What is Public Health Ethics?
Public Health Ethics refers to a system of moral principles that apply values to the practice of public health and scientific research in public health including community medicine. In practice, ethics allow for people, regardless of their race, gender, or religion to be guaranteed quality and principled care. Medical ethics is based on a set of values that public health professionals and other health practitioners can refer to in the case of any confusion or conflict. These values include the principles of non – maleficence, beneficence, respect for autonomy, and justice.
The Nuffield Bioethics Council 2007 and several other seasoned scholars have identified a number of general moral considerations that includes:
- Building and maintaining trust.
- Distributing health benefits fairly, or distributive justice (fair distribution of social goods).
- Producing benefits, often but not exclusively health benefits.
- Protecting non-dominant subgroups from marginalization and stigmatization.
- Preventing harms, often health harms, such as preventable morbidity and premature death.
- Procedural justice (fair process), participation, and transparency.
- Respecting individual autonomy and liberty of action.
- Respecting and fulfilling universal human rights.
- Respecting privacy and confidentiality.
Public health activities and programs routinely brings some of these moral considerations into conflict. One important area concerns the power of public health as an agent of the state to restrict individual choice in efforts to promote health and prevent diseases. While many public health activities try to influence individual actions, in a less restrictive way the impact of certain public health policies may completely eliminate choice altogether, a typical example is the compulsory quarantine of patients with infectious diseases such as Ebola or Lassa fever, another example of restriction of choice is the banning of smoking in some public places.
Paternalism in Healthcare
The major objectives of Public health action is to influence human behavior that arguably does no harm to self and to others. In developed countries of the world chronic diseases account for the majority of deaths, and personal behaviors account for a significant cause of their onset and progression. Current research and action in public health seeks to change behaviors whose consequential effects are felt primarily by those who engage in them.
What is Paternalism?
Paternalism occurs when the state or a situation or an individual interferes with the preferences of a person for his/her own benefit with the sole aim of promoting health. Paternalism also involves limiting a person or group’s freedom or autonomy with sole aim of promoting their own good.
What are the Types of Paternalism Healthcare?
Hard and soft Paternalism
Soft Paternalism: Under this form of paternalism, action can only be justified when an action to be committed is involuntary.
Soft Paternalism Example: An example of soft paternalism is preventing a person from crossing a bridge when we know the bridge is damaged and we are unable to tell the fellow that the bridge is damaged as he doesn’t speak our language. If he knows and intends to jump off the bridge and commit suicide and we allow him this is soft paternalism.
Hard paternalism: Under this form of paternalism, action can only be justified when an action to be committed is voluntary.
Hard Paternalism Example: An example of hard paternalism is forcefully preventing a man who knows a bridge is damaged from crossing the bridge and committing suicide.
Pure and impure Paternalism
Pure paternalism: Under this form of paternalism a person or group of persons have their freedom or autonomy restricted due to their being protected.
Impure paternalism: Under this form of paternalism a person or group of persons have their freedom or autonomy violated and are not just the persons being protected.
Moral and welfare
Moral paternalism: Under this system paternalism is justified to promote the moral well-being of a person or group of persons even if their welfare wouldn’t improve.
Moral paternalism Examples: An example of moral paternalism is preventing a man or woman from prostitution even if they make a decent living from the action and they practice safe sex.
What constitutes a fair distribution of health?
The most important question in the allocation of scarce resource for health is often how to balance the objective of achieving maximum health benefits against genuine concerns relating fairness of the distribution of health. Systematic analysis of social justice and health equity have thrown up a number of basic but important questions, which includes the following:
- Are social inequalities in health unjust?
- Which inequalities are most urgent?
- What constitutes a fair distribution of health?
It is vital to note that, while the utilitarian goal aims to maximize aggregate health, the distributive goals principal objective is to produce a fair distribution of health even though health policies and public health activities tend to produce more health improvement and reduce health inequalities, health initiatives can often reproduce or exacerbate health disparities because individuals who are better off people tend to benefit sooner and disproportionately from most health promotion interventions. The systematic distribution of health in a fair and equitable manner involves two major approaches.
- Constructing Measures Of The Inequality In Health (The Inequality Adjustment Approach)
This involves constructing measures of the inequality in health, in addition to proposing ways of constructing measure of aggregate goodness which can be achieved by combining measures of health inequality and measures of aggregate health.
- Cost-Effectiveness Approach
Distributional objectives are not included into standard cost effectiveness analysis, such goals can easily be accommodated within this approach by attaching distributional weights to health outcomes. This method just as the inequality adjustment approach, will produce an overall measure of goodness that represents both the concern for a fair distribution of health (equity) and the concern for aggregate health (efficiency).
What is participation in health?
Participation in health is defined as a collaborative process that equitably engages members of the community, organizational representatives, researchers, among others in knowledge creation and social change. In practice, such processes produce more equitable and effective outcomes and may also protect non-dominant communities, cultures and tribes from health interventions that will marginalize, stigmatize or place them in a further disadvantaged position.
