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| 0P a g e
Introduction to
EMPNET Online
Course on Public
Health Ethics
E a s t M e d i t e r r a n e a n P u b l i c
H e ...
| 1P a g e
Table of Contents
Introduction ...................................................................................
| 2P a g e
2.9 Professional misconduct.......................................................................................
Part One: Definitions and Main Concepts in Public Health Ethics
| 3P a g e
Introduction
This  handout  is  the  student’s ...
| 4P a g e
1.2 Intended Learning Objectives (ILOs):
1. Identify the main differences between public health and clinical pr...
| 5P a g e
Though demarcation of the two fields is obvious, it is worth noting that there are many overlaps and
similariti...
| 6P a g e
1.3.3.3 Clinical (medical) ethics:
It is that branch of bioethics that is related to the
identification, analys...
| 7P a g e
1.4 References & Required Readings:
Bayer R and Fairchild A. The Genesis of Public Health Ethics. Bioethics. 18...
Part One: Definitions and Main Concepts in Public Health Ethics
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Part	
  Two	
  
2 Ethical principles and theori...
Part Two: Ethical Principles and Public Health Core Values
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example, you do not cheat in your exams because chea...
Part Two: Ethical Principles and Public Health Core Values
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2.3.3 Utilitarianism  
(Consequentia
lism)
Actions ...
Part Two: Ethical Principles and Public Health Core Values
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they are key to make our professional/ethical justi...
Part Two: Ethical Principles and Public Health Core Values
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2.5 Duty of care
Healthcare providers have committe...
Part Two: Ethical Principles and Public Health Core Values
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2.6.3 Voluntariness:
For an informed consent to be ...
Part Two: Ethical Principles and Public Health Core Values
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and welfare; here comes the issue of conflicting in...
Part Two: Ethical Principles and Public Health Core Values
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misleading ascription of authorship
failure to decl...
Part Two: Ethical Principles and Public Health Core Values
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susceptible persons, so not all the pilgrims were c...
Part Two: Ethical Principles and Public Health Core Values
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2.11.1 Group work:
To develop a national Code of et...
Part Two: Ethical Principles and Public Health Core Values
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Martin, Douglas K., Joseph L. Pater, and Peter A. S...
Part Three: Ethical Issues in Vaccination
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Part	
  three
3 Ethical issues in Vaccination
3.1 Description of the...
Part Two: Ethical Principles and Public Health Core Values
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vaccinated (such as new-borns and those with chroni...
Part Two: Ethical Principles and Public Health Core Values
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Figure 1 Measles in the US (1950-2007). Source: htt...
Part Two: Ethical Principles and Public Health Core Values
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teenagers to protect them from catching the virus, ...
Part Two: Ethical Principles and Public Health Core Values
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in order to maintain their safety, and probably the...
Part Two: Ethical Principles and Public Health Core Values
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bearing in minds the millions of children who die e...
Part Two: Ethical Principles and Public Health Core Values
| 25P a g e
3.5.2 Optional/additional readings:
Colgrove, J. 20...
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Students handout online course introduction to public health ethics (phe)

Students handout for the online course I have delivered for the EMPHNET: Introduction to public health ethics (PHE)

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Students handout online course introduction to public health ethics (phe)

  1. 1. | 0P a g e Introduction to EMPNET Online Course on Public Health Ethics E a s t M e d i t e r r a n e a n P u b l i c H e a l t h N e t w o r k I n p a r t n e r s h i p w i t h T h e   P e o p l e s ’   U n i 2 0 1 5 Ghaiath MA Hussein MBBS, MHSc. (Bioethics), Doctoral Researcher (UK)
  2. 2. | 1P a g e Table of Contents Introduction ............................................................................................................................................3 1 Introduction to Public Health Ethics (PHE) .....................................................................................3 1.1 Description of the module:.....................................................................................................3 1.2 Intended Learning Objectives (ILOs):......................................................................................4 1.3 Topics included in the module................................................................................................4 1.3.1 The roles of the healthcare practitioner.........................................................................4 1.3.2 The technical and ethical differences between clinical care and public health practice4 1.3.3 The definition and taxonomy of ethics (ethical issue, ethics, bioethics, clinical ethics, research ethics and public health ethics) .......................................................................................5 1.3.4 The importance of ethics in PH practice and research...................................................6 1.4 References & Required Readings:...........................................................................................7 1.5 Optional/additional readings:.................................................................................................7 2 Ethical principles and theories and the core professional public health values.............................8 2.1 Description of the module:.....................................................................................................8 2.2 Intended Learning Objectives (ILOs):......................................................................................8 2.3 Topics included in the module................................................................................................8 2.3.1 The main ethical theories (and their role as lenses in moral reasoning)........................8 2.3.2 The global/western approaches to bioethics .................................................................8 2.3.3 Utilitarianism  (Consequentialism) ................................................................................10 2.3.4 Deontology  (Duty-based)..............................................................................................10 2.3.5 Virtue-based Ethics .......................................................................................................10 2.3.6 Casuistry........................................................................................................................10 2.3.7 Principlism.....................................................................................................................10 2.3.8 Feminist ethics ..............................................................................................................10 2.4 Core PHE professional values................................................................................................10 2.5 Duty of care...........................................................................................................................12 2.6 Informed consent..................................................................................................................12 2.6.1 Competence:.................................................................................................................12 2.6.2 Disclosure:.....................................................................................................................12 2.6.3 Voluntariness: ...............................................................................................................13 2.7 Privacy and confidentiality....................................................................................................13 2.8 Conflict of interests...............................................................................................................13
  3. 3. | 2P a g e 2.9 Professional misconduct.......................................................................................................14 2.10 Rationing and Resource allocation .......................................................................................15 2.11 Student’s  evaluation .............................................................................................................16 2.11.1 Group work: ..................................................................................................................17 2.11.2 Individual/group assignment:.......................................................................................17 2.12 References & Required Readings:.........................................................................................17 2.12.1 Optional/additional readings:.......................................................................................17 3 Ethical issues in Vaccination .........................................................................................................19 3.1 Description of the module:...................................................................................................19 3.2 Intended Learning Objectives (ILOs):....................................................................................19 3.3 Topics included in the module..............................................................................................19 3.3.1 Overview on vaccines, vaccination and immunization.................................................19 3.3.2 Benefits and harms .......................................................................................................20 3.3.3 Paternalism and Duty to care for others (or not to harm other)..................................22 3.3.4 Compulsion and refusal of vaccination.........................................................................23 3.4 Student’s  evaluation .............................................................................................................24 3.5 References ............................................................................................................................24 3.5.1 Required Readings: .......................................................................................................24 3.5.2 Optional/additional readings:.......................................................................................25
  4. 4. Part One: Definitions and Main Concepts in Public Health Ethics | 3P a g e Introduction This  handout  is  the  student’s  guide  to  the  Public  Health  Ethics  (PHE)  online  course  organized  by  the   East Mediterranean  Public  Health  Network  (EMPHNET)  in  partnership  with  the  People’s  Uni.  It  aims   at helping the trainees enrolled in this course to understand its structure, objectives, and their duties as trainees in this course. This online course is a modified version of the PHE course that was delivered in Amman, Jordan in a 5-day full day training course in May 2014 to 19 trainees from Afghanistan, Bangladesh, Egypt, Jordan, Morocco, Pakistan, Tunisia, Yemen, and the Occupied Palestinian Territories. The training covered an introduction to Public Health Ethics, including the ethical principles and theories and the core professional public health values, followed by the ethical issues in: surveillance, screening and outbreak investigation, health promotion, vaccination, public Health emergencies, and public health research. The trainees were introduced to the ethical codes and frameworks in public health ethics. One of the main suggestions that arose from the participants is make an online version of the course to overcome the logistic requirements of face-to-face training and to make it easier to those who may not be able to travel to the country where the training is held. Out of the eight modules delivered in the previous training; this online course will include three main parts: 1- Part one: An introduction to PHE 2- Part TWO: Ethical principles and theories and the core professional public health values 3- Part three: Ethical issues in Vaccination In each of the following section, there will be a summary on the topic, its learning objectives, and its assessment methods, followed by the readings for each part. Part  One:   1 Introduction to Public Health Ethics (PHE) 1.1 Description of the module: This module presents the main concepts related to ethics and its healthcare-related categories. It also explores the differences between clinical and public healthcare and the scope of ethical issues encountered by each field. This module aims to define the terminology and clarify the differences between various aspects of healthcare (i.e. clinical care, health research and public health). It will also summarize the ethical theories and illustrate the importance of moral reasoning in a well presented ethical argument.
