Essentials of Public Health Ethics

Portokalis/ShutterStock, Inc. Essentials of Public Health Ethics Ruth Gaare Bernheim, JD, MPH James F. Childress, PhD Chair, Department of Public Health Sciences University Professor School of Medicine John Allen Hollingsworth Professor of Ethics Institute for Practical Ethics and Public Life Institute for Practical Ethics and Public Life University of Virginia University of Virginia Charlottesville, VA Charlottesville, VA Richard J. Bonnie, JD Alan L. Melnick, MD, MPH, CPH Harrison Foundation Professor of Law and Medicine Public Health Director/Health Officer Clark County, Washington Professor of Public Policy School of Law University of Virginia Charlottesville, VA Adjunct Associate Professor Oregon Health & Science University School of Medicine Departments of Family Medicine and Public Health & Preventative Medicine Portland, OR 9780763780463_FMxx_00i_xvi.indd 1

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Portokalis/ShutterStock, Inc. Dedication To our many students and colleagues, who have taught us so much. 9780763780463_FMxx_00i_xvi.indd 3

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Portokalis/ShutterStock, Inc. Table of Contents Preface Prologue ix xi Part I Foundations 1 Chapter 1 Introduction: A Framework for Public Health Ethics 3 by James F. Childress and Ruth Gaare Bernheim Introduction: Public Health Ethics: A Preliminary Analysis What Is Public Health Ethics? Public Philosophy Moral Norms Moral Considerations in Public Health Relations Between Moral Norms and Public Health Addressing Ethical Conflicts and Dilemmas in Public Health Absolutist and Contextualist Approaches A Presumptivist Approach Interlude: Summary Justificatory Conditions for Overriding Norms in Conflict Situations Public Justification in Context Ethical Conflicts: Pervasive or Occasional? Ethical Dimensions of Public Health Decisions Competing Claims about Ethical Trade-offs in Public Health Scope of Societal Values: Inclusion of Personal Values Historical Perspective on Conflicts in Public Health 9780763780463_FMxx_00i_xvi.indd 5 3 4 5 5 5 5 6 6 7 7 7 9 10 10 11 11 11

vi Table of Contents Analyzing Ethical Issues in Particular Situations 12 The Role of the Public Health Code of Ethics 13 Metaphors in Public Health Ethics 14 Public Health as Warfare 14 Public Health as Stewardship 16 Conclusions 17 Discussion Questions 18 References 19 Chapter 2 Moral Considerations: Bases and Limits for Public Health Interventions 21 by James F. Childress Introduction 21 Utility: Balancing Probable Benefits, Costs, and Risks 22 Utility 22 Cost-Effectiveness and Cost-Benefit Analyses 23 Risk Assessment 25 Variations in Risk Perception 25 Distributive Justice 25 Formal Justice and Material Justice 26 Theories of Distributive Justice 26 Excursus: Just Care in a Public Health Crisis: Utility and Egalitarian Justice 28 Triage in a Public Health Crisis 28 Types of Utility-based Triage 28 Applications of Medical and Social Utility 29 Public Participation, Public Trust, and Social Stability 30 Fair Procedures and Processes 31 Respect for Autonomous Choices and Liberties 32 The Intervention Ladder 32 Paternalistic Interventions 37 Privacy and Confidentiality 38 Privacy 38 Confidentiality 39 Conclusions 41 Discussion Questions 42 References 43 Chapter 3 The Political and Legal Context of Public Health Ethics 45 by Ruth Gaare Bernheim and Richard J. Bonnie Introduction 45 The Relationship Between Law and Ethics in Public Health 46 9780763780463_FMxx_00i_xvi.indd 6

Table of Contents vii Source and Distribution of Government Authority in Public Health 49 Case Study: Bathhouse Scenario 51 Constraints on Government Authority: Balancing Individual and Public Interests 53 Does Government Have a Duty to Protect Health? 59 Law as a Tool for Improving Public Health 60 Public Deliberation and Leadership 63 Case Study: Smoke-Free Policies in Outdoor Public Spaces 68 Conclusions 69 Discussion Questions 70 References 71 Chapter 4 Public Health Perspectives 73 by Ruth Gaare Bernheim Introduction 73 Improving Population Health 74 Evidence-Based and Value-Based Approaches 75 Setting Goals in State and Local Public Health 77 Case Study: Addressing Heart Disease 77 Proposals for Advisory Committee Review 80 Population Prevention 81 Implications of Population-Wide Approaches 82 Determinants and Pathways 83 Ecological Approaches and Health Inequalities 84 Evidence in Public Health Practice 86 Healthy Communities: Collaborations, Stakeholders, and Systems 88 Conclusions 90 Discussion Questions 92 References 93 Part II Tools and Interventions in Public Health 95 Chapter 5 Surveillance and Public Health Data: The Foundation and Eyes of Public Health 97 by James F. Childress Introduction 97 Public Health Surveillance: Its Nature and Goals 98 What Is Public Health Surveillance? 98 Types of Public Health Surveillance 98 Who Is Involved in Public Health Surveillance? 99 9780763780463_FMxx_00i_xvi.indd 7

