How should local public health officials involve the public in developing plans to ration scarce medical resources such as ventilators and medications during a pandemic flu? How can they engender the public trust necessary to provide community leadership in public health emergencies?
Leadership questions like these in emergency preparedness--which are both practical and ethical--challenge local public health officials to think anew about the need for an expanded, and perhaps more explicit, role for ethics in public health practice and management. Such a "practical ethics" approach in public health practice would require more than an ethical analysis of any one case or public policy issue. Instead, it would require principled leadership that focuses on public health values and an agency-mission statement, and that integrates ethics throughout the organization by, for example, setting performance measures based on them.
Public Health Ethics in Practice
As demonstrated by emergency preparedness, leadership in public health practice requires an ongoing approach to ethics that focuses on two dimensions of practice-the professional relationships of officials developed over time with their communities and the ethical aspects of day-to-day public health activities. Relationship-building activities, such as collaboration and deliberation with community stakeholders, provide opportunities for public health officials to integrate professional values into everyday practice. When animated by public health principles, such as justice and respect for individuals and diverse cultures, these activities may be more important for biopreparedness than having legal authority, because over time they engender community trust and nurture civic cooperation. A growing body of empirical literature provides evidence for "a link between perceptions of trustworthy government and citizen compliance[horizontal ellipsis]" and some studies explicitly address the importance of "the psychological interactions between the governed and their governors."1(p492) Other recent studies describe possible components of trust, such as perceived competence, consistency, fairness, and openness on the part of government officials, as well as, in a participatory democracy, an active public.2 For public health officials, empirical evidence about public involvement, deliberation, and political legitimacy can be helpful, particularly for designing different strategies or ways to encourage and strengthen public engagement, for example, town hall meetings and focus groups.3
Ethics, however, provides yet another form of inquiry--it addresses an important complementary question, that is, which moral norms should guide our behavior and why? For example, when allocating scarce medical resources in an emergency, which norms should guide decisions, treat on the basis of the most good for the greatest number, or treat the most vulnerable and sickest first?
In general, ethics as a discipline examines such questions as how we should live and treat one another, and how, all things considered, should we act. Public health officials, who are both government officials with obligations to the public and also healthcare professionals with their own professional norms, face ethical tensions and conflicting obligations when deciding how to act in many situations. Education and competencies in at least three different spheres of ethics may be helpful in practice, by providing, at a minimum, frameworks and principles to structure analysis and discussion in health departments and with community stakeholders.
Professional ethics, which focuses on the professional relationship between the official and the community. What does it mean to be a professional? The term profession generally refers to a vocation or occupation that has a practice with specialized training, a commitment to serving clients, self-regulation, and often a public purpose or social function. Some suggest that the professions and society negotiate the terms of their relationship to satisfy the profession's interest in autonomy and the public's interest in accountability.4 Most professions have at least an implicit professional morality, and in recent years many groups are developing or strengthening explicit codes of conduct and values to educate and transmit moral guidelines about professional relationships and actions.
In public health, the professional relationship between the public health professional and client is complex. Public health officials act as both government officials with police powers and healthcare professionals with health as a primary public good. In a democracy, public health officials are like physicians to the community with an ethical duty to engage in a consent process that involves transparency and public accountability and yet have the duty to override the decisions of individuals who put the health of the public at risk. Implicit in the traditional social obligations of professions, including public health, are tensions because a professional often owes obligations to a number of parties, including individuals, numerous groups in society, the public at large, other professionals, and government authority.