  5. 5. | 4P a g e 1.2 Intended Learning Objectives (ILOs): 1. Identify the main differences between public health and clinical practice from an ethical perspective 2. Describe the categorization and terminology related to healthcare ethics, mainly ethics, bioethics, and public health ethics 3. Recognize the importance of ethics in PH practice and research 1.3 Topics included in the module 1.3.1 The roles of the healthcare practitioner There are main roles that any healthcare practitioner is expected to perform at different levels and different times. They can be categorized into the following main roles: 1- Practitioner (i.e. direct service provider), like a clinician who treats patients or a public health practitioner who conducts a public health activity (e.g. surveillance or health education); 2- Researcher, including designing and conducting scientific research that generates knowledge that could contribute to the improvement to the health of the people; 3- Educator who educates the public about their health (health education) as well as his/her colleagues (teaching); 4- Counsellor who provides professional advice to his/her clients as needed; 5- Manager/administrator who is responsible for managing the resources to be utilized in the most efficient and fair way; and 6- Advocate who works not only on raising the awareness of the people about their rights but also defends and advocates for them. 1.3.2 The technical and ethical differences between clinical care and public health practice Though these roles are applicable to both clinicians and public health professionals, there are some differences between these two fields, which we need to explore as they would affect the kind and the approaches to the ethical issues in each field. These are summarized in the following table. Aspect Clinical care Public health Main aim Treat sick individuals (cure) Prevent healthy individuals from getting ill (prevention) Beneficiaries Individuals (healthy or sick) and families Population (community) Scope Clinical care, diagnosis, and treatment Health education, health promotion, and community-based interventions Fields (specialties) Internal medicine, surgery, paediatrics, obstetrics and gynecology, etc. Epidemiology, health promotion, biostatistics occupational health, etc. Guidance Clinical guidelines, hospital policies, etc. PH guidelines, regulations, laws Examples of ethical issues and questions Issues  related  to  the  individuals’  right  to   decide (autonomy), privacy and confidentiality, etc. - When is it ethical to disclose a patient’s  medical  information? - How to decide which patient should have which service (e.g. an ICU bed)? Issues related to the tension between the individual rights (interests) and the public good (interests) - When is it ethical to limit the freedom of movement of a patient with an infectious disease (e.g. in case of pandemic)? - Do parents have the right to refuse vaccinating their children?
  6. 6. | 5P a g e Though demarcation of the two fields is obvious, it is worth noting that there are many overlaps and similarities between the two fields. We will only highlight these differences from an ethical perspective. Clinical care is mostly conducted on one-to-one basis, or client-to-provider to be more specific. Therefore, most of the ethical issues arise from the interaction between the individual patients and their families with the healthcare system usually at the hospital level. They are mainly attributed to the  patient’s  rights  to  a  given  set  of  rights,  which  are  reflected  by  a  set  of  duties  on  the  provider   (mainly doctors and nurses). These duties are usually enforced by ethical codes of conducts, hospital polices and sometimes laws and regulations. In public health, the interaction is not between individual persons and providers, yet more between individuals within a community and a system, usually conducted by the government through the authorized (public) health authorities. This level of interaction gives rise to another set of ethical issues, usually related to relations and limits of freedom that could be given to any individual when the public benefit is threatened by this freedom. The ethical issues may include the distribution of benefits of public health interventions compared to the risks, the determination of whether a public health activity (e.g. surveillance) need to be considered as research, which of the these activities need its participants to consent, and many other ethical issues and dilemmas that will be explored along this course. In summary, both clinical care and public health have good intentions to help the communities in which they are practiced. However, both disciplines provide some benefit to its target beneficiaries through interventions that carry some risks. In clinical practice, risks may result from a wrong medication, or a complication of a surgery, for example. In public health there are the risks of stigmatization, or invasion of privacy. In addition, in clinical practice the risk is associated with the limited  ‘power’  of  the  provider  that  could  be  challenged  through  disciplinary  or  even  legal  means   (e.g. suing the doctor or the hospital). In public health, the individuals may find themselves facing the government represented by the health authorities, which are usually hard to challenge, especially in the context of many of the developing countries. 1.3.3 The definition and taxonomy of ethics (ethical issue, ethics, bioethics, clinical ethics, research ethics and public health ethics) 1.3.3.1 Ethics: Ethics can be defined as the system of moral principles that govern the conduct of an individual or a group of individuals and according to which the human actions are judged as right or wrong, good or bad. It generally divided into:1 - Meta-ethics that seeks to understand the nature of ethical properties, statements, attitudes, and judgments (the philosophical study of morality); - Normative ethics that investigates the set of questions that arise when considering how one ought to act, morally speaking. Normative ethics is distinct from meta-ethics because it examines standards for the rightness and wrongness of actions; and - Applied ethics that studies how to apply the moral standards in various practical fields like healthcare (bioethics), business (business ethics), environment (environmental ethics), etc. 1.3.3.2 Bioethics: It is the division of applied ethics that helps in defining, analyzing, and resolving the ethical issues that arise along with the provision of healthcare or the conduct of health-related research.