Parents Right To Refuse Vaccination
As a health personnel there are times you will have to deal with issues related to preventative health measures or interventions that provide little or no benefit to the individual, yet provide substantial or valuable collective benefit to the public’s health.
A typical example being immunization. When most of the people in a community are vaccinated, those who did not receive the vaccines are also protected from the contagious disease due to the lower risk of an outbreak. This is referred to as herd or community immunity. If a patient refuses a legally required immunization in locations where it is mandatory to be immunized either due to personal, religious or cultural beliefs the best and most effective response is to maintain a therapeutic alliance with a child’s parent and gently move in a direction to douse their fears and address their concerns about vaccination by promoting the importance and safety of vaccination.
However, If not legally required, a duly filled informed refusal form, expressing compelling personal, cultural or religious beliefs, may be respected. Vaccination refusal is very common in northern Nigeria, this has exacerbated the polio epidemic and resulted in the eventual return of the wild polio virus after 2 year absence.
How Should Communicable Diseases Be Reported To Public Health Authorities?
Each country or state has specific protocols and or guidelines that identify specific diseases with public health implications, such as communicable diseases, which require mandatory reporting. If you are uncertain whether reporting is required or not it is often advised that you contact the local public health authority for clarifications and further guidance. Beyond this statutory or legal requirement lies the ethical question of when it is justified to potentially break the code of confidentiality to protect the public’s interest or health.
It is ethically justified and morally correct to disclose a diagnosis to public health authorities if the potential risk to the general public has the following characteristics:
- The magnitude of risk is serious.
- The probability of risk is high.
- The risk relates to an identifiable individual or group
What Diseases are Included in the Mandatory CDC Reportable Diseases?
Complete List of CDC National Notifiable Conditions
- Arboviral diseases, neuroinvasive and non-neuroinvasive
- California serogroup virus diseases
- Chikungunya virus disease
- Eastern equine encephalitis virus disease
- Powassan virus disease
- St. Louis encephalitis virus disease
- West Nile virus disease
- Western equine encephalitis virus disease
- Botulism, foodborne
- Botulism, infant
- Botulism, wound
- Botulism, other
- Carbon monoxide poisoning
- Chlamydia trachomatis infection
- Congenital syphilis
- Syphilitic stillbirth
- Dengue virus infections
- Dengue-like illness
- Severe dengue
- Ehrlichiosis and anaplasmosis
- Anaplasma phagocytophilum infection
- Ehrlichia chaffeensis infection
- Ehrlichia ewingii infection
- Undetermined human ehrlichiosis/anaplasmosis
- Foodborne Disease Outbreak
- Haemophilus influenzae, invasive disease
- Hansen’s disease
- Hantavirus infection, non-Hantavirus pulmonary syndrome
- Hantavirus pulmonary syndrome
- Hemolytic uremic syndrome, post-diarrheal
- Hepatitis A, acute
- Hepatitis B, acute
- Hepatitis B, chronic
- Hepatitis B, perinatal infection
- Hepatitis C, acute
- Hepatitis C, chronic
- HIV infection (AIDS has been reclassified as HIV Stage III)
- Influenza-associated pediatric mortality
- Invasive pneumococcal disease
- Lead, elevated blood levels
- Lead, elevated blood levels, children (<16 Years)
- Lead, elevated blood levels, adult (≥16 Years)
- Lyme disease
- Meningococcal disease
- Novel influenza A virus infections
- Pesticide-related illness and injury, acute
- Poliomyelitis, paralytic
- Poliovirus infection, nonparalytic
- Q fever
- Q fever, acute
- Q fever, chronic
- Rabies, animal
- Rabies, human
- Rubella, congenital syndrome
- Severe acute respiratory syndrome-associated coronavirus disease
- Shiga toxin-producing Escherichia coli
- Spotted fever rickettsiosis
- Streptococcal toxic shock syndrome
- Syphilis, primary
- Syphilis, secondary
- Syphilis, early latent
- Syphilis, late latent
- Syphilis, late with clinical manifestations (including late benign syphilis and cardiovascular syphilis)
- Toxic shock syndrome (other than streptococcal)
- Typhoid fever
- Vancomycin-intermediate Staphylococcus aureus and Vancomycin-resistant Staphylococcus aureus
- Varicella deaths
- Viral hemorrhagic fever
- Crimean-Congo hemorrhagic fever virus
- Ebola virus
- Lassa virus
- Lujo virus
