Guide Evaluating the Processes of Neonatal Intensive Care: Thinking Upstream to Improve Downstream Outcomes

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Table of contents

While much work remains to be done to develop the public health potential of human rights analysis Gostin, , a human rights perspective has already become an important part of international health practice. Public health raises a number of moral problems that extend beyond the earlier boundaries of bioethics and require their own form of ethical analysis Callahan and Jennings, Public health is confronted with a wide array of ethical issues and questions, including issues involving: advances in technology and how they will be applied to improve the health of populations e.

The ethical basis for the practice of the health professions has been well studied by both health professionals and ethicists for some time. A statement of public health practice ethics has only recently been produced, and very little attention is paid to public health ethics in educational programs. Few schools of public health have trained ethicists on faculty, despite the fact that 22 of the 25 responding schools of public health report teaching ethics.

To foster appropriate thinking and action. Much of the material in this section is abstracted from the commissioned paper prepared for the committee by James C. Thomas, M.

Callahan and Jennings have described the scope of issues in public health ethics as encompassing four general categories: health promotion and disease prevention, risk reduction, epidemiological and other public health research, and structural and socioeconomic disparities. They further identify different types of ethical analysis: professional ethics, applied ethics, advocacy ethics, and critical ethics, and they encourage all schools of public health to promote the teaching of ethics. This code is based upon certain identified values and beliefs of public health including:.

Public health ethics differs from medical ethics, which is typically concerned with an individual who is ill or disabled. Part of the ethical equation in medicine is whether withholding a treatment is tantamount to failing to rescue a person when rescue is possible. Moreover, the risks of introducing an intervention may be more palatable in view of the suffering that is likely in the absence of the intervention. In the case of public health prevention, 2 however, the person or population is not necessarily ill or disabled, and the potential benefits of an intervention are less salient to those who might experience them.

Seldom do people think, for example, of the illnesses they did not get because they were vaccinated, or the cavities they did not have because the water supply was fluoridated. The hidden nature of some prevention benefits places an extra burden on public health professionals to clarify to the public the benefits of an intervention and how those benefits outweigh the risks of not intervening.

Prevention can be categorized into three types: primary, secondary, and tertiary. Primary prevention, to which this statement refers, is the prevention of an illness or a disability. Secondary prevention is the treatment of a curable illness, and is designed to limit the progression of an illness or a disability. In the case of irreversible conditions, tertiary prevention is prevention of the progression to a more serious illness or disability, or the postponement of death. Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes.

Public health should achieve community health in a way that respects the rights of individuals in the community. Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members. Public health should advocate for, or work for the empowerment of, disenfranchised community members, ensuring that the basic resources and conditions necessary for health are accessible to all people in the community.

Public health should seek the information needed to implement effective policies and programs that protect and promote health. Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community.

Public health programs and policies should be implemented in a manner that most enhances the physical and social environment. Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public.

Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others. Public health institutions should ensure the professional competence of their employees. Reprinted with permission of Am J Public Health , ; —9. The public health focus on populations also differs from the medical focus on interactions between a patient and a care provider.

With a population perspective, public health institutions think in terms of healthy populations and communities as well as healthy individuals. The health of a community includes the quality of interactions among community members consider, for example, the prevention of violence and among institutions serving the community e. A community perspective thus highlights the interdependence of individuals and organizations. This stands in contrast to the importance given to autonomy in medical ethics, in which the concern is principally to prevent a patient from being abused by a care provider who wields much power.

Although personal autonomy remains. Thus, in public health the personal choices and preferences of some will be overridden by a greater concern for the well-being of a whole population.


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Policies and practices affecting a population are typically designed and implemented by government and other organizations, raising the question of how an agency develops and maintains an ethical compass. Is it through policy-making, or, in the case of governmental agencies, through legislation?

Does it include understandings within a community that transcend legislation e. How are ethical conundrums resolved or decisions made in an organization that includes employees with different perspectives and sensibilities? An important part of public health ethics is sorting through ethical issues in a group setting. The combination of a population perspective and institutional action presents a particular ethical danger to public health.

