this presentation was part of the Public Health Course at the University of Palestine, Health Administartion Department

1. Ethics in Public Health, Health Care, Health Research and
the Biomedical Sciences
Hatem El-Dabbakeh, DrPH
University College of Ability Development - PRCS
Universal Declarationof Human Rights, 1948 Article25.
Everyone has the right to a standard of living adequate for the
health and well-being of himself and of his family, including
food, clothing, housing and medical care and necessary social
services etc.
Helsinki Declaration1964 (World MedicalAssembly 1964 to present)
Privacy and integrity of individual protected, Adequate
informed consent, Research for valid scientific benefits
Accepted scientific principles, Benefits outweigh risks
Publication, Protect control group, Individual well-being
vs. needs of science and society
What is PublicHealthEthics?
• A systematic approach to balancing competing interests and
providing justification for public health policies and decisions.
– Often individual rights of autonomy and privacy v.
community interests and responsibilities
• “Public health law provides authority to place significant
restrictions on individuals; the law describes what public health
can do, Public Health Ethics helps in determining what public
health should do.”

2. Why StudyEthics in PH
 Many issues of conflict between good of the individual and good of
society
 Immunization, chlorination, fluoridation
 Food fortification
 HIV/AIDs, DOTs vs. DOTS Plus
 Aging and chronic diseases
 Genetically modified foods
 Technology and resourceallocation
 Stem cell research
 The Case-for-Action
Ethics in PH
 Moral imperative of PH to ensure and protectthe health of the
population and the individual
 Ethical foundations traditionally implicit in PH
 The right to health
 Responsibility for population health
 Renewed awareness of and accountability
 Conflict between individual and community rights
 Effects of doing or not doing public health interventions or “best
practices”
 New issues all the time – disasters, genocide
When and When Notto Act
 Public (community) right to protection and bestavailable standards

3.  Dangers/costs of not acting exceed those of acting
 Judgment, experience, evidence, ethics
 Experience of Good Public Health Practice (GPHP)
 Threats of preventable mortality or risk factors
 Public right to know
 Individual rights
 Balance of contradictions
 Accountability, transparency
Basic Questions
 Does society’s responsibilities = paternalism?
 Does freedom of individual = rejection of responsibility of the state
in health?
 Do we need informed consent for all PH interventions?
 Do individual rights over-ride social responsibility? E.g. AIDS
contact tracing
 “Precautionary Principle” = must prove zero risk of an new
medication or PH intervention?
 Equity in health?
 Adequacy of funding and its allocation?
Old-New Battles

UK Variolists opposevaccination vs. smallpox C19th
 US Opposition to public health departments in 1920s
 UK GPs opposeimmunization with pertussis (1980s) and MMR
(2002+)
 AMA opposesto national health insurance 1920s +

4.  Civil rights vs. HIV control, 1980s US
 Anti-fluoridation 1950s to present
 Resistance to innovations e.g. MMR, Hib, Pap smear
 Anti-food fortification in Europe
 Anti-genetic engineering of food in Europe
PH Law and Ethics
o Gov’tobligation to protecthealth of the population
o Power of government to legislate, tax, spend, regulate, punish
o Restriction of personal and business liberties e.g. seat belt laws;
smoking restrictions vs. human rights
o Economic, social impact of intervention vs. non-intervention e.g.
inequities of the poorand rural
o Laws enacted by legislative bodies
o Court decisions
o Public scrutiny
o Accountability
Individual Rights and PH Ethical Issues
 Right to quality health services
 Provider responsibility to act for benefit of client
 Euthanasia - right to die
 Confidentiality – right to privacy
 Informed consent – right to know
 Birth control – religion vs. individual rights
 Supply and distribution of resources for health
 Incentives - disincentives

5.  Equity – social, ethnic, regional
 Social solidarity
Individual and Community PH Ethics
Individual Community
• Personal hygiene
• Immunization
• Right to health care
• Self-care
• Choice of provider
• Right to know
• Right to die
• Confidentiality
• Privacy
• Informed consent
• Patients' Bill of Rights
• Sanitation
• Herd immunity
• Universal access
• Education
• Gatekeeper function
• Mandatory reporting
• Case follow-up
• Resources for health
• Costcontainment
• Equity
• Minority and special groups
• High risk groups
Groups at SpecialRisk
 Women
 Children
 Civilians in war and terror situations
 Disaster victims
 Native peoples
 Minority groups
 Prisoners
 Military
 Refugees and internal migrants

6.  Mentally ill
 Rural vs. urban
The New Public Health
o Sanitation, environment, infectious disease control
o Managing health systems and resources
o National target e.g. reduce stroke mortality
o Health promotion e.g. food fortification, smoking restriction
o Health education e.g. nutrition, exercise, self-care
o Personal preventive services e.g. hypertension, MI, CHF, diabetes
o Clinical standards, guidelines e.g. AMI, diabetes
o Ambulatory and home care
o Long term care
Principles of the Ethical Practice of Public Health: Code of Ethics
1. Public health should addressprincipally the fundamental causes of
disease and requirementsfor health, aiming to prevent adverse
health outcomes.
2. Public health should achieve community health in a way that respects
the rightsof individualsin the community.
3. Public health policies, programs, and prioritiesshould be developed
and evaluated through processesthatensure an opportunity for
input fromcommunity members.
4. Public health should advocate for, or work for the empowermentof,
disenfranchised community members, ensuring that the basic
resources and conditionsnecessary for health are accessible to all
people in the community

7. 5. Public health should seek the information needed to implement
effective policies and programsthatprotectand promote health
6. Public health institutions should providecommunitieswith the
information they have that is needed for decisions on policies or
programsand should obtain thecommunity’sconsent for their
implementation.
7. Public health institutions should act in a timely manner on the
information they have within the resourcesand the mandate given to
them by the public
8. Public health programsand policiesshould incorporate a variety of
approachesthat anticipateand respect diverse values, beliefs, and
culturesin the community.
9. Public health programsand policiesshould be implemented in a
manner thatmost enhances the physical and social environment.
10. Public health institutions should protect theconfidentiality of
information thatcan bring harm to an individualor community if
made public. Exceptions must be justified on the basis of the high
likelihood of significantharm to the individualor others.
11. Public health institutions should ensure the professional competence
of their employees.
12. Public health institutions and their employeesshould engage in
collaboration and affiliations in waysthatbuild the public’strust
and the institution’seffectiveness