- Marburg virus
- New World arenavirus – Guanarito virus
- New World arenavirus – Junin virus
- New World arenavirus – Machupo virus
- New World arenavirus – Sabia virus
- Waterborne Disease Outbreak
- Yellow fever
- Zika virus disease and Zika virus infection
- Zika virus disease, congenital
- Zika virus disease, non-congenital
- Zika virus infection, congenital
- Zika virus infection, non-congenital
Complete List Of Notifiable Diseases in Canada
|IDS||1986 – present|
|Anthrax||1930 – 1982, 2002 – present|
|Botulism||1933 – present|
|Brucellosis||1928 – present||Originally called ‘undulant fever’|
|Campylobacteriosis||1986 – present|
|Chickenpox (Varicella)||1924 – 1958, 1986 – present|
|Chlamydia||1991 – present||See ‘sexually transmitted infections’ in the listing of links|
|Cholera||1930 – present||Asiatic’ cholera specified between 1930 and 1958|
|Clostridium difficile Associated Diarrhea (CDI)||2009 – pr|
|Congenital Rubella Syndrome (CRS)||1979 – present|
|Congenital Syphilis||1993 – present||See ‘sexually transmitted infections’ in the listing of links|
|Creutzfeldt-Jakob Disease (CJD)||2000 – present||Not presented on the application|
|Cryptosporidiosis||2000 – present|
|Cyclosporiasis||2000 – present|
|Diphtheria||1924 – present|
|Giardiasis||1983 – present|
|Gonorrhea||1924 – present||See ‘sexually transmitted infections’ in the listing of links|
|Group B Streptococcal Disease of the Newborn (GBS)||2000 – present|
|Hantavirus Pulmonary Syndrome||2000 – present|
|Hepatitis A||1927 – 1958, 1969 – present||Originally named ‘infectious jaundice’. Between 1959 and 1968, hepatitis was reported as a combined category, and since the type of hepatitis cannot be determined, these data are not reported.|
|Hepatitis B||1969 – present||Originally named ‘serum hepatitis’. Reporting does not differentiate between acute and chronic cases|
|Hepatitis C||1991 – present||Hepatitis C cases would have been captured in the earlier categories of Hepatitis non-A, non-B, and Hepatitis, unspecified by type|
|HIV Infection||2000 – present|
|Influenza, Epidemic||1924 – 1958|
|Influenza, Laboratory Confirmed||2000 – present|
|Invasive Group A Streptococcal Disease||2000 – present|
|Invasive Haemophilus influenzae, non-b Disease||2007 – present|
|Invasive Haemophilus influenzae, type b Disease||1986 – present||Invasive Haemophilus influenzae disease was collected from 1979 onward, but with no type specified|
|Invasive Meningococcal Disease||1924 – present|
|Invasive Pneumococcal Disease||2000 – present||Replaced pneumococcal meningitis. Invasive pneumococcal disease is a more general category that would include pneumococcal meningitis, but would also include other invasive pneumococcal infections.|
|Legionellosis||1986 – present|
|Leprosy||1925 – present|
|Listeriosis||1990 – 1999, 2007 – present||All forms of listeriosis were notifiable from1999-2000. Starting in 2007, only invasive forms required notification|
|Lyme Disease||2009 – present|
|Malaria||1929 – 1978, 1983 – present|
|Measles||1924 – 1958, 1969 – present|
|Mumps||1924 – 1958, 1986 – present|
|Norovirus Infection||2007 – present||Only outbreaks are to be notified|
|Paralytic Shellfish Poisoning||2007 – present|
|Paratyphoid||1924 – present||Paratyphoid was reported in a separate category between 1924 and 1952 then from 1953 to 1968 combined with typhoid, once again reported separately from 1969 to 1999, then combined with salmonellosis in 2000.|
|Pertussis||1924 – present||Also known as whooping cough|
|Plague||1930 – present|
|Poliomyelitis||1924 – present||Non-paralytic poliomyelitis was presented in the viral meningitis category starting in 1962|
|Rabies||1927 – present|
|Rubella||1924 – 1958, 1969 – present||Also referred to as German measles|
|Salmonellosis||1959 – present||Paratyphoid was included with salmonellosis beginning in 2000|
|SARS||2004 – present||Though SARS was added to the list in 2004|
|Shigellosis||1924 – present||Originally named ‘bacillary dysentery’|
|Smallpox||1924 – 1981, 2002 – present||Although Smallpox was eradicated globally in 1980. It was returned to the list of notifiable diseases in 2000 as a potential bioterrorism agent|
|Syphilis||1924 – present|
|Tetanus||1957 – present|
|Tuberculosis||1924 – present|
|Tularemia||1930 – 1982, 2002 – present|
|Typhoid||1924 – 1952, 1969 – present||Between 1953 and 1968, was presented as a combined category of ‘typhoid and paratyphoid’|
|Verotoxigenic Escherichia coli Infection||1991 – present|
|Viral Hemorrhagic Fever||1979 – 1982, 2002 – present|
|West Nile Virus Infection (WNV)||2003 – present|
|Yellow Fever||1930 – present|
Complete List Of Notifiable Diseases in Nigeria