viii Table of Contents Surveillance: Necessary but Insufficient for Effective Public Health 99 Health Security, Securitization, and Surveillance 101 Ethical Considerations in Public Health Surveillance 101 Practice vs. Research: Is the Distinction Ethically Significant for Surveillance? 103 The Practice/Research Distinction in Public Health Surveillance 103 Ethical Review of the Public Health Practice of Surveillance 106 CHEERS: A Case of Ethically Unjustified Research? 107 Case Study: Nonconsensual Name-Based Surveillance of Diabetes Control 109 New York City s Surveillance Program for Inadequately Controlled Diabetes 109 Ethical Issues Raised by the NYC Diabetes Surveillance Program 109 Ethical Analysis and Assessment of the NYC Diabetes Surveillance Program 113 Public Disclosure of Surveillance Data 115 Conclusions 115 Discussion Questions 116 References 117 Chapter 6 Case Finding: Screening, Testing, and Contact Tracing 119 by Alan L. Melnick Introduction 119 Newborn Screening 120 Case Contact Tracing and Contact (Partner) Notification 122 Summary: Newborn Screening and Contact Tracing/Notification 123 Screening and Coerced Treatment of a Pregnant Woman for HIV Infection 123 Overview of Prenatal HIV Screening and Treatment 123 Case Description 128 Ethics Framework 128 HIV/Syphilis Contact Investigation and Partner Notification 134 Overview of Contact Investigation and Partner Notification 134 Case Description 135 Ethics Framework 135 Conclusions 139 Discussion Questions 141 References 142 Chapter 7 Immunization: Protection Through Vaccination 145 by James F. Childress Introduction 145 Mass Immunization Programs: Justifications 146 Jacobson v. Massachusetts 146 9780763780463_FMxx_00i_xvi.indd 8

Table of Contents ix Societal Self-Defense for the Common Good 146 Balancing Principles 147 More Specific Guidance for Mass Immunization Programs 148 Voluntary and Mandatory Immunization Programs 148 Persuasion and/or Coercion? 148 Incentive Rewards or Monetary Sanctions? 149 Targeted Vaccinations 151 Case Study: Annual Influenza Vaccination for Nursing Home Staff: Mandatory or Voluntary? 151 Exemptions from Mandatory Vaccination Programs 152 Variations in State Exemptions 152 Exemption of Conscientious Objectors 154 Case Study: Should Religiously Based and Philosophical/Personal Objections to Vaccinations Be Recognized as Bases for Exemption? 154 Religious Convictions 154 Philosophical and Personal Beliefs 155 Free Choices or Hurdles and Nudges? 155 Case Study: Debating Whether the HPV Vaccination Should Be Mandatory 156 Background 156 Pro and Con Arguments About the HPV Vaccine 156 For Females Only? 158 Cost 158 Symbolic Significance of Legal Mandates 159 Exemption from HPV Mandates 159 Justice, Fairness, and Compensation for Vaccine-Related Injuries 159 Allocating Scarce Vaccines: Utility and Fairness 160 Case Study: Allocating Influenza Vaccine in a Serious Shortage: The 2004 2005 Crisis 160 Background 160 Public Health Decisions About Vaccine Allocation 161 Other Criteria and Methods of Rationing Vaccine 163 Lessons Learned, Questions Raised for a Possible Influenza Pandemic 164 Conclusions 166 Discussion Questions 167 References 168 Chapter 8 Containing Communicable Diseases: Personal Control Measures 171 by Alan L. Melnick Introduction 171 Directly Observed Therapy for Multiple Drug-Resistant Tuberculosis 172 Background 172 9780763780463_FMxx_00i_xvi.indd 9

