Ethics in Public Health: Principles and Applications, Study notes of Ethics

Download Ethics in Public Health: Principles and Applications and more Study notes Ethics in PDF only on Docsity! Definition of Ethics (1) • The discipline of dealing with what is good and bad, with moral duty and obligation • A set of moral principles or values • The principle of conduct governing an individual or group • Webster’s Ninth New Collegiate Dictionary Definition of Ethics (2) A Dictionary of Epidemiology, 4th ed, 2001 (J.M. Last (ed)) The branch of philosophy that deals with distinctions between right and wrong – with the moral consequences of human actions PRINCIPLES OF ETHICAL PRACTICE OF PUBLIC HEALTH (2) • PH should base policies on evidence • PH should obtain community consent for implementation of policies/interventions • PH should respond to health problems in a timely manner • PH must respect diverse values, beliefs and cultures PRINCIPLES OF ETHICAL PRACTICE OF PUBLIC HEALTH (3) • PH programs should enhance the physical and social environment • PH should protect the confidentiality of individuals and communities whenever possible • PH must assure the professional competence of their employees • PH should engage in collaborations that build public trust and their effectiveness (e.g., NGOs) PRINCIPLES OF PUBLIC HEALTH • Interdependence of individuals is the essence of community • The health of the individual is tied to their community PHILOSOPHY OF PUBLIC HEALTH (3) • Scientific evidence should provide the basis for policy decisions • It is unethical to approve and support poor quality research • In the absence of scientific evidence PH values should inform policy decisions • Given the necessary knowledge and essential resources individuals will act responsibly PUBLIC HEALTH AND POWER • The need to use power to ensure health • What should be the limits of that power? PUBLIC HEALTH ACTION (1) • The quandry of Human Rights! Incarceration of infectious individuals; e.g., “Typhoid Mary” Quarantine of contacts (China H1N1) • Right to privacy vs. mandatory disease reporting (STDs, HIV) • Persuasion vs. coercion vs. manipulation ETHICS The ethics of taking action vs. the ethics of avoiding action ETHICAL CONDUCT OF RESEARCH Justification of Research in Humans (1) • Impossible to reach the important conclusions without studying humans  Human physiologic studies, because  animal responses often are not the same  Epidemiological studies, because they they depend on human susceptibilities and human interactions  Agents for treating humans because animal experiments don’t always predict results The Nuremberg Code (World War II) • Informed consent is absolutely essential • Qualified researchers must use appropriate research designs • There must be a favorable risk/ benefit ratio • Participants must be free to stop at any time The Declaration of Helsinki World Medical Association (1964, 1975, 1983, 1989, 1996, 2002) • “The well-being of the subject should take precedence over the interests of science and society” • Consent should be in writing • Use caution if participant is in dependent relationship with researcher • Limited use of placebo, especially if treatment is available • Greater access to benefit once research is concluded The Belmont Report (The U.S. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1978) Ethical Principles and Guidelines for the Protection of Human Subjects of Research: Respect for persons Beneficence Justice Basic Principles of Research on Human Subjects (1) • Respect for persons Choices of autonomous individuals should be respected People incapable of making their own choices should be protected Voluntary subjects need adequate information for informed decision-making Basic Principles of Research on Human Subjects (2) • Beneficence Participation in research is associated with a favorable balance of potential benefits and harms Maximize possible benefits, minimize potential harm Basic Principles of Research on Human Subjects (3) • Justice Participation in research is associated with a favorable balance of potential benefits and harms May not exploit or exclude vulnerable individuals who may benefit without good reason Risk and benefits must be shared by all (e.g., poor and wealthy) TWO CASE STUDIES CASE 1: CLINICAL TRIAL TO PREVENT MATERNAL/CHILD TRANSMISSION OF HIV • Without treatment, 30+% of infants born to HIV-infected mothers will be infected • Long-term treatment used in rich countries costs several thousand dollars per mother • Poor countries cannot afford long-term treatment • Can short-term treatment reduce transmission? CLINICAL TRIAL TO PREVENT MATERNAL/CHILD HIV TRANSMISSION Ethical issues • Is a trial of short-term treatment ethical when it is known that long-term treatment is effective? • Is it ethical to have a control group? • What should the control group receive? • What are the ethical responsibilities of the investigator towards participants, particularly in the control group? PRE-EXPOSURE PROPHYLAXIS Ethical concerns • Is a clinical trial in poorly educated sex workers in a developing country exploitation? • Should there be a control group? • What should the control group receive, if anything? • What responsibility does the investigator have for sex workers who become infected? Cohen J: Cambodian leader throws novel prevention trial into limbo. Science 305:1092, 2004. SEX WORKER DEMANDS • Lifetime care if she becomes HIV-infected or suffers side-effects • Health insurance for 30 years • More counseling • Free female condoms