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1. What is ethics?

2. What is public health?

3. What is public health ethics?

4. What are some important public health ethics principles?

5. What other important ethical principles apply to decision making in public health?

6. What is an epidemic?

7. What is a pandemic?

8. Why is public health ethics especially important in an influenza pandemic situation?

9. What are some major issues that are expected to arise during an influenza pandemic?

10. How can I learn more about ethical issues in pandemic influenza?






1. What is ethics?

Ethics is about how we live our lives. It includes thoughts about our values, our duties, and the consequences of our actions for others. Ethics is not just about how people do treat each other, but also about how they ought to act. We face ethical issues all the time in day-to-day life in relation to family and friends, our community and nation, as well as in relation to global and environmental factors. Ethics is about the responsibility that you have for the decisions that you make and the actions that you perform.

2. What is public health?

Public health is an area of health care that tries to protect and promote the health of populations, groups or communities. It is different than clinical medicine where the goal is to maintain or improve the well-being of an individual. Public health is concerned with identifying, preventing or reducing harm for many people and with increasing justice and fairness in health. Because of the need to address the underlying conditions for health, many public health activities are overseen by governments.

3. What is public health ethics?

Public health ethics is concerned with the ethical issues that arise when the aim is to protect and promote the health of populations (as opposed to individual patients). While these issues may be most commonly faced by public health professionals and policy makers, individual citizens are also faced with public health ethics challenges in their daily lives (e.g. should they vaccinate their child? Should they cycle rather then drive to work?).

4. What are some important public health ethics principles?

When anyone is thinking of making a decision about an issue related to public health they may find the following ethical principles helpful. However, this list only describes some of the important factors to think about. Not all of the principles will always be relevant, and no one principle will always take priority. The type of disease in question (e.g. how it is passed from person-to-person, what symptoms it causes, etc.) will also be important in deciding what action to take.

(a) Common good: Many public health actions require collective activities that are organized by the state to work for the good of the population or the common good (e.g. restaurant inspections). Creating and maintaining public health is only possible when public policies allow such actions to protect the common good.

(b) Solidarity: Solidarity recognizes what some people call “relational personhood”: the fact that people are not simply individuals but are part of the communities within which they live. Important values are promoted when people are able to support each other and stand together against a common threat to their wellbeing.

(c) Equity: Public health ethics needs to pay attention to the ways some people can become disadvantaged or privileged as a result of their background or baseline conditions with special attention paid to those who are most disadvantaged.

(d) Reciprocity: Where society benefits from the actions of individuals or communities who are contributing to public health, society must try to ‘re-pay’ such individuals and communities for their efforts (e.g. making sure that people who are confined to their homes to prevent possible transmission of disease have enough food and means of communication with family and friends).

(e) Least restrictive means: Interventions should be the least restrictive to the individual as possible, and more extreme measures (e.g. forced confinement to home) should only be used if less extreme measures have failed (e.g. voluntary confinement to home).

(f) Necessity: The proposed action must be necessary to prevent an avoidable health threat.

(g) Effectiveness: The proposed public health action should be based on the best possible evidence in terms of being effective at preventing or improving specific health conditions.

(h) Proportionality: The public health benefits of an action must outweigh the personal costs to individuals.

(i) Harm: Public health actions that go against an individual’s wishes must only be put into place to prevent harm to others.

(j) Individual Liberty: In a public health crisis, restrictions to individual freedom should be proportional, necessary, relevant, employ the least restrictive means, and be applied equitably (see above for definitions).

(k) Privacy: Individuals have a right to privacy in health care. In a public health crisis, it may be necessary to override this right to protect the public from serious harm.

(l) Trust: During a public health crisis, decision makers must work hard at maintaining the trust of stakeholders (patients, health care providers, various health care and community organizations, and the public). Trust is enhanced by the principle of transparency (see below).

(m) Duty to provide care: For all health care professionals, there are ethical codes that relate to the duty to provide care and to respond to suffering. In public health emergencies, health care providers will have to weigh the demands of their professional roles against their duties to their own health, and to friends and families.

(n) Stewardship: Those who are governing and making decisions must be guided by stewardship. This principle implies trust, ethical behaviour, and good decision making. Decisions regarding the public health action should be made in an attempt to achieve the best patient health and public health outcomes given the unique circumstances of the public health issue at hand.

5. What other important ethical principles apply to decision making in public health?

(a) Reasonable: Decisions must be based on reasons (i.e. evidence, principles, and values) that stakeholders (patients, health care providers, various health care and community organizations, and the public) can agree are relevant to meeting health needs in a public health crisis.