Managing the tensions that arise in emergency preparedness and public health practice is made even more difficult by the fast changing social and political landscape and the evolving understanding of public health. There has been a shift in emphasis between the 1988 Institute of Medicine report on public health,5 which emphasized strengthening of governmental public health agencies, and the 2002 Institute of Medicine report, The Future of the Public's Health in the 21st Century,6 which focuses on the public health system as a "complex network of individuals and organizations that have the potential to play critical roles in creating the conditions for health." This new context requires that public health officials be managers and community leaders who often work in large public health agencies and in partnerships and through collaborations with numerous public and private stakeholder groups and citizens--"who have widely varying values" that often shift over time as the political and social context evolves.7(p110)
A vision of public health as "healthy people in healthy communities" expands the scope of public health to include behavioral and socioeconomic factors that require the development of long-lasting community action and community relationships to affect change and have any impact. In addition, whereas most states have updated public health laws in recent years, commentators emphasize that legal authority should be a last resort in public health and that public health action in a liberal democracy should rely not on force but on persuasion and should express, not impose, community.8
Relationship building, whether between public health officials and the public they serve or between and among community partners, is not merely instrumental, but rather the substance of public health work, particularly in emergency preparedness. Other related contemporary roles of public health professionals also include that of translators, mediators, negotiators, educators, or caretakers.9 Commentators have suggested that "(B)uilding a community of stakeholders--educating and facilitating individuals and entities to see themselves as 'connected through health'-is central to the professional identity of public health officials."10(p1213)
These values of professionalism are captured in the Public Health Code of Ethics discussed in the later sections of this article. Codes of ethics have been used by professions throughout history to provide a source of guidance about right and wrong behavior and good and bad practice. The recent development of a code for public health demonstrates the field's commitment to enriching its identity and role and its relationship with the public. The principles elucidated in the public health code can serve as an important frame of reference for public health officials when they communicate with the public about their role and the underlying goals of their activities. The code can provide a foundation for principle-based leadership.
Organizational ethics, which focuses on the mission, values, and systems within an agency that creates a climate for ethical behavior, practices, and policies. Organizational ethics involves providing public health leaders and workers with training, tools, and organizational structures, such as committees, to help them recognize the ethical dimensions of their work and integrate the agency's values into the performance of their tasks. Some empirical research, primarily in the business context, suggests that ethical codes of conduct and ethics training within an organization can be associated with changes in behavior and decision making (see A Review of Empirical Studies Assessing Ethical Decision Making in Business11 and the book, Built to Last: Successful Habits of Visionary Companies12). More empirical research on organizational ethics is needed.13 Ethicists, however, have provided much normative guidance about the ways organizations can explicitly include ethical analyses into organizational activities, such as compliance, risk management, quality improvement, and evaluation measurements for employee performance review and agency accreditation.14 Later in this article, principled leadership in practice will explore opportunities for integrating ethics into day-to-day practice.
Public policy ethics, which can offer a deliberative framework and process that leads to public justification. Some issues that arise in public health practice, such as providing and allocating scarce funds for particular interventions, are policy questions that must be resolved in the political arena. This process involves the engagement of community stakeholders and the public at large in the development of political consensus and support for public health activities. Public justification is a requirement of public officials who are accountable to the public they serve for the ethical reasons underlying their decisions and policies. Although public health professionals' values and codes of ethics can be part of the public deliberation about policy, justifications in any particular case will be based on an analysis of the benefits and burdens of particular options and of the interests and moral claims of all the stakeholders. The following framework provides one approach to analysis by posing questions to help frame deliberation with the public or within the health department management team.15
1. Analyze the ethical issues in the situation:
* What are the public health risks and harms of concern?
* What are the public health goals?
* Who are the stakeholders, and what are their moral claims?
* Is the source or scope of legal authority in question?
* Are precedent cases or the historical context relevant?
* Do professional codes of ethics provide guidance?
2. Evaluate the ethical dimensions of the alternate courses of public health action:
* Utility: Does a particular public health action produce a balance of benefits over harms?
* Justice: Are the benefits and burdens distributed fairly (distributive justice), and do legitimate representatives of affected groups have the opportunity to participate in making decision (procedural justice)?
* Respect for liberty: Does the public health action respect individual choices and interests (autonomy, liberty, and privacy)?
* Respect for legitimate public institutions: Does the public health action respect professional and civic roles and values, such as transparency, honesty, trustworthiness, promise-keeping, protecting confidentiality, and protecting vulnerable individuals and communities from undue stigmatization?