  7. 7. | 6P a g e 1.3.3.3 Clinical (medical) ethics: It is that branch of bioethics that is related to the identification, analysis, and resolution of moral issues that arise in the healthcare of individual patients. 1.3.3.4 Research ethics: That is the branch of bioethics that is related to the identification, analysis and resolution of the ethical issues that are encountered before, during and/or after the conduct of health-related research, specifically on humans (or animal). This is specifically important for research that involves the collection and further processing of human tissues, biological materials, or identifiable information. 1.3.3.5 Public health ethics: It aims at the identification, analysis, and resolution of ethical issues that are encountered along the conduct of public health interventions, policy, and/or research. It is also concerned with the concepts, values, aims, methods and arguments arising in all aspects of public health practice and policy. 1.3.3.6 Islamic bioethics: It is the methodology of: defining, analysing and resolving the ethical issues that arise in healthcare practice, or research; based on the Islamic moral and legislative sources (Koran, Sunna & Ijtihad); and aims at achieving the goals of Islamic morality (i.e. preservation of human’s  religion,  soul,   mind, wealth & progeny ) 1.3.4 The importance of ethics in PH practice and research Basically, bioethics helps us in answering three main questions that are usually encountered in healthcare provision, which are: 2 deciding what we should do (what decisions are morally right or acceptable); explaining why we should do it (how do we justify our decision in moral terms); and describing how we should do it (the method or manner of our response when we act on our decision). Apparently, all these questions are applicable to the context of public health practice and research. There are many reasons why you, as public health practitioner, need to know about ethics. We would like to emphasise two of them. First, it is a public expectation that your practice is based on scientific and ethical standards, which is the basis of trust that public puts in the health system. Deviations from what are considered as the ethically acceptable norms would negatively affect the public trust in the health system, which could make them reluctant to approach the system or cooperate with it. For example, they could give wrong information, or deny access to public health workers who are investigating an outbreak or refuse vaccinating their children. Second, knowing about ethics and how its frameworks can help you in defining, analysing and resolving the ethical issues that you encounter would help you perform better with less stress that the healthcare providers usually face when they encounter situations with ethical uncertainties.
  8. 8. | 7P a g e 1.4 References & Required Readings: Bayer R and Fairchild A. The Genesis of Public Health Ethics. Bioethics. 18(6). 473-492. November 2004. Upshur R. Principles for the Justification of Public Health Intervention. Canadian Journal of Public Health. 93(2): 101-103. March-April 2002 . 1.5 Optional/additional readings: K.M.. MacQueen, E. McLellan, D.S. Metzger, S. Kegeles, R.P. Strauss, L. Blanchard, R. Scotti, R.T. Trotter. What is Community? An evidence-based definition for participatory public health. American Journal of Public Health 2000; 91 (12): 1929-1938. Principles of Community Engagement. Atlanta, GA. Centers for Disease Control and Prevention, Public Health Program Practice Office. 1997. Betancourt J et al. Cultural Competence And Health Care Disparities: Key Perspectives And Trends. Health Affairs. 24(2): 499-505. 2005. Racher F. The Evolution of Ethics for Community Practice. Journal of Community Health Nursing, 2007, 24(1), 65–76.
  9. 9. Part One: Definitions and Main Concepts in Public Health Ethics | 8P a g e Part  Two   2 Ethical principles and theories and the core professional public health values 2.1 Description of the module: Part 2 will present the ethical analytical methodologies that are followed by different (philosophical) schools of thoughts to tell right from wrong without extensive philosophical deliberations. This module will also introduce the crosscutting ethical issues that may be encountered in any aspect of PH practice or research. The ethical issues that will be covered include: autonomy and informed consent, privacy, confidentiality, conflicts of interest, professional misconduct, conflict of interests, rationing and resource allocation, and information sharing ethics, including publication. In addition, the common PHE values such as proportionality, reciprocity, fairness, liberty, efficiency, and utility will also be introduced. Indeed this is too much to be fully covered in details, so we will present some of the very basic concepts, supported by some readings, in order to be aware of the topic. The reference, referred to widely in literature and similar courses, is the APHA code of ethics and curriculum. This module will present these core values within an East Mediterranean Region (EMR) perspective 2.2 Intended Learning Objectives (ILOs): 1- Differentiate between the main ethical theories 2- Apply at least one of the ethical theories to public health practice and research 3- Identify key ethical principles and values relevant to public health practice and research 4- Present an argument based on the ethical theories and core values of public health practice 2.3 Topics included in the module 2.3.1 The main ethical theories (and their role as lenses in moral reasoning) Why do we do what we do? Why is it ethical to do X but not Y? It is not only about being the legal thing we have to do. It is about the reason why people do (or do not) things. Different people have different reasons, and the way they defend their choices about a given  issue  is  what  we  can  refer  to  as  the  ‘moral  reasoning’.  Some  people  refer  to  a  divine  reference,   e.g. the Quran said that, or the Bible advised us to do  it.  Others  refer  to  other  set  of  more  ‘neutral’   methodologies that can be used by those who do not share the same faith. The following represent some of the main moral references that people refer to when they justify their actions (or inactions). They are usually referred to as the ethical theories. 2.3.2 The global/western approaches to bioethics As mentioned earlier, one of the main roles of the field of bioethics is to help us justify our ethical choices. Any person refers to some 'moral reference' to justify what she did (or did not). For
  10. 10. Part Two: Ethical Principles and Public Health Core Values | 9P a g e example, you do not cheat in your exams because cheating is against your religion. Others may see it wrong because they think it is against the ethical principle of justice. Other people have other reasons why they would not cheat in the exams, e.g. it is not legal. To understand how the people think about ethical issues to tell right from wrong, it is important to have an idea on the 'ethical schools of thought'. The following diagram shows a brief 'taxonomy of ethics'. Figure 2.1 A brief taxonomy of the main ethical theories and schools Table (2.1) describes briefly the main ethical theories that people, including academicians and clinicians, tend to refer to when they provide an ethical argument to defend an ethical stand they believe in as the right thing. Theory Main ethical points Acts are ethically right  when… Examples from practice
  11. 11. Part Two: Ethical Principles and Public Health Core Values | 10P a g e 2.3.3 Utilitarianism   (Consequentia lism) Actions not morally right in themselves—they become morally right if they produce certain consequences They achieve overall amount of good (or the least overall harm) for the greatest number Patients with public health threatening disease are quarantined for the sake of the good of the general public 2.3.4 Deontology   (Duty-based) Consequences are either morally irrelevant, or relevant but by themselves  don’t   determine the ethical nature of action They follow a set of duties and rules that are applicable on anyone in the community without exceptions Doctors are bound to 'the duty to serve' their patients, even if there is risk attached to this duty. 2.3.5 Virtue-based Ethics   Emphasizes moral character—not just moral action The acts are done by a moral person, not just simply to be done morally Smoking doctors cannot advice their patients not to smoke. If smoking is morally wrong the moral person should not do it. 2.3.6 Casuistry   case comparison/analogy used toward ethical consensus it is the theory of adopting no theory There's practical judgment in that particular case with appeal to precedent (“paradigm  cases”)  is possible This approach is very similar to that of Fatwa issuance. For example, we cannot generalize a fatwa that permitted abortion for one patient to all patients of the same condition 2.3.7 Principlism   A framework that includes four clusters of moral principles for identifying and reflecting on moral problems They respect the 4 main principles of autonomy, believes, non-maleficence, and justice Taking consent from patients before surgery is a respect to the patient's autonomy. 2.3.8 Feminist ethics oppression (of all people, in all its forms) is morally and politically unjust and must be addressed autonomy should be a relational (rather than an individualistic) notion fair relationships among social groups They consider one's self as essentially a “self-in-relation” Giving the female patient the right to consult and consider her family before giving a consent. Doctors should not insist on her to take her decision alone (to avoid the potential undue influence of the family on her) Source: Modified from a lecture by Prof. Barbara Secker on ethical theories given in the University of Toronto Joint Center for Bioethics master program of bioethics (October 2007). 2.4 Core PHE professional values In the domain of public health, there are core professional values that many public health codes/guidelines mention them. They are mainly targeting the professional values, i.e. what makes the field of public health professional. Nevertheless, they have indeed their ethical implications and
