Introduction to Public Health Ethics Online Course

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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)

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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

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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

Part One: Definitions and Main Concepts in Public Health Ethics
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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.

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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?

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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.

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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.

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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.

Part One: Definitions and Main Concepts in Public Health Ethics
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Part
Two

2 Ethical principles and theories and the core professional public
health values
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
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
2.3.1 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

Part Two: Ethical Principles and Public Health Core Values
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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

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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

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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.

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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.

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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

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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

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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

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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.

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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).

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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.

Part Three: Ethical Issues in Vaccination
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Part
three
3 Ethical issues in Vaccination
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.
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
3.3.1 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

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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).

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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

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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

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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

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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.

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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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