resources, are
there restrictions on the kinds of funding
sources from which a health institution may
accept support? What if there is a conflict of
interest between the values of the potential
funder and the health institution?
 For example,

• Workplace ethics. What obligations do health

institutions have to their staff to ensure that the
workplace is safe, respectful, and just? What
supports ought to be in place to assist staff at all
levels in dealing with ethical issues in their daily
practice?
• Equitable access. What obligations do health
institutions or systems have to care for the
uninsured, patients beyond their catchment area
or jurisdictional borders, or future patients?
 For example,

• Individual versus population health. How much

priority ought to be given to population health
needs versus individual patient needs, if not all
needs can be met? This question overlaps with the
issues discussed above regarding the appropriate
allocation of resources between prevention and
treatment.
• Public accountability. What obligations do health
institutions and systems have to the communities
they serve to be transparent about how health
resources are used and to reflect community
values in their decisions?
• Organizational and health system ethics are also concerned with the
institutional environment within which decisions are made and the
conditions that contribute to the development of a culture that
supports and reinforces ethical decision-making.
• Accreditation bodies are increasingly emphasizing the importance of
ethical accountability at the highest level of health organizations, are
giving increasing attention to defining the moral attributes and
competencies of ethical leadership and are developing standards to
monitor and evaluate ethical performance of health organizations.