  12. 12. Part Two: Ethical Principles and Public Health Core Values | 11P a g e they are key to make our professional/ethical justifications of our choices when we choose, for example, to do this screening on this population and not others, or to adopt this intervention and not that. The following are the commonly used principles and core values. They are not intended to be an exhaustive list, but just to present to you some of the key values to which the profession of public health refer and base on. As this is not a textbook, we will remain concise. We will only mention the value, one of its explanations, and then mention and example of its use. You are highly advised to refer to the readings to have more insights about what each value means to your practice as a public health practitioner. Utility: acting so as to produce the greatest good. Public health research and interventions are widely based on this value. Public health authorities gain the moral power to impose certain interventions that would restrict the individual liberties based on this principle. For example, quarantining is apparently an act that limits the freedom of movement of an individual, sometimes against his/her will. However, it is a generally acceptable act because it produces greater good to greater number of people. Liberty: one should impose the least burden on personal self-determination that is necessary to achieve a legitimate goal. Though at an initial glance, this value may seem contradictory to the first value; in reality it is not. This core value works as a complimentary value for utility, so as to make sure that the interventions done by the public health authorities are not abusive. For example, quarantining is considered a choice for specific patients with specific diseases that should be done in a way that does not make it equal to prisoning this person. This could be practically translated into giving this quarantined person the chance to communicate with his family in a safe way, for example through phone or internet. Efficiency: calls for minimizing the resources needed to produce a particular result or maximizing the result that can be produced from a particular set of resources. Public health interventions are deemed professionally and ethically acceptable because it is seen and defended as an efficient way of utilizing the resources for health. For example, vaccination of children against the immunizable diseases is way less costly than building rehabilitation centers for the children physically disabled by polio for example, or mentally handicapped by meningitis. Fairness: it is used interchangeably with justice and it is not the purpose of this course to burden you with deep philosophical arguments on the differences between closely user terms that would have different meanings in the ethics literature. In its simplest forms, it could  be  stated  as  “treating  like  cases  alike”.  For  example, a given population in a given geographical area who share similar demographic public health characteristics are expected to have the same public health interventions. Any skew from that norm need to be justified on epidemiological evidence not for economic or racial reasons for example, so that the poorer parts of the city (or country) remain neglected from a public health intervention like insecticide spraying in favour to the richer neighbourhood. Reciprocity: individuals (professionals) accept of the risk in executing their duties would engender reciprocal duties on the part of the community to them. Many arguments have been raised on whether there is a duty on healthcare practitioners, in general, including the public health professionals to expose themselves to personal risks in the time of outbreaks and pandemics. This principle is key to these arguments. For example, they are exposed to the risk to get an infection and according risking other members in their families. They may found themselves forced to work in sub-optimal conditions, which is the case unfortunately in  many  of  our  region’s  countries.  In  general,  this  value  justifies  asking  the  public  health   professionals to accept the risk associated with the service they provide to the community but the community has to provide them an appropriate compensation for that. This compensation is not necessarily financial, though this is a part of it, but also includes recognition, appraisal, compensation for their families, and provision of healthcare conditions that meet the universal conditions for infection control.
  13. 13. Part Two: Ethical Principles and Public Health Core Values | 12P a g e 2.5 Duty of care Healthcare providers have committed themselves to a duty of care to their beneficiaries. This includes public health practitioners. This duty is based on other more basic duties like the duty to do good and the duty not to harm. However, it is challenged sometimes by the extent to which the healthcare providers are bound to this duty, especially when they are dealing with serious contiguous diseases like as it was in SARS, H1N1, and H1N5 among other pandemics. These providers have their own families who may be in turn hurt. Here comes other ethical principles and core values to help us judge on that extent. These include the core value of reciprocity, in which the community has to provide reciprocal support to those who serve it. Nevertheless, the exposure to risk as such is not a reason that would stop anyone from providing the service. This is especially important in conditions where the care providers are in contact with a patient with HIV/AIDS, TB, cholera, etc. This risk is not a new risk, and the provider should have known the risks associated with his/her job. Technically, no job is risk-free. It is on the shoulders of the person and the institution providing the service to make sure that the service providers are protected to the best level of protection with the known standards of infection control, for example. 2.6 Informed consent The informed consent is now widely an ethical and sometimes legal requirement for almost all kinds of  research,  and  many  ‘non-research’  activities.  It  could  be  defined  as  a  shared  decision  making   process between the healthcare provider or the researcher and the patient or the research participant, respectively. It is based on the ethical principle of respect for autonomy. It is considered the way by which, we as professional providers or researchers respect the decision-making capacity of our patients or research participants as morally competent individuals. As this definition implies, there should be conditions that need to be present to consider it ethically valid. These conditions may vary from one guideline to another, so we will try to provide the common conditions. 2.6.1 Competence: This condition refers to the mental capacity of the person being involved in the informed consent process to take decisions related to his/her condition. This competence is usually estimated by two main components: understanding of the given information, and appreciation of the risks associated with the intervention or research. This competence is assumed to be present, unless there is suggestive or definitive evidence that it could be absent. For example, an unconscious person, a minor/child, and some mentally ill patients are not usually deemed competent and someone else should replace them in making the decisions related to their health or participation to research. 2.6.2 Disclosure: Obviously, no sound decision making process can take place with appropriate information given to the person taking the decision. To consider the given information appropriate there are many requirements, which again may vary from one guideline to another. Some of the common criteria are those related to the clarity, the relevance, the adequateness of content, the suitability of the information delivery, and the time of delivering this information. Some of the examples of the common mistakes done by practitioners or researchers during taking the consent include using medical/scientific terminology, inappropriate translations, too many (or too little) information, inaccurate information, not giving them the chance to ask, and not answering their questions adequately.