(b) Transparency: The public should be consulted about the public health decisions made by policy makers and the decision making process should be communicated clearly to the public.

(c) Inclusive: Decisions should be made with stakeholder’s views in mind (patients, health care providers, various health care and community organizations, and the public) and there should be opportunities to engage stakeholders in the decision-making process.

(d) Responsive: There should be opportunity to come back and revise decisions as new information becomes available throughout a public health crisis. There should be ways to address conflicts and complaints.

(e) Accountable: There should be ways to ensure that the decision makers are answerable for their actions and inactions.

6. What is an epidemic?

Any disease will be present at a normal ‘background’ level within a population. Epidemics occur when the number of cases of a particular infectious disease in that population or region is greater than what would usually be expected in a given time frame. Cases may be expressed, for example, in terms of the number of infections per 100,000 of the population (allowing comparisons to be made between different countries or time periods).

7. What is a pandemic?

A pandemic occurs when an epidemic crosses international borders affecting a large number of people. The key to an influenza pandemic developing is when a new strain of the virus begins to circulate and most of the population has no immunity. This may result in severe disease. The World Health Organization has a more specific definition for when they declare an influenza pandemic. This definition focuses on the virus spreading from person to person (as opposed to from animals to people) and the epidemic existing across different regions of the world.

8. Why is public health ethics especially important in an influenza pandemic situation?

When an influenza pandemic happens, many difficult decisions have to be made. Many people will be sick and some will die. Governments will need to decide how to best control the spread of influenza and how to make use of the available health care resources to help those who are ill. Some of the government’s actions may mean that people’s rights will be restricted (e.g. if they are confined to their homes) and some actions may mean that some people will have access to treatment while others may not (e.g. if there is limited room in the hospital). As explained above, ethical principles can serve as a guide when such difficult decisions must be made.

9. What are some major issues that are expected to arise during an influenza pandemic?

(a) Global issues: A pandemic threat puts all nations at risk and global cooperation is essential for managing the threat. One way that governments try to control the spread of disease is by restricting to travel and trade. These restrictions can have major effects on both individuals and on countries (including serious economic consequences that can be long lasting). The World Health Organization must carefully weigh ethical principles (such as necessity, effectiveness, proportionality) when making public health recommendations. Individual countries also have a responsibility to work together to prevent a worsening crisis by sharing important information with the WHO and other nations, and by sharing the expertise and resources needed to respond to public health emergencies.

(b) Restrictions to individual freedoms: In order to prevent the spread of influenza, the government may use the following restrictive measures:

• SOCIAL DISTANCING: This is when schools are closed and public gatherings are cancelled to reduce contact between people.
• QUARANTINE: Restricting the movement/activities of a person who is not know to have the disease, but has been exposed to someone who has, during the time when it could have been passed on.
• ISOLATION: Separating people who have the disease, for the time during which they may be infectious.
All of the above restrictions limit a person’s freedom and if the government decides to do so, the public health principles described above must be considered.

(c) Priority setting in relation to scare resources: During a pandemic the health care system is likely to be overwhelmed. There may not be enough medicine, medical equipment, or health care workers to treat everyone (both people with influenza and other illnesses). Governments and health care professionals will have to make difficult decisions such as who should get medicines first (the sickest? the most likely to get better with treatment? the youngest?), who should be treated in the hospital, and who should get vaccinated first as vaccines become available. Ethical principles as described above can help to guide decision makers when they set priorities.

(d) Duty to provide care: A flu pandemic will put large demands on health care workers. They will be faced with a serious disease from which they may not be able to completely protect themselves and which may have no cure. They have a duty to care for the sick who need their help, but they also have a duty to protect their own health and the health of their family and friends. If the government and society fulfill their reciprocal duty to help health care professionals by providing protective equipment and giving them appropriate training, these issues may be less significant.

10. How can I learn more about ethical issues in pandemic influenza?

The above issues will possibly affect most people at one time or another during an influenza pandemic. Although ethical principles do not provide clear cut answers to complicated questions, they can help both individuals and policy makers to make good decisions in difficult times. If you are interested in knowing more about these ethical issues and some of the recommendations made by the Joint Centre for Bioethics regarding these topics, please see any of the following links:
JCBUniversity of Toronto Joint Centre for Bioethics
88 College Street
Toronto, ON  M5G 1L4
CANADA
Funded by the
Canadian Institutes of Health Research