3. Provide Justification for a particular public health action:
* Effectiveness: Is the public health goal likely to be accomplished?
* Proportionality: Will the probable benefits of the action outweigh the infringed moral considerations?
* Necessity: Is it necessary to override the conflicting ethical claims to achieve the public health goal?
* Least infringement: Is the action the least restrictive and least intrusive?
* Public justification: Can public health agents offer public justification for the action or policy, on the basis of principles in the Code of Ethics or general public health principles that citizens and in particular those most affected could find acceptable in principle?
Emergency Preparedness in Public Health as an Illustration
Emergency preparedness, then, may require public health officials to first and foremost take an active role in building a community of stakeholders, integrating ethics into day-to-day practice that involve emergency-preparedness tasks, and generating debates on such policies as rationing in an emergency. The fire department metaphor for public health provides an understanding of this role, according to commentators,
by suggesting that drills to prepare for and challenge our potential responses, are appropriate preventive measures. Drills are important not only as instructive devices for practicing activities (such as "know the nearest exit"), but also because, in the context of biopreparedness and state power, we need to "prepare" our civic responses when challenged as a community. The purpose of public debate is not merely to have fair procedures or reach consensus on any one course of action, but rather to build and strengthen our civic commitment to continued cooperation, essentially to sustain a collaborative relationship over time. Most importantly, deliberation actively engages the public in preparation and response as partner and full participant in public health.16(p115)
A brief examination of a community's need to develop guidelines for rationing scarce medical resources in a public health emergency illustrates why drawing on the three spheres of public health ethics is helpful. The Implementation Plan for the National Strategy for Pandemic Influenza, released by the White House in May 2006,17 describes the way public health agencies at all levels of government are expected to work with hospitals and private healthcare providers in the community to address the medical needs of citizens. The plan also describes the challenges that will arise with the expected surge in medical need. Here is how the plan presents the situation,
if a pandemic overwhelms the health and medical capacity of a community, it will be impossible to provide the level of medical care that would be expected under prepandemic circumstances. It may be necessary because of hospital overcrowding, to establish prehospital facilities and alternate-care sites to provide supplemental capacity. In some circumstances, it may be necessary to apply triage principles in the hospital to regulate, which patients gain access to intensive care units (ICUs) and ventilators and it is likely that vaccines, pharmaceuticals, and other medical material will also be rationed[horizontal ellipsis]. As in all situations involving the allocation of scarce medical resources, the standard of care will be met if resources are fairly distributed and utilized to achieve the greatest benefit. In a pandemic, hospital and ICU beds, ventilators, and other medical services may be rationed. As in other situations of scarce medical resources, preference will be given to those whose medical condition suggests that they will obtain greatest benefit from them. Such rationing differs from approaches to care in which resources are provided on a first-come, first-served basis or to patients with the most severe illnesses or injuries[horizontal ellipsis]. In all cases, the goal should be to provide care and allocate scarce equipment, supplies, and personnel in a way that saves the largest number of lives[horizontal ellipsis]. In making adjustments in the delivery of care because of constrained resources, individual autonomy, privacy, and dignity should be protected to the extent possible and reasonable under the circumstances. Finally, clear communication with the public is essential before, during, and after a mass casualty even such as a pandemic.17(p110)
Simply put, what is the role of the local health department official in preparing a community for hospital triage (as described above) during a public health emergency?
Drawing on an understanding of and competencies in the three spheres of public health ethics, officials' effectiveness in addressing emergency-preparedness questions such as these will be affected by (1) the strength of their ongoing professional relationships with the public and community stakeholders, enriched by codes of ethics or ethical principles; (2) the expertise they have demonstrated and trust they have built through the ethical management of day-to-day public health activities over time; and (3) the public's involvement in the development of both the rationing policies and guidelines and the public justification for them.