  14. 14. Part Two: Ethical Principles and Public Health Core Values | 13P a g e 2.6.3 Voluntariness: For an informed consent to be ethically valid, the person giving it needs to be free from undue pressure, coercion, and exploitation. There are many forms of lack of voluntariness, which are usually not physically clear. For example, people may accept to participate in a study if, the researcher is seen to be representing the government, s/he expects to have special benefits from his/her participation, or if other family members (e.g. the husband) are observing the person while taking the decision. There are many other forms in which the participant in the interventions (or research) are afraid, under pressure, or have false expectations from this participation. All of these factors need to be known and addressed by the public health practitioners as they approach the community, especially the vulnerable populations. 2.7 Privacy and confidentiality These are two key principles and duties, which are sometimes used interchangeably. This is not correct. They are not synonymous, though both are related to the process of collecting information from the people. Privacy is mainly concerned with the setting in which the collection of information is taking place. For example, in clinical practice, the patients have the right to have their bodies covered and only the parts needed to be exposed for only those directly related to the treatment of the patient. In public health though we do not  usually  expose  the  people’s  bodies,  unless  for  taking  blood  or  other   body sample, we do need to make sure that the data we collect from the participants of surveys, for example, are taken in privacy. This practically means to have the data collection done in a place isolated from others, who cannot see or hear what being said. This is particularly important if you are collecting sensitive data related to socially-troubling or stigmatizing diseases, like TB or HIV/AIDS. Confidentiality is more concerned with the data after being already collected. The people have the right to have the information they provide to the healthcare system, including public health kept confidential. This practically means only those who are related to the data management (collection, analysis, interpretation, and dissemination) are exposed to the data. Even more, the data should be coded, unidentifiable, kept in safe places (like locked file cabinets or password-protected electronic files). That being said, confidentiality in public health is not definite in any condition. There are lots of exceptions in which the public health professionals (and other healthcare practitioners) are required ethically  and  legally  to  report  some  diseases.  They  are  usually  referred  to  as  the  ‘notifiable  diseases’,   which vary from one country to another but it is usually a long list. This means lot of patients can be granted that their information can be kept secret from anyone but at the same time this does not mean that they should be shared with everyone. The public health authorities have gained this ethical and legal privilege based on the ethical principles that we have discussed above, namely the utility and non-malifecence (the duty not to harm others). This situation gets even more difficult when the reporting is not only done at the local country level but should be shared with the international community, usually through the World Health Organization (WHO) regional offices. 2.8 Conflict of interests People may have personal interests for doing or not doing something. Those interests are not necessarily bad, yet could be considered as motivation factors. However if these personal interests come to a point where they have the potential to affect our professional judgments and the integrity expected by the public in a way that could harm our beneficiaries and negatively affects their rights
  15. 15. Part Two: Ethical Principles and Public Health Core Values | 14P a g e and welfare; here comes the issue of conflicting interests. They are conflicting because they get to the point at which there is conflict between our moral duties (to do good, to not to do harm, to be fair, etc.) and our personal interests. Here are some examples. Later, we will demonstrate how they would  affect  our  beneficiaries’  welfare  and  rights. Examples of these interests that could affect our professional integrity include: Financial interests: this is usually through having some direct or indirect financial relationship with an institute that has financial interests in the service you are providing. For example, these interests may include being paid for services, a stock shareholder, or working in an agency that is related to that institution. This is considered one of the main conflicting interests, because your role as a service provider or a researcher may be affected by these financial issues. This could include for example changing the study design so as to make the sample  selected  f  better  outcome,  ignoring  the  negative  data  not  favoring  the  company’s   product, or even manipulating or falsifying the data. In the context of public health, this may include using a commercial kit to test the case in a case investigation that is not supported by enough research-based evidence. Career and Academic interests: Sometimes the interests are personal and not directly related to monetary gains. These may include the peer-pressure, desire for promotion, and academic publications. In many institutions, the personnel need to achieve a given level of training, performance and academic publications to get promoted. These factors are also seen  as  signs  of  ‘prestige’  in  many professional and academic contexts. Though these measures were primarily put as motivation for the staff of these institutions to keep updated and up to the standards; it may lead sometimes to behaviors that might affect their professional integrity. It has been reported, for instance that many researchers have fabricated works that never took place in reality. At the field level, some data collectors, surveyors, or case detectors may be required to complete a given number of questionnaires, for example. There have been incidents in which these data collectors have fabricated the answers and even signed on the informed consents on behalf of the people that they should have met. Social interests: In some communities, especially in our region, there is some level of social relationships based on having the same ethnicity, the same tribe, or the same language. There are some expectations from some people that the healthcare providers, including the public health professionals, to favor them in the services they provide. They might exert some social pressure on the public health workers when they work in their own communities, which may make some public health professional provide some additional services to their communities on the expense of other more needy communities. Such an attitude infringes some ethical principles and core values, mainly justice. 2.9 Professional misconduct There is a wide range of unethical activities that have been reported in the field of healthcare provision and research and have been referred  to  as  ‘scientific  misconduct’,  ‘professional   misconduct’,  and  sometimes  ‘academic  misconduct’,  when  they  are  related  to  the  students’   attitudes but they are quite similar. They include but limited to: (modified from Australian code for the responsible conduct of research) fabrication of results falsification or misrepresentation of results plagiarism
  16. 16. Part Two: Ethical Principles and Public Health Core Values | 15P a g e misleading ascription of authorship failure to declare and manage serious conflicts of interest falsification or misrepresentation to obtain funding conducting research without ethics approval as required by the national ethical guidelines and regulations in the country where the research in conducted risking the safety of human participants, or the wellbeing of animals or the environment deviations from the approved professional standards that occur through gross or persistent negligence willful concealment or facilitation of research misconduct by others. Other forms of misconduct that are not related to research include but not exclusive to: performing a professional duties without the needed knowledge and competencies to perform them sexual misconduct, including verbal harassment or any form of abuse of the position of being a healthcare provider to conduct or maintain in appropriate association or contact with the client of the service you provide, regardless his/her sex or age. There are many reasons why students/researchers may indulge in such practices. You need to be aware of them to avoid and manage them. They can be either for financial reasons, for example when the researcher is benefiting from the results of his/her research, or when the researcher thinks that the positive results would please the funding agency. There could be peer pressure where one professional finds that most of his/her colleagues are publishing and s/he is not. s/he may come up with fabricated or falsified work that might have never been conducted to get published.  