x Table of Contents Case 1: Ordering Directly Observed Therapy for MDR TB 173 Background 173 Ethical Analysis and Assessment of this Case 174 Personal and Community Control Measures in Response to Outbreak of Severe Respiratory Illness 179 Background 179 Monitoring: Active and Passive 180 Types of Quarantine 180 Focused and Community-Wide Measures to Create Social Distance: Benefit-Risk Analysis 181 Case 2: Controlling Severe Respiratory Illness of Unknown Etiology at a Major University 182 Background 183 Ethical Framework 183 Conclusions 188 Discussion Questions 189 References 190 Chapter 9 Health Communication 193 by Ruth Gaare Bernheim and Richard J. Bonnie Introduction 193 Government s Role in Using and Regulating Mass Communication 194 Early Government Health Education Efforts 194 Possible Aims and Justifications 195 Overview of First Amendment Constraints 196 Principles and Concepts 196 Commercial Advertising 197 Mandated Factual Disclosures 198 Government Speech 198 Aggressive Tobacco Control: New Frontiers of the First Amendment 199 Restrictions on Tobacco Advertising 200 Aggressive Package Regulation 202 Government-Supported Media Campaigns 206 Ethical Dimensions of Government Communication 207 Providing Information 207 Persuading With and Without Explicit Reasons 208 Marketing Health 210 Empowering Health 210 Conclusions 214 Discussion Questions 215 References 216 9780763780463_FMxx_00i_xvi.indd 10

Table of Contents xi Chapter 10 Public Health and the Environment 219 by Alan L. Melnick Introduction 219 Part 1: Ethical Perspectives on Environmental Policies: Water Fluoridation and Lead 221 Water Fluoridation: Too Much or Too Little? 221 Fluoridation History and Trends 221 Benefits of Fluoridation 223 Opposition to Fluoridation 223 Continuing Deliberation 224 Lead: Too Much for Some 224 Part 2: Environmental Public Health Practice 227 Introduction 227 Case Study: Lead Poisoning at a Private Indoor Shooting Range 228 Ethical Framework 232 Case Study: Banning Raw Milk Sales at Local Farmers Markets 239 Ethical Framework 240 Conclusions 244 Discussion Questions 246 References 247 Index 249 9780763780463_FMxx_00i_xvi.indd 11

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Portokalis/ShutterStock, Inc. Preface This book grows out of our interactions in teaching, research and writing, and collaborative projects. Even though this is the first project in which all four of us have collaborated at the same time, we have had many opportunities to work together in various combinations. Those collaborations enabled us to develop the frameworks for this book. This is an integrated book, which grows out of these shared experiences, but we decided it would be useful to list the primary author or authors for each chapter. We have dedicated this book to our many students and colleagues from whom we have learned so much. Our interactions with students in the classroom as well as those with colleagues in co-teaching, collaborative projects, and conferences have stimulated our reflections and helped us refine our ideas. They have also given us confidence that the frameworks we use in this book can be helpful. We thank several doctoral students in ethics in the Department of Religious Studies at the University of Virginia for their valuable assistance in the preparation of this book. Laura Alexander, Matthew Puffer, and Mark Storslee provided research assistance on bibliography and arguments for several chapters, and Betsy Mesard, Travis Pickell, and Matthew Puffer prepared the teaching ancillaries. We are also grateful to Aaron Pannone for his help in developing several figures for the book. James Childress wishes to thank his colleagues at the Centre for the Advanced Study of Bioethics at the University of Münster for helpful conversations on John Stuart Mill, public health ethics, and paternalism, in May and June of 2011. Ruth Gaare Bernheim wishes to express her appreciation to Drue Barrett and Leonard Ortmann in the Public Health Ethics Unit at the Centers for Disease Control and Prevention. Ruth Gaare Bernheim, James F. Childress, Richard J. Bonnie, and Alan L. Melnick 9780763780463_FMxx_00i_xvi.indd 13

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Portokalis/ShutterStock, Inc. Prologue As series editor of the Essential Public Health series, I am delighted that Essentials of Public Health Ethics is now part of our offerings. Essentials of Public Health Ethics represents a world-class effort to teach ethics and integrate it into the continuum of public health education. The book reflects the combined efforts of four exceptional authors with decades of experience teaching ethics to a wide range of students in a variety of formats. The authors are all distinguished practitioners, teachers, and scholars in public health ethics and law. The book begins with a clear, compelling framework for thinking about public health ethics. This framework is integrated throughout the book. Subsequent chapters are devoted to areas of application presented in a logical order, enabling the text to develop an integrated approach. The variety of applications provides flexibility in utilizing the text in course work. The cases and approach are classroom- and practitioner-tested, having been successfully used to teach students from across the country as well as discussed by practitioners at local and national meetings. Students will find the cases relevant and the analysis insightful. The authors extraordinary talents and experience allow them to walk students through complex ethical decision making, providing students with progressive ability to tackle new ethical issues on their own. Take a look at the table of contents and the introductory material, followed by a scan of the chapters. You will find a welcoming yet challenging approach to public health ethics that should appeal to students from a wide range of disciplines headed for diverse careers. Public health ethics has become a key component of public health education. Now there is a text that makes public health ethics come alive. Richard Riegelman, MD, PhD Editor, Essential Public Health series 9780763780463_FMxx_00i_xvi.indd 15

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