Because biopreparedness includes policy making in the political sphere, public justification will play a key role because public consent is the source of moral authority and legitimacy for public decision making in public health. As one political theorist suggests, public authorities should reflect the moral understanding of the group in whose name any decision is being taken and justify decisions in a way the public will find persuasive because moral judgments, unlike scientific judgments, are "everyone's job" in society.18
At a minimum an official's role would include convening stakeholders and coordinating collaborations and forums for deliberation with many partners and community members. In addition, public health officials may take a more active role as conveyers of public information, educators, or partners with other government officials in forging public consensus about guidelines on rationing and on the options for securing some type of public consent to rationing in an emergency. Requirements for public engagement could range from mere notice to the public through the media, to invitations to the public to participate in community deliberations and hearings, to conducting community focus groups and surveys about public values that should guide rationing, to the establishment of community ethics boards that could have either rotating memberships such as a jury or predominantly community experts as permanent members. Each community must address which of the options for community engagement is appropriate, on the basis of such factors as community values and trust.
Emergency preparedness illustrates that effective public health leadership and practice are enriched by professional ethics and stronger public health relationships developed over time, by local agencies that have integrated ethics into their organizational structure and management, and by communication, deliberation, and public justification with the public as partner. Attention to the ethical dimensions in these activities, in effect, extends and deepens the meaning of "public" in public health. The goal is a stronger, trusting public that collaborates and cooperates with government public health officials.
Principled Leadership in Practice
The emergency-preparedness case we have described illustrates that ethical decision making is not an isolated case, but rather takes place in a particular context and community. As we have discussed in the previous section, public health officials committed to incorporating ethics into practice must create an organizational context within their agencies that is grounded in ethics. This could be accomplished by tying employee-performance standards to ethical principles and by encouraging staff to integrate ethics into their daily work by developing goals, objectives, and measurable outcomes that are based on public health values and principles. We describe this as principled leadership. The first part of this section highlights some of the ethical implications of daily public health activities. The second part describes how public health officials can incorporate ethical processes throughout the work of their organizations by drawing on the Code of Ethics to provide a guide and language for deliberation.
Protecting the public: Recognizing and responding to public health threats19
Surveillance
The nature of governmental public health work, specifically activities like surveillance, community notification, and other disease control efforts, requires that public health officials make trade-offs between individual rights and community benefits virtually every day. Given the responsibility of local and state public health departments to protect the public, the first step for organizations committed to ethical practice is to recognize public health threats promptly. Clues to the presence of public health threats can come from several sources, including the notifiable disease-notification system, disease registries, or anecdotal reports, such as calls from emergency-department physicians. Decisions to set the response sensitivity at different levels, such as statistical requirements (incidence above a set level), staff intuition or supervisor mandate or decisions to require staff to collect additional data, with the attendant delay in response, can have ethical implications. In addition, any personal conflicts of interest could influence whether public health officials are willing to acknowledge the existence of a threat19
Once public health officials and their staff deem it necessary to collect additional information, they have several methods available, all involving some form of active surveillance, such as outbreak investigations or community surveys. The problem they wish to characterize could be short term, such as a communicable disease, or long term, such as youth obesity. Ethical considerations underlie many of the decisions involved in active surveillance efforts, including which populations or groups to survey and which specimens or data to collect. Examples include determining whether the active surveillance process threatens confidentiality or unfairly creates burdens or stigma for specific populations, groups, or individuals.
All public health surveillance activities involve trade-offs between individual privacy (the interest in restricting access to personal information and body specimens) and confidentiality (legal obligations to prevent redisclosure of private information) and the public's right to know about problems that could affect them. Although public health law allows public health officials to gather notifiable disease information without individual consent, the nonconsensual nature of these activities entails that public health officials should give particular attention to the privacy and confidentiality of individuals from whom they gather data. When collecting data, ethical considerations require public health officials to collect only data elements and specimens necessary for disease control or health promotion efforts and to remove personal-identifying information from the dataset once it is no longer useful.
When conducting case-control investigations into outbreaks of either notifiable conditions or diseases of uncertain origin, public health officials must gather information from healthy people as well as ill people to help them identify associations between exposure and illness. Most state laws give local public health officials the authority to collect data from ill people without conducting formal, explicit informed consent. However, public health authority to collect data without consent from healthy people serving as controls, such as those identified eating at an affected restaurant through credit card receipts, is unclear.