It  could  also  attributed  to  abuse  of  authority,  where  a  ‘boss’  simply  puts  his/her  name   on a scientific product that s/he has not contributed to in a significant way. Lastly, this could be out of laziness. Copying and pasting from Google takes very short time to be done, especially when  the  due  dates  are  close  but  it  also  takes  most  of  the  profession’s  dignity  with it. 2.10 Rationing and Resource allocation You may (and will) find whole books discussing this issue. There are many attempts to answer the questions related to how to fairly distribute the allocated resources, especially in case of emergency. Let’s  consider  the example of the Hajj season during the H1N1 pandemic. The Saudi government managed to buy slightly less than one million doses of the newly discovered (at that time) and she was faced by the major question, who should get it, given that there are hundreds of thousands of police staff, passport officers, health care providers, etc. this is not to mention that there were over two million pilgrims that year, the majority of whom came from countries that could not afford vaccinating all its pilgrims. In this short of space, it may not be appropriate to discuss the many criteria that have been developed in the literature on how to distribute the resources, so we will only present the concept of need and explore one approach to the resource allocation process known as Accountability for Reasonableness. The main criterion on which many people would rely when deciding on who should get what is the concept of need, i.e. those in more need of the resource should be given priority. This sounds logic, but again how to decide on the need, in order to decide who the neediest ones are. This has been usually resolved by referring to an epidemiological indicator. For example, back to the vaccine in Hajj example, the elderly people, the pregnant women, and children were given priority over other pilgrims to be vaccinated. The police officers and the healthcare providers were prioritized based on the magnitude of risk, which is based partially on the time and frequency of exposure to the
  17. 17. Part Two: Ethical Principles and Public Health Core Values | 16P a g e susceptible persons, so not all the pilgrims were considered as susceptible. This was again based on other epidemiological and biometric measures like the incidence, prevalence, and case fatality of the infections  with  the  virus  in  the  pilgrim’s  country,  as  well  as  his/her  temperature  (using  the thermo- scans in the arrival gates). These measures are not perfect. Nor any other concept. Therefore, another attempt was based on shifting thinking about allocating resources from the question of “who  gets  what”  to  another  concept  based  on  how  we  take  the decisions not the outcomes of these decisions. Sabin and Daniels have proposed what they called Accountability for Reasonableness (A4R). They have argued that if we cannot agree on the criteria on which we can distribute the resources;  then  let’s  agree  on the process by which we decide on this distribution. Accountability for Reasonableness (A4R) describes four main criteria that should be present in any resource allocation decision making process to be considered as ethically defendable. They argue that by fulfilling these criteria, we will be considered as accountable to convince our beneficiaries that  we  have  reasonably  chosen  what  we  have  chosen;  hence  the  name  ‘accountability  for   reasonableness’.  The framework attempts to set ground rules for a procedure that ensures that whatever decisions result will be fair, reasonable, and legitimate to the extent that even those who would be adversely affected will have reason to abide by them. The four main conditions that they proposed for any fair resource allocation process are: 1- Publicity about the reasons and rationales that play a part in decisions. Decisions regarding both direct and indirect limits to care and their rationales must be publicly accessible. 2- Relevance: The rationales for limit-setting decisions should aim to provide a reasonable explanation  of  how  the  organization  seeks  to  provide  ‘value  for  money’  in  meeting  the   varied health needs of a defined population under reasonable resource constraints. Specifically, a rationale will be reasonable if it appeals to evidence, reasons, and principles that are accepted as relevant by fair-minded people who are disposed to finding mutually justifiable terms of cooperation. Fair minded people those who seek mutually justifiable grounds for cooperation must agree that the reasons, evidence,and rationales are relevant to meeting population health needsfairly, the shared goal of deliberation. 3- Revision and Appeals: There must be mechanisms for challenge and dispute resolution regarding limit-setting decisions, and, more broadly, opportunities for revision and improvement of policies in the light of new evidence or arguments. Fair process also requires opportunities to challenge and revise decisions in light of the kinds of considerations all stakeholdersmay raise. 4- Enforcement: There is either voluntary or public regulation of the process to ensure that conditions 1–3 are met. A4R has gained considerable degrees of international acceptance. You will discuss it in discussion forum and might be asked to apply it in the context of your country. 2.11 Student’s  evaluation In addition to the marks given to your contribution in the discussion forum based on your readings, you are evaluated for this module submitting an assignment (of no less than 1000 words) that describes a case from your practice or readings (e.g. from newsletters, internet, etc.) that involved ethical issues. In this assignment you are expected to describe the case, and state the ethical issues as you see them, then finally describe how you expect this course to help you to resolve them.
  18. 18. Part Two: Ethical Principles and Public Health Core Values | 17P a g e 2.11.1 Group work: To develop a national Code of ethics (only the principles), if not present in the trainees country, or review the current available code and submit a report on how to improve it 2.11.2 Individual/group assignment: On a case scenario that targets one or more of the ethical issues discussed in the module. develop culturally-sensitive appropriate approach to consent in a country in the region 2.12 References & Required Readings: APHA Code of ethics: http://www.apha.org/NR/rdonlyres/1CED3CEA-287E-4185-9CBD- BD405FC60856/0/ethicsbrochure.pdf Childress, James F. Et al., Public Health Ethics: Mapping the Terrain, Journal of Law, Medicine and Ethics, 30 (2002): 170-178. Verity C and Nicoll A. Consent, Confidentiality, and the threat to public health surveillance. BMJ. 324: 1210-1213. May 2002. Myers et al. Privacy and Public Health at Risk: Public Health Confidentiality in the Digital Age. AJPH. 98(5): 793-801. May 2008. O’Neil  O.  Informed  Consent  and  Public  Health.  Phil. Trans. R. Soc. Lond. B (2004) 359, 1133–1136. MacQueen K and Buehler J. Ethics, Practice, and Research in Public Health. AJPH. 94(6): 928-931. June 2004. Miller,  TE.  Sage,  WM.  “Disclosing  physician  financial  incentives.”  JAMA.  281  (15):1424-1430. April 1999. Daniels, N. and J. E. Sabin (2008). "Accountability for reasonableness: an update." BMJ 337. Alex  Friedman  (2008).  “Beyond  Accountability  for  Reasonableness”.  Bioethics  22  (2),  101–112. Doi:10.1111/J.1467-8519.2007.00605.X 2.12.1 Optional/additional readings: McGraw, D et al. Privacy as an enabler, not an impediment: Building Trust into Health Information Exchange, Health Affairs 28(2): 416-427 (2009). Achrekar, A.,  Gupta,  R.  “Informed  Consent  for  a  Clinical  Trial  in  Thailand.”  NEJM.  339  (18):1331-1332. 1998 Garland M, Stull J. Public health and health system reform: access, priority setting, and allocation of resources. ASPH: Ethics and Public Health Model Curriculum, 2003: 241-251. Wynia MK. Breaching confidentiality to protect the public: evolving standards of medical confidentiality for military detainees. Am J Bioethics 2007;7(8):1-5. Gostin,  LO  and  Powers,  M.  What  Does  Social  Justice  Require  for  the  Public’s Health? Public Health Ethics and Policy Imperatives. Health Affairs 25(4): 1053-1060 (2006).
  19. 19. Part Two: Ethical Principles and Public Health Core Values | 18P a g e Martin, Douglas K., Joseph L. Pater, and Peter A. Singer. "Priority-setting decisions for new cancer drugs: a qualitative case study." Lancet 358.9294 (2001): 1676-1680. Mshana, Simon, et al. "What do District Health Planners in Tanzania think about improving priority setting  using  ‘Accountability  for  Reasonableness'?."  BMC  Health  Services  Research  7.1  (2007):  180. Priority setting. BMJ 1998;317:1000-07.
