Bridging the Public Health Ethics Gap

During the Covid-19 pandemic, public health decision makers have not always been transparent to the public, with changes such as mask mandates, quarantine and isolation policies, mandatory testing, and the shift to remote. They often fail to adequately explain the reasons behind decisions about intervention. work and learn. Public health leaders often report that the data models they rely on have varying degrees of accuracy and reliability, that the available evidence evolves and requires re-evaluation, and that reasonable People can disagree on how to translate data into policy. In fact, officials sometimes resorted to “virtuous lies,” deliberately misrepresenting the facts, to support decisions, simplify communications, or maintain composure.1 In many cases, policies were deemed ethically sound simply because they were legally permissible.

These tactics have undermined public confidence, hindered the adoption of Covid mitigation measures, and fueled social movements against health policies and officials. Once “following science” was exposed as an oversimplified mantra, different segments of the public chose for themselves which guidance to follow.

One way to avoid the resulting ineffective public health campaigns and further polarization of the population might have been to incorporate ethicists into public health teams. may not have prevented, ethicists could have warned policy makers of the dangers associated with insufficient transparency and directed them toward a more open and accountable approach.

But more than two years after the Covid-19 pandemic, and despite fierce battles over how to balance health, economic, social and educational concerns, public health officials have received systematic input from ethicists. Information was rarely integrated into the decision-making process. Instead, it has relied primarily on ethical analysis by physicians, epidemiologists, and other public health professionals, most of whom do not have extensive training or experience in applied ethics. Public health ethics has its own set of norms and principles, so much can be gained from working with an experienced ethicist.

Public health agencies have long worked on approaches to formally integrate ethical analysis into workflows.2,3 The Centers for Disease Control and Prevention (CDC) has a Public Health Ethics Unit, but the CDC’s primary publication is Ethical Guidance for Public Health Emergency Preparedness and Responsehas not been updated since 2008.Four None of the dozens of pandemic-related resources provided by the National Association of County and City Health Officials detail how to incorporate ethics and ethicists into public health decision-making. The lack of hands-on guidance and educational opportunities in this area is particularly troublesome given the country’s patchwork public health system. In the United States, he has over 3,000 local public health departments and her over 13,000 public school districts, each with substantial decision-making authority.

There is a shortage of professionals trained in public health ethics due to several factors. All accredited schools of public health are required to offer content on ethics, but few graduate programs require an ethics course, and most use only limited case studies to cover ethics topics. covers the Even within the field of bioethics, public health ethics often gets sidetracked by ethical issues related to patient care, emerging technologies, and research protection, and ethicists with clinical or research-oriented training are often left out of their profession. Knowledge may not be available to the public. health policy. Some public health decision makers may believe they can engage in ethical analysis without outside consultation.

Although there is no universal public health ethical framework, in the United States the field developed rapidly in the early days of the AIDS epidemic and began to coalesce after 2000. As an example, pioneers of public health ethics initially advocated blind serum surveillance (after the development of HIV tests, screening of blood drawn without identification for other purposes; Ending this form of surveillance when it becomes clear that unblinding will require testing without consent for populations such as people or people undergoing treatment for sexually transmitted infections. supported theFive

Public health ethics sets itself apart from other areas of bioethics by emphasizing community values ​​and social justice. Balancing individual autonomy and common interests remains important, but the public health ethical framework does not begin with an emphasis on individual interests. Public health ethics emphasizes principles of good governance that require harmonizing democratic participation and expertise, promoting transparency while protecting privacy, and building and maintaining trust. .2 Public health decisions are not made in a political vacuum, and policy makers must consider the needs of different constituencies. Decisions made without an ethicist can be morally sound, but emphasizing the consistent inclusion of an ethicist in the decision-making process explicitly takes ethical considerations into account. Ensure robust interactions.

The integration of ethicists into public health workflows includes procedural and training considerations. Ethics departments can be established within public health departments to enable efficient workflows, and local bioethics advisory committees can be established to provide independent opinions free from institutional or political pressure. I can do it. In situations where the ethics department or committee is impracticable, public health professionals can request ethics consultations, and health committees can further integrate ethicists into their teams. To facilitate these efforts, states or localities can partner with schools of public health.

Some of these mechanisms are employed. Michigan counties have created local pandemic ethics committees, and Ohio has staffed several pandemic response committees with ethicists from Ohio State University, where we work. The Defense Advanced Research Projects Agency frequently asks external ethics committees to advise on the social and ethical implications of technological innovations.

It is imperative to ensure that ethicists entrusted with such roles are sufficiently trained to consider practical public health concerns. Ethicists should have a solid understanding of public health conceptual frameworks, research methods, and public health politics. You must be ready to translate your ethical theory into timely, actionable advice. They must recognize that their role in public health policymaking is that of nonpartisan advisors. The best advisors concisely identify the strengths and weaknesses of various possible courses of action. The goal should be to provide concise, unbiased advice based on the intersection of values ​​and evidence.

Certainly, the training and employment of ethicists is not a panacea for pandemic policy-making concerns, nor is it the only perspective that should be consistently incorporated into public health workflows. Key social issues include the extent to which ethics should inform decision-making and the role ethicists should play in helping the public understand complex public health issues. However, public health ethicists can help determine how diverse perspectives can be incorporated into public health deliberations. It can also make an important contribution to the public conversation about policy decisions that affect community health, helping to frame and explain the complex trade-offs and limitations of data and policy.

Public health leaders and agencies may not have the power to influence policy, even when ethical considerations are incorporated into the debate. This is especially true in states where public health authority is preempted by legislators. Thus, although independent organizations such as the American Public Health Association are often involved in policy issues and have formal public health ethics codes, they are more active in highlighting ethical issues relevant to public health policy-making. can play a role.

Lawmakers, state officials, and the public are demanding an explanation for the U.S. government’s emergency preparedness and pandemic response. The PREVENT Pandemics Act, which establishes a commission to evaluate the U.S. response to COVID-19, has bipartisan congressional support. Some states, such as Indiana, have created panels to evaluate pandemic response policies as a means of rethinking public health systems.

These initiatives include ethicists to assess both the role ethical considerations have played in Covid-19 policymaking and strategies for systematically integrating such considerations into public health practice. It is important to Public health practitioners must address complex issues of health, equity and social justice. We believe that the deliberate and strategic involvement of ethicists in these decisions is essential.

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