Data analysis and reporting
Once surveillance activities have collected information, public health officials have additional ethical considerations when performing data analysis and when reporting the data. Ethical considerations in data analysis include ensuring data quality and accounting for data-quality limitations in the analysis, determining statistical thresholds for defining significance, and ensuring confidentiality, especially when small numbers are involved. Even when reporting aggregated data, public health officials must balance the public's need for information with the possibility that their analysis could stigmatize specific populations or reduce property values, for example, when identifying populations affected by toxic emissions from a nearby power plant. In addition, when reporting associations between exposure and illness, public health officials must ensure that those who use the data, including the media and policy makers, avoid drawing inappropriate conclusions regarding cause and effect.20 While spending time on these considerations, public health officials must still endeavor to ensure to report their findings promptly, especially to individuals and community partners who contributed information to the surveillance process, especially if they wish to maintain trust with affected communities.
Public health interventions
After gathering information and conducting the analysis, public health officials will consider potential responses, each likely to have ethical implications. Responses might include isolating someone with a communicable disease, such as tuberculosis, restricting the movements of healthy people exposed to a communicable disease such as severe acute respiratory syndrome (quarantine), or restricting children from school until they obtain immunizations. All of these decisions, which invoke the public health police powers, involve balancing individual liberties with community benefits. Scarce resource allocation decisions, such as determining who will receive antiviral medications during a flu pandemic, involve working with community stakeholders in developing an equitable, transparent system for distribution and allocation.
Governmental public health officials have many interventions at their disposal ranging from health education, to regulation, and to taxation. All of these interventions have ethical implications.
The objective of public health education campaigns, such as tobacco and substance abuse campaigns, is to change individual health behaviors and community social norms. Even if these campaigns provide accurate information, they raise ethical questions about the role of government in doing so. One framework for ethical consideration of these campaigns distinguishes between persuasion, defined as appeals to reason that enhance individual autonomy, and manipulation (psychological manipulation or manipulation of information), which does the opposite.21 Other ethical considerations in health promotion campaigns include whether public health officials involve community stakeholders in determining the topic of the campaign, the nature of the campaign itself, including marketing materials, and whether public health officials share campaign goals with the target population.
Regulatory interventions present another set of ethical considerations. Some examples include regulating whether health-promoting or health-reducing substances, such as tobacco, are present in specific areas, decisions affecting the flow of information related to health and behavior, and the prescription of sanctions to individuals to promote desired behavior and deter undesired behavior. Using sanctions to require compliance raises concerns about paternalism and the trade-offs between individual liberty and community benefit, and public health officials must provide justifications for suppressing the flow of information.
When implementing interventions that may place individual liberties at odds with community benefits, public health officials must consider three factors:
* Whether the intervention is the least restrictive of individual rights.
* Whether public health officials have attempted to reduce any negative effects of these restrictions, such as providing food and water for quarantined individuals, or providing directly observed therapy for tuberculosis in a confidential location with incentives.
* Whether the burdens involved do not disproportionately affect a minority or otherwise vulnerable population.
Program evaluation
Governmental public health programs involve the use of scarce public resources. Therefore, public health officials have an obligation to ensure that they use these resources efficiently and effectively. For example, public health officials should be able to demonstrate how their interventions address problems identified through surveillance. Such program evaluation requires data collection without any formalized consent process, and public health officials should consider individual privacy and confidentiality for these activities. Some potential solutions involve collecting the minimal amount of data necessary and removing personal identifying information as soon as possible to do so without compromising the evaluation.
Clearly, governmental public health officials make public health decisions involving ethical trade-offs virtually every day. Given the frequency and consequences of these decisions, public health officials might benefit from ethical guidelines or tools to help frame their deliberations.