  20. 20. Part Three: Ethical Issues in Vaccination | 19P a g e Part  three 3 Ethical issues in Vaccination 3.1 Description of the module: This module will introduce the ethical issues that arise from vaccination both from the viewpoint defending making at least of the vaccinations mandatory and those who advocate for the right to refuse vaccination. The latter group are either grounding their arguments on moral basis, i.e. adopting a liberal individualistic model of decision making or on scientific grounds by casting doubts on the safety and efficiency of some vaccines. There are ethical issues related to specific groups with vaccination like children under 5 years of age or female adolescents, as they are not usually competent enough to decide for themselves. Many of the countries in our region made vaccination mandatory to issue a birth certificate or for school admission. Similarly, there is another set of ethical issues related to making vaccination mandatory to some healthcare providers. Therefore, in ethical terms, there are potential tensions between autonomy on the one hand, and paternalism, justice and nonmaleficence on the other hand. 3.2 Intended Learning Objectives (ILOs): 1.2.1. Identify the ethical issue related to vaccination 1.2.2. Analyze the arguments that support and that reject making vaccination mandatory. 1.2.3. Outline an ethical framework to vaccination in the EMR context 3.3 Topics included in the module 3.3.1 Overview on vaccines, vaccination and immunization The following exacerbations from vaccines.gov and the world health organization (WHO) immunization websites describe the differences between the three terms. A vaccine is a product that produces immunity from a disease and can be administered through needle injections, by mouth, or by aerosol. A vaccination is the injection of a killed or weakened organism that produces immunity in the body against that organism. An immunization is the process by which a person or animal becomes protected from a disease. Vaccines cause immunization, and there are also some diseases that cause immunization after an individual recovers from the disease. (Source: http://www.vaccines.gov/basics/index.html) WHO defines Immunization as the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine.  Vaccines  stimulate  the  body’s  own  immune  system  to   protect the person against subsequent infection or disease. Community (Herd) immunity: A situation in which a sufficient proportion of a population is immune to an infectious disease (through vaccination and/or prior illness) to make its spread from person to person unlikely. Even individuals not
  21. 21. Part Two: Ethical Principles and Public Health Core Values | 20P a g e vaccinated (such as new-borns and those with chronic illnesses) are offered some protection because the disease has little opportunity to spread within the community. Table 1: Examples of vaccine-preventable diseases (modified from vaccines.gov and WHO) Chickenpox (Varicella) Hepatitis A Hepatitis B Hib (Haemophilis Influenza type b) HPV (Human Papillomavirus) Influenza (Flu) Diphtheria Japanese Encephalitis (JE) Measles* Meningococcal meningitis Mumps Pertussis (Whooping Cough) Pneumococcal Polio* Rabies Rotavirus Rubella (German Measles) Shingles (Herpes Zoster) Tetanus (Lockjaw) (Maternal and Neonatal MNT)* Tuberculosis (TB) Typhoid Fever Yellow Fever. *: diseases that the WHO targets by specific programs of elimination or eradication 3.3.2 Benefits and harms The assessment of benefits of vaccinations is crucial to understand and perhaps justify why vaccination is one of the most widely accepted compulsory public health interventions. However, these benefits are not totally agreed on and are challenged on grounds of safety and efficiency. This was well reflected in the media and professional handling of the H1N1 pandemic vaccine in 2009. This section will provide an orientation on these benefits then give a harm approach to vaccinations that is relevant to the EMR region like the threats that the vaccinators may be exposed to. The benefits of vaccination are mainly related to the production of immunization, which the evidence proved that it is a proven tool for controlling and eliminating life-threatening infectious diseases and the WHO estimated  that  vaccination  averts  between  2  and  3  million  deaths  each  year.  WHO  describes  it  as  “one  of  the   most cost-effective health investments, with proven strategies that make it accessible to even the most hard- to-reach and vulnerable populations that can be delivered effectively through outreach activities; and vaccination does not require any major lifestyle change.” There are two levels of inter-related and inter-dependent benefits: individual and community. To illustrate, those who are vaccinated are usually protected from the disease they were vaccinated against. They will be less likely to develop the disease  if  they  come  into  contact  with  it.  However,  if  ‘sufficient’  members  of  the   community get vaccinated, then the community will develop the herd community, as we have examined earlier in the module. In addition, even those who were not vaccinated due to their age (like new-borns), chronic medical condition, suppressed immunity, or those who have missed their scheduled vaccinations would be protected by being less exposed to infected persons. This benefit is well reflected by the dramatic reductions in the infections from the immunizable diseases like diphtheria, or even the eradication of polio from many of the countries worldwide and in our region, as well (see graph).
  22. 22. Part Two: Ethical Principles and Public Health Core Values | 21P a g e Figure 1 Measles in the US (1950-2007). Source: http://www.vaccines.gov/basics/effectiveness/index.html Figure 2 Total and vaccine preventatble diseases specific deaths, children under age 5, by WHO region, 2008 (Source: http://www.who.int/immunization_monitoring/burden/estimates_burden/en/index.html) Harms, on the other hand, are less clear. There is very little evidence that suggests that vaccines would really cause serious side-effects like getting infected by the disease in the case of being injected. The side effects are usually minor and local at the site of injection, like redness, itching, bruises, and discomfort at site of infection. Other harms are moderate like a high fever, chills, or muscle aches. Other severe complications are extremely rare like febrile seizures, severe allergic reactions, or brain damage. However, there are other forms of harm that need to be considered and that are not usually considered as they are not related to the efficiency or safety of the vaccine. They are more related to the process of them having the population vaccinated. We will discuss here two examples and you will have more discussion in your discussion forum and group work. On example is related to the population being vaccinated and another related to the vaccinators. First, there are the harms on the population being vaccinated. Some vaccines target specific individuals of the population. For example, the Human Papilloma Virus (HPV) vaccine targets
  23. 23. Part Two: Ethical Principles and Public Health Core Values | 22P a g e teenagers to protect them from catching the virus, which may develop into cancer in both females (cervical, vaginal and vulvar) and males (mainly penile). Receiving this vaccine has been perceived by some parents (in some western communities) as if it encourages the teenagers to get involved into sexual  relations  by  virtue  of  feeling  ‘safe’.  Furthermore,  it  might  cause  stigmatizing  those  who  would   have the HPV vaccine as sexually active. This may not be a big deal in communities where sexual relations are expected and accepted as social norm among teenagers. However, this is a major issue in  most  of  the  EMR  communities  where  the  general  norm  is  that  ‘no  sex  before  marriage  and  no  sex   outside  marriage’.  This  is  true  for  most  of  the  Muslim  and  non-Muslim communities. Later in the module, we will discuss the issues related to forcing people to get the vaccines. The second example of harms might also be less important in the developed countries. They are the harms on the vaccinators themselves, which might not be many but could be really serious. For example, the misconceptions that may be adopted in some communities about vaccines might be reflected as hostility on the vaccinators. Two striking recent examples were the murder of nine female vaccinators in Kano, Nigeria and five female health workers who were vaccinating children in Pakistan. These serious acts of hostility are severe reactions to the conceptions of vaccines as ‘western  conspiracy  to  cause  infertility’  or  the  doubts  that  these  vaccinators  may  be  spies  working   for the US intelligence after the C.I.A. used a vaccination team headed by a local doctor, Shakil Afridi,  to  visit  Osama  bin  Laden’s  compound  in  Abbottabad,  reportedly  in  an attempt to obtain DNA proof that the Bin Laden family was there before an American commando raid on it in May 2011 (BBC 2013, URL: http://www.nytimes.com/2012/12/19/world/asia/attackers-in-pakistan-kill-anti- polio-workers.html). 3.3.3 Paternalism and Duty to care for others (or not to harm other) As we have mentioned earlier, the benefits related to vaccinations are not only individual in nature; they also involve others. Those who are vaccinated do not only protect themselves from the immunizable diseases but also reduce the exposure of others to infection, as well as contributing to the  development  of  the  community’s  herd  immunity.   