This site is intended for health professionals only

Should public health ethics be shaping our practice?

Is there a public health ethic and is it different from medical ethics? Alison Wall argues that it is. Here she examines the emerging science of public health ethics, a subject that is becoming more relevant to primary care practitioners …

Alison Wall
BSc SRN SCM HV FPCert
Health Visitor/
Public Health Nurse/
Child Protection Lead West Hertfordshire PCT

Public health ethics is becoming more relevant to primary care practitioners with the increase in screening tests and strategies developed to improve the health of populations.
Tensions can arise between different public health messages, leaving people with uncertainties and anxiety. Questions can be raised - to what extent do individuals have moral obligations to contribute to protecting the public good? What limits should be placed upon activities? How do we address increasing inequities?
We need to focus much more on the consequences of introducing public health initiatives and ensure that we maintain a balanced and rational perspective.

So what's so different about public health ethics? 
Public health ethics has evolved from medical and bioethics. The latter is very much based on urgent aspects of life, and centres on the doctor-patient relationship.(1) Medical and bioethics are all to do with individual rights. Although public health is hard to define, its key characteristic is the population perspective.(2) Public health recognises the multideterminants of health and the complex interaction of factors that affect health status.
What is distinctive is the fact that alongside population benefit there may be individual "costs". It is the relative values of both that make up the core ethical questions in public health. Clearly when we consider the principles inherent in the public health domain, the principle of autonomy will be overshadowed by population considerations (see Box 1).

[[nip39_box1_74]]

Some have argued for a clear framework for public health ethics such as Kass,(3) but Holland argues that frameworks should emerge out of the developing practice of public health.2 New concepts and ethical challenges will evolve, depending on future issues.

Ethical dilemmas
A key public health concern was the advent of HIV/AIDS in the 1980s. The dilemma arose about legal issues such as mandatory testing, reporting and contact tracing. Risks were perceived as being huge, due to routes of transmission and lack of cure.
Some policies have benefits or disbenefits that are more far-reaching.
The recent smoking legislation has had clear positive health consequences, but has also had consequences unrelated to health.(4) Smoking has enhanced the social life of many people, but with the ban imposed in England in July this year smokers have had to reconsider where they meet.

Public health research can throw up dilemmas for practice
Breastfeeding mothers typically choose not to use pacifiers in order to establish their breastmilk. However, research shows that dummy use can be beneficial in reducing the risk of sudden infant death.(5) Bedsharing has also thrown up tensions between health promotion messages, as bedsharing increases the risk of cot death, but seems to help mothers breastfeed. Some sort of consensus has to be agreed in order for these public health initiatives to be accommodated. In the case of dummies it is recommended that they can be used when the baby is over four weeks of age, thereby prioritising breastfeeding in the early weeks. There has, however, been an uneasy alliance between the research body for cot death and the baby-friendly initiative over the issue of bedsharing.(6)
Dilemmas arise in the field of screening and immunisation. Screening is secondary prevention, and allows relative risks to be determined. This can result in anxieties and uncertainty, eg, in the area of antenatal testing. A high-risk result introduces a real dilemma about whether the unborn should be terminated. There is a clinical conflict with autonomy over the issue of immunisation, as we know that herd immunity protects populations, but the very act of immunising introduces a small degree of risk to the individual.
 
Government policies
The White Paper Our Health, Our Care, Our Say, set out clear plans for the future of health and social care in the 21st century.(7) People overwhelmingly said that they wanted more choice and control over their lives. However, some choices can involve taking risks so it is essential that safety for the individual and society is evaluated, and that decisions are made regarding who is responsible if things go wrong.
The government acknowledges that clear guidance is needed and has published a recent document Independence, Choice and Risk: A Guide to Best Practice in Supported Decision Making.(8) The paper stresses that corporate approaches to risk are critical; organisations should move away from a defensive risk-averse stance to one of supported decision-making.

Importance of practice and clinical governance
In reality we know that when something goes wrong, people quickly look to apportion blame. It is necessary therefore that alongside greater freedoms of choice and user control, strict practice and clinical governance systems are in place. Public health involves working across systems and service areas, so we need joint posts in place where joint assessments and packages of care can be agreed. IT systems need to talk to each other, and quality standards set in place. Clients need lots of information in order for them to make informed choices, and it is essential that this information is accessible and identifiable. In July this year the Secretary of State for Health Alan Johnson asked Lord Ara Darzi to conduct a review of health services in England. His interim report has just been published, and he recommends opening up access much more in primary care.(9) This will increase the need for watertight systems even more. The final report is expected by spring next year.

Conclusion
The area of public health ethics is in its infancy. Bioethics is a field that is well grounded in medical practice and has been relevant since the days of Hippocrates. Public health ethics has now become everyone's business in primary and community care. It is not an area that we can pass over and delegate to other disciplines; it needs to be the central focus of all that we do. Every proposed public health intervention should be evaluated ethically. Much more debate is needed both locally and centrally. We all need to consider the work that we do and determine whether all the ethical issues have been explored.

References

  1. Beauchamp TL, Childress JF. Principles of biomedical ethics. Oxford: Oxford University Press; 1994.
  2. Holland S. Public health ethics. Cambridge: Polity Press; 2007.
  3. Kass NE. An ethics framework for public health. Am J Public Health 2001;91:1776-82.
  4. Department of Health. The health act: code of practice for the prevention and control of healthcare associated infections. London: DH; 2006.
  5. Li De-Kun, Willinger M, Petitti DB, et al. Use of a dummy (pacifier) during sleep and risk of sudden infant death syndrome: population based case-control study. BMJ 2006;332:18-22.
  6. UNICEF. Sharing a bed with your baby. London: Unicef Enterprises Ltd; 2005.
  7. Department of Health. Our health, our care, our say: a new direction for community services. London: DH; 2006.
  8. Department of Health. Independence, choice and risk: a guide to best practice in supported decision making. London: DH; 2007.
  9. Department of Health. Our NHS, our future: next stage review. Interim Report. London: DH; 2007.

Your comments: (Terms and conditions apply)
"A nice article, public health ethics is indeed everyone's business, as is public health in general. The areas of practice and clinical governance are especially important for nurses.  Patient choice is good, but it is worrying that nursing practice is increasingly being decided by non-nurses. As a profession nurses need a stronger voice in deciding which advanced roles to take on, and which tasks to delegate to less qualified members of the team. There are ethical dilemmas with both,  and patients need an informed choice of exactly what service they are being offered, and by whom. Clinical IT systems are capable of demonstrating patient outcomes across the care pathway and could be utilized more to support appropriate nurse staffing in GP practice teams - Cath Gleeson, Practice Nurse, Respiratory Clinics, West Yorkshire