The ability to sympathize with another is a fundamental aspect of being able to think and act ethically towards that person. Personal interactions can lead to sympathy. However, interactions between an institution and a population occur in such a way that sympathy is not a common element of the interaction. To an epidemiologist, the population may be represented as a data set. Even to a public health ethicist, thinking about a population may be an exercise in wrestling with other abstract concepts such as the distribution of scarce resources. All too frequently such an exercise does not stem from direct interaction with those who will be most affected by a decision regarding those resources.

From the perspective of the individual in the community, the public health institution also lacks a human face. In this situation, however, the primary concern resulting from the impersonal nature of the institution is not the ethical treatment of the institution by individuals but the ability of individuals to trust the institution. A widespread absence of trust can severely limit the effectiveness of the institution. Ethical treatment of an individual and community by the institution, however, builds trust.

In this way, the ethical functioning of a public health institution also affects its effectiveness in accomplishing its mission. Public health needs both scholars who can articulate the unique aspects of public health ethics and public health practitioners who understand and operate within the ethics structures of the field. Nancy Kass discusses a six-step ethics framework for public health that can serve as an analytic tool used to help consider ethical implications of. The six steps are as follows:. Thomas, in the paper prepared for this committee, identified seven areas for education in public health ethics.

First, are the values and beliefs inherent to a public health perspective. They are presented on the Web at www. Secondly, education in public health ethics should address ethical principles that follow from the values and beliefs outlined above. The Public Health Code of Ethics consists of 12 ethical principles see Box that address the relationship between public health institutions and the populations they serve.

Other codes of ethics for epidemiology and health education provide additional information more specific to these practices located on the Web, respectively, at www. Public health mandates and powers is another important component of education. Students should understand the legal mandates given to public health institutions and the powers available to them to meet the mandates and the potential abuses of these powers. It is also important to know that the powers of non-public-health organizations, such as some private companies, affect the health of the public and to consider how public health ethics might extend to them.

Further, ethical tensions within public health should be included in an understanding of public health ethics. Some ethical questions arise frequently because of an underlying, irresolvable tension between ethical principles. One that is common in public health is the tension between the need to protect the health of an entire community and the need to honor the rights of individuals in the community. This tension is brought to the fore when an individual claims that a public health regulation violates his or her rights. Examples of how some of these situations have been handled can be helpful in navigating future conflicts.

It is important to review historical ethical failures and triumphs. One ethical failure in public health was the study of syphilis that was conducted by the Public Health Service and the Tuskegee Institute. Students should be aware of this study and what went wrong. It is also important to provide examples of ethical triumphs and more modest failures. Two other areas to include are the history and purposes of research ethics institutions and the application of ethics to specific topics such as informatics and genomics.


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Institutional Review Boards IRBs currently review research proposals to ensure that they are consistent with rules and regulations concerning human experimentation. It is imperative that public health researchers and practitioners know how to interact with such boards and appreciate the value of this review system. In terms of specific topics, much of contemporary practical ethics is driven by new technological developments.

The use of information about individuals that can be managed through sophisticated electronic systems, and in some instances acquired through genetic tools are two that bear directly on public health and affect nearly every public health practitioner. Students need to be informed of the prevalent ethical standards for using these tools.

However, the barriers to teaching ethics are substantial and, if not required, it is likely that ethics will not be taught in any meaningful way. Requiring ethics instruction in the curriculum does not necessarily mean requiring a free-standing course. Conversely, sometimes ethics teaching is best received when it is not billed as ethics.

For example, a course may include instruction in how to interact with community members and thus communicate the importance of community input without appealing to it explicitly as an ethical principle. There are dangers in not creating a free-standing course in ethics, however. In the absence of a required course, individual courses are likely to include an ethics lecture or two. Unless there is some coordination among courses, they are likely to cover similar material.

A look inside Covenant HealthCare's Neonatal Intensive Care Unit