This mutual benefit raises some ethical issues related to whether the individuals should be given the choice not to get vaccinated based on the individual benefits that they may choose not to get, like any  other  healthcare  ‘individual’  benefit,  or  should  they  be  forced  to  be vaccinated in order to build and  maintain  the  ‘herd  immunity’  that  necessities  enough  proportion  of  the  population  is   vaccinated. The first argument is mainly linked to the ethical duty to respect the autonomy of the competent people to decide on the decisions related to their health and bodies. The latter position is based on a principle known as paternalism. It has more than one definition, but it refers usually to the  interference  with  another  person’s  choices  by  a  state  (or  other  individual  or  group) with or without  this  person’s  will  and  this  interference  is  justified  on  the  claim  that  this  interference  is  in  the   best interests of the person being interfered or the community in which this person lives. This interference is usually divided into soft paternalism and hard paternalism. The soft paternalism refers to the interference done on behalf of individuals who are not able to take their decisions properly, including children, adults with serious learning difficulties or who are mentally incompetent. Vaccination of children is considered an example of soft paternalism, as the decisions related to their vaccination are usually done by the caring adults (usually the parents). On the other hand, the hard paternalism is about overruling the decision of a competent adult. There are many examples of that, like the traffic laws that forces everyone who rides a bicycle to wear a helmet, or any motor vehicle driver to fasten his or her seatbelt. They are not given the choice to not to do that
  24. 24. Part Two: Ethical Principles and Public Health Core Values | 23P a g e in order to maintain their safety, and probably the safety of other road users. Other examples include banning of smoking in closed public places and public transports. In your discussion forum, you will have further discussions on whether it is justifiable to force even the competent persons to take follow given measures and changes in their lifestyle. The duty of care usually refers to the professional duty of healthcare providers to act in their patients’  best  interests.  However,  it  can  be  taken  in  its  wider  implementation to include the other members in the community. In other words, the relation between the provider and his or her client (patient) would justify such a duty, but what about other community members with whom we do not have relations. Do we have to act (or not)  in  each  other’s  best  interests?   3.3.4 Compulsion and refusal of vaccination In order to have a better understanding of the compulsion or refusal of vaccinations, we need to outline the following regarding vaccinations. Vaccinations are against serious diseases that are contagious, i.e. can cause non-trivial harm to ourselves and others. Vaccinations themselves are manufactured in compliance with high standards of safety, so they would rarely cause any serious harm to those who receive them. Though there have been some studies done to study the link between vaccination and other health conditions, like autism for example; yet there is no reliable research evidence that vaccines are linked to more serious long term complications. Compulsion of vaccinations has many forms. First, there are some vaccinations that are required by some  countries  as  a  visa  requirement,  as  it  is  the  case  with  getting  visa  to  perform  Hajj  (Muslim’s   pilgrimage)  or  Umra  (Muslim’s  visit  to  the  holy  places)  in  Makah,  Saudi  Arabia.  Also  there is the conditioning of having a full vaccination card for the first year of life in order to get the birth certificate. In addition, vaccinations of the pre-school children are needed to register them in the school. There are other forms related to the vaccination of the healthcare providers and other public sector workers (e.g. custom officers, police staff, etc.) who come in contact with crowds or suspected patients. Compulsion of vaccinations in its many forms is based on the argument that it is in the best interests of those who receive them, and the harms that they might cause are rare and trivial if compared to the serious complications of catching the disease. It is also compared to other public health interventions enforced by law like fastening the seatbelts, for example. However, there are arguments against such compulsion, which in turn argue for giving the people the right to refuse getting the vaccination, or at least to be consented before getting it in similar ways that are done for therapeutically interventions. First, there are those who base their refusal on issues related to the vaccines safety and efficiency. These arguments have been on- going in many parts of the world, even the developed countries. However, in our region countries they were quite exaggerated  by  linking  vaccinations  to  a  ‘conspiracy  to  cause  infertility’.  There  was  no  reliable   research evidence that would link the administration of any of the vaccines, especially polio vaccine, to infertility or any other long term health conditions. A second argument in favour of the right to refuse vaccinations is based on comparing the preventive public health measures to the therapeutic ones. This is hard to achieve on both moral and logistic basis. Morally, consent is taken from individual patients in relation to interventions that would physically involve their bodies only. Vaccination is about interventions related to diseases that would harm both the targeted persons and other persons in the community directly. Second, if we compare the harms, we would find that those of the diseases overweigh those of the vaccines
  25. 25. Part Two: Ethical Principles and Public Health Core Values | 24P a g e bearing in minds the millions of children who die every year in many parts of the world, including our region of vaccine-preventable diseases. There are also arguments related to the presence of other preventative alternatives than vaccination. It is true that there are other protective measures that could be followed but they need more time, resources and compliance from the people in order to be effective. Lastly, there  is  the  argument  related  to  the  ‘rights’  of  the  people.  This  argument  claims  that   compulsion of vaccination is against the right to decide and bodily integrity. There are two points that need to be emphasized in this argument. First, rights are based on a justification why they were considered rights in the first place. For example, the right to consent and bodily integrity is based on the justification that no mentally competent would normally harm himself knowingly and intentionally. Therefore, the person is the primary beneficiary of maintaining his or her bodily integrity, while others may have their reasons that would not make them working in the best interest of the person, e.g. if the family wants him to die to inherit his fortune, or if the doctors are interested in having his organs after his death. Does that apply to vaccination? Secondly, there are issues related to the socio-political context in which this compulsion is taking place. Normally, in a democratic country where the government, including the health authorities, are  held  accountable  for  their  acts,  the  people  would  expect  the  government  to  act  in  its  people’s   best interests, at least for the mere pragmatic purpose of getting re-elected in the next presidential or parliamentary elections. In non-democratic countries, where the presidents stay presidents for life by the power of the security forces and fake elections, there is usually lack of trust in the public sector. People may expect the government to harm them, or at least would not stop others from harming them. This is hard to prove given that these countries have limited freedom of press, so much of the issues related to the compulsory governmental interventions, even if related to health will remain victim of rumours that lay people share. The public health sector will have more burden to convince the people to comply with the compulsory interventions, given that these countries usually suffer from political and financial corruption, which may make people find it safer to bribe an employee  to  issue  them  a  certificate  or  accept  their  child’s  admission  to  school. 3.4 Student’s  evaluation Student (or group) assignment on discussing a case scenario (or an article), where the student(s) presents an argument for (or against) the pre-employment tests (or the ban on recruiting smokers) 3.5 References Dawson, A. 2011, "Vaccination ethics", Public Health Ethics pp. 143-153. 3.5.1 Required Readings: Krantz, I., Sachs, L., & Nilstun, T. 2004, "Ethics and vaccination", Scandinavian Journal of Public Health, vol. 32, no. 3, pp. 172-178. Omer, S. B., Salmon, D. A., Orenstein, W. A., deHart, M. P., & Halsey, N. 2009, "Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases", New England Journal of Medicine, vol. 360, no. 19, pp. 1981-1988.
  26. 26. Part Two: Ethical Principles and Public Health Core Values | 25P a g e 3.5.2 Optional/additional readings: Colgrove, J. 2006, "The ethics and politics of compulsory HPV vaccination", New England Journal of Medicine, vol. 355, no. 23, pp. 2389-2391. Van Delden, J. J., Ashcroft, R., Dawson, A., Marckmann, G., Upshur, R., & Verweij, M. F. 2008, "The ethics of mandatory vaccination against influenza for health care workers", Vaccine, vol. 26, no. 44, pp. 5562-5566

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