Ethics Tools: Codes of Ethics
Physicians have long recognized the value of using ethical codes in making medical decisions. The American Medical Association established a Code of Ethics at its first meeting in Philadelphia in 1847.22 In helping physicians practice, the ethical principles underlying these codes stress the responsibility physicians have for improving the health of their individual patients, although improving the health of society is a secondary concern.
Medical ethics and public health ethics
Like physicians, local and state public health officials are interested in improving the health of people they serve. However, as already identified, governmental public health practice activities have unique features that medical codes of ethics do not address. Compared to physicians, the foremost concern of public health practitioners is the health of entire community, although individual health is also a concern. To improve the community's health, state and local public health officials frequently use public health law, regulations and policies based on the police power of states. The consideration of community health as primary and the use of police powers to enforce public health measures can sometimes place public health officials at odds with individuals including the physicians caring for them.
Although public health law tells public health officials what they can do, it does not give guidance to public health officials regarding what they should do in specific situations, especially when officials must balance community concerns against individual liberties and property rights. In addition, public health law varies by state, making decision making based on legal authority, unique across jurisdictions. In many specific situations, legal authority may be ambiguous, leaving public health officials without clear guidance regarding actions they should take and requiring them to offer ethical justifications and reasons for their actions.
Recognizing the need for a tool that could help public health officials make decisions unique to them, the Public Health Leadership Society (PHLS) developed the Public Health Code of Ethics (2) (see Box 1). To obtain broad input in developing the code, PHLS consulted with Association of State and Territorial Health Officials and National Association of County and City Health Officials leadership, held focus groups with public health practitioners, and presented drafts of the Code at American Public Health Association town hall meetings.
In creating the code, PHLS members and their partners recognized that decisions based solely on epidemiology or on public health legal authority do not always have the best outcomes. Instead, public health officials should always question whether a given action is necessary, whether there are less restrictive alternatives, and whether they can justify their actions to their community constituents. Ethical codes provide a systematic means to balance trade-offs between individual and community interests as well as systematic guidance for justifying public health interventions on the basis of what is good and right for health and social welfare. The use of ethical principles in guiding decision making recognizes that processes, doing things right, are as important as outcomes, or doing the right things. In addition, the use of ethical principles recognizes that public health officials are accountable to the communities they serve, that the law alone does not justify specific actions, and that public health officials cannot perform their work adequately without the public's trust.
The Code of Ethics helps public health leaders question whether the benefits, such as reducing the transmission of illness or ensuring the availability of critical services, such as antiviral medications for hospitalized patients with pandemic influenza, justify the means, such as restricting the movement of someone with tuberculosis or restricting availability of antiviral medications for prophylaxis. Principle 4, for example, might focus attention on the way particular actions affect basic resources for disenfranchised community members. The Code of Ethics is a valuable tool because public health officials can use the same principles consistently when deliberating about various decisions. Consistency of values over time, on different issues, and throughout the organization builds community trust.
Recognizing the importance of knowledge and skills in ethics, the American Association of Schools of Public Health included professionalism as one of the core competency domains for students graduating with MPH degrees. American Association of Schools of Public Health defined professionalism as "the ability to demonstrate ethical choices, values, and professional practices implicit in public health decisions; consider the effect of choices on community stewardship, equity, social justice and accountability; and to commit to personal and institutional development." The seventh competency within this domain is the ability "to apply basic principles of ethical analysis (eg, the Public Health Code of Ethics, human rights framework, other moral theories) to issues of public health practice and policy" (http://www.asph.org/document.cfm?page=896).
While defining ethics competencies for MPH graduates is helpful, these individuals make up a small proportion of the public health workforce. Public health officials engaged in principled leadership must ensure that ethics is considered at all levels of their organizations. As health departments prepare for accreditation, public health workers might integrate ethics codes and principles into the required agency evaluation plan as well as into particular activities. For example, during preparedness exercises, public health officials could ensure that the incident-management system incorporates ethical principles and performance measures based on them into response decisions. By doing so, by providing moral as well as scientific and political justifications for their public health activities, we believe that state and local public health departments will engender community trust and enrich their practice, thereby improving the health of their